Joana Bravo
Francisco Lima Buta1
Miguel Talina
Amílcar Silva-dos-Santos- 1Department of Psychiatry, Hospital Vila Franca de Xira, Vila Franca de Xira, Portugal
- 2NOVA Medical School, NOVA University of Lisbon, Lisboa, Portugal
- 3Hospital CUF Tejo, Lisbon, Portugal
Introduction
In this article, we highlight the need to implement care transition interventions to reduce the revolving door phenomenon (RD) in the general population and homeless patients (HP). We have looked at studies concerning: (1) RD, (2), its impact on HP, and (3) models of care transition interventions in psychiatry and mental health. We conclude with suggestions on improving care transitions in mental health and reducing the RD.
The revolving door phenomenon
Early hospital readmission is a problem worldwide and an adverse clinical care outcome (1–3). It is estimated to cost $17 billion yearly in the United States (US) (4). In high-income countries, 13% of psychiatric patients are readmitted after hospital discharge (5). In addition, 50% of all discharged psychiatric patients are readmitted within 1 year (6).
The term revolving door means multiple readmissions in a period of 30, 60, or 90 days, according to different studies (7). These patients consume up to 30% of health care resources, although they represent only 10% of the total number of patients (8).
The main factors linked to the RD phenomenon remain uncertain (9). Studies found that revolving door patients are younger, single, with low education and unemployed. They often suffer from psychosis and alcohol or other substance use (10, 11). Also, they have a younger age on disease onset, poor compliance to medication, more suicide attempts and voluntary admissions (12).
There are several reasons for the increase in hospital readmission. One of the main factors is the lack of support from the patient's environment or care system (13). Another cause is early patient discharge before reaching clinical remission and no coordination of medication with the patient or family. Also, a lack of care transition planning and adequate communication among hospital staff, patients, family and primary care providers worsen outcomes (14).
Several treatment strategies reduce hospital readmission: (1) the use of long-acting injectable antipsychotics (15, 16), (2) maintenance electroconvulsive therapy (ECT) (17, 18), and (3) community-based interventions (discussed below). Patients undergoing ECT (19, 20) need a family member or caregiver to monitor them for 24 h after each session. Those without family or social support are vulnerable to RD. To solve this problem, in our department, they are admitted the day before the procedure. They undergo ECT and are discharged after 24 h. A care transition element will follow them up via telephone, reminding them of their schedule to ensure they do not miss their maintenance ECT.
The revolving door problem in the homeless population
Homeless people are a vulnerable population and the RD is especially high among them. They have more medical comorbidities and more mental health problems. A reason for these issues might be their lifestyle. They have more difficult access to health care in the community and do not receive adequate medical care (11, 21).
A large study across three US examined the association of homelessness with hospital readmissions. The four most common causes were: (1) mental illness, (2) peripartum complications, (3) cardiac diseases, and (4) diseases of the digestive system (21).
A study in Nicaragua focused on the gender issue in homelessness. The female population is in a particularly vulnerable position. The “revolving door to homelessness” is more prevalent since they spend multiple episodes living as homeless after having access to independent housing. Also, they had more barriers to finding regular work (22).
It was also shown that men remained homeless for longer periods. A larger proportion of them had alcohol use issues. They also spent time in prison. Women were more prone to use a regular place to spend the night. An important proportion of them suffered sexual violence as a minor. They also suffered intimate partner violence and physical violence as adults. Homelessness in women poses another problem. The children under their care have an increased risk of suffering sexual, physical, or verbal violence (22).
One-fourth to one-third of homeless persons have a severe mental illness. Schizophrenia, bipolar disorder, or major depression are the most prevalent conditions (23). The cost of hospital admissions for the homeless is much higher than in the general population. Homeless people with mental health problems are more likely to use acute and emergency services. Also, they are less likely to receive general primary care than other populations (24).
Mental illness is an independent risk factor for homelessness. Single adults with a major mental illness have a 25–50% risk of homelessness over their lifetime (10, 23). When homelessness and mental illness are combined, the burden on the health system increases. This results in four times higher use of the health services than the housed population (11). Homeless people display low access to community-based health services. Despite being a vulnerable population (with higher illness severity and a higher need for care continuity), they have poor care after discharge (11, 25).
Some authors proposed that homeless people with mental illness should become the object of Marontology. This term origins in the greek word marontos which means unwanted. This proposed field is an effort to provide a better response to the particular challenges of this population (26). Other authors suggested that a street Psychiatry rotation should be part of the residency in Psychiatry (27).
General models of care transition intervention
One of the better-known intervention models in general Medicine is the Care Transitions Intervention created by Eric Coleman and his team (28). It consists of enabling the patient and family to become independent by providing them with the tools and information required. It uses a transition coach that interacts with the patient and family and is based on four pillars: medication self-management, patient-centred record, follow-up and red flags. The transition coach visits the patient in the hospital and home after discharge. Later he follows-up the patient via telephone call for 28 days. According to this randomized controlled trial, this intervention reduced early readmission from 13.9% in the control group to 8.3% in the intervention group after 180 days (28).
A prospective cohort study centered on a care transition intervention showed a significant readmission rate reduction compared to the control group (20.0 vs. 12.8%, respectively). It was an intervention based on coaching to empower patients to manage their health and improve their communication with their providers. The complete intervention occurs across 30 days and includes a home visit within 3 days, a first telephone call within 7–10 days, and the final telephone call by day 30 (29).
Some effective care transition interventions in psychiatry and mental health
There is more research on care transition interventions in general Medicine than in psychiatry (30, 31). Nonetheless, several studies have shown the positive impact of a care plan in the transition from acute mental health inpatient to community care (32–34).
According to a systematic review (31), effective interventions in psychiatry include several aspects, namely: (1) pre and post-discharged psychoeducation; (2) timely communication of the discharge plan to the outpatient provider; (3) pre-discharge medication education; (4) telephone follow-up, and (5) a transition manager.
In terms of care transition models in mental health, Ezra Susser's Critical Time Intervention (CTI) studies in New York (35) was one of the first to show long-term impact and be cost-effective in the prevention of homelessness. Each person was assigned to a CTI worker and provided community housing. The worker would give close support and build durable ties between patients and long-term supports (family, caregivers, psychiatrist, general practitioner). It included home visits, accompanying patients to appointments, giving support and advice and mediating conflicts between patients and caregivers.
Other CTI, showed a significant reduction in homelessness and in readmissions (34). This highlights the importance of strategies that include housing stability to reduce revolving door in the HP.
A network-based concept (32) integrates different health care specialists. This includes psychiatrists, specialized nursing staff and psychologists, social workers and pedagogues. An emphasis is given to psychosocial support and psychoeducation. Other features include socio-therapy, visiting care and family support. This program also includes specialist nursing to provide home treatment. There is cooperation with the hospital in case of admission. Crisis service is available 24/7 for patient and family. The psychiatrist is in charge of the therapy and is the preferred contact for the patient.
Another intervention showed improvements in mental and physical health status, substance misuse, and the number of hospital admissions. It offered case management, peer support, access to primary psychiatric care, and community services (33). Several studies have shown the positive impact of a care plan in the transition from acute mental health units to community care (32–34).
Discussion
The aggregate data suggest that much more studies about care transition in psychiatry should be conducted. Another note is that the revolving door phenomenon and homelessness remain marginalized. As improvement suggestions, we highlight the need to foster the teaching of care transitions approaches in the residency program of Psychiatry. The development of the subspecialty of Marontology should be considered to address the super difficult patients, revolving door and homelessness (36). There is much more to be done by the mental health services, institutions and the government. Integrative perspectives are relevant to a better knowledge of the mechanisms of mental illnesses (37). This approach merges the knowledge of different areas such as psychiatry and neuroscience, psychology, neuroimaging, and neurology, to name a few. The concept of care transition can be added to the integrative perspectives of mental illnesses.
Important measures of care transition include early follow-up consultation via telephone and home visits, psychoeducation, access to prescribed medications, accompanying appointments and bridging ties between patients and long-term supports, such as family members and medical professionals. In order to improve care transition, some initiatives to improve post-discharge outcomes should be encouraged. Care after discharge should be integrative and multidisciplinary.
A particular intervention for the homeless population that includes housing and social support is needed. These measures are cost-effective and have a significant impact in reducing hospital readmission.
Author contributions
JB and AS-d-S: writing, editing, and review. FB and MT: editing and review. All authors contributed to the article and approved the submitted version.
Conflict of interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Publisher's note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.
References
1. Hermann RC, Mattke S, Somekh D, Silfverhielm H, Goldner E, Glover G, et al. Quality indicators for international benchmarking of mental health care. Int J Q Health Care. (2006) 18:31–8. doi: 10.1093/intqhc/mzl025
3. Rumball-Smith JHP. The validity of readmission rate as a marker of the quality of hospital care, and a recommendation for its definition. N Z Med J. (2009) 2009:63−70. Available online at: https://www.researchgate.net/profile/Juliet-Rumball-Smith/publication/24218843_The_validity_of_readmission_rate_as_a_marker_of_the_quality_of_hospital_care_and_a_recommendation_for_its_definition/links/00b7d52e2b3550dbfe000000/The-validity-of-readmission-rate-as-a-marker-of-the-quality-of-hospital-care-and-a-recommendation-for-its-definition.pdf
4. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the medicare fee-for-service program. N Engl J Med. (2009) 360:1418–28. doi: 10.1056/NEJMsa0803563
5. Leslie DL, Rosenheck RA. Comparing quality of mental health care for public-sector and privately insured populations. Psychiatr Serv. (2000) 51:650–5. doi: 10.1176/appi.ps.51.5.650
6. Bridge J, Remy B. Reducing hospital readmission in depression and schizophrenia: Current evidence. Curr Opin Psychiatry. (2004) 17:505–11. doi: 10.1097/00001504-200411000-00015
7. Gastal FL, Andreoli SB, Quintana MIS, Gameiro MA, Leite SO, McGrath J. Predicting the revolving door phenomenon among patients with schizophrenic, affective disorders and non-organic psychoses. Rev Saude Publica. (2000) 34:280–5. doi: 10.1590/S0034-89102000000300011
8. di Lorenzo R, Sagona M, Landi G, Martire L, Piemonte C, del Giovane C. The revolving door phenomenon in an Italian acute psychiatric ward: a 5-year retrospective analysis of the potential risk factors. J Nerv Ment Dis. (2016) 204:686–92. doi: 10.1097/NMD.0000000000000540
9. Koparal B, Ünler M, Utku H, Candansayar S. Revolving door phenomenon and related factors in schizophrenia, bipolar affective disorder and other psychotic disorders. Psychiatr Danub. (2021) 33:18–24. doi: 10.24869/PSYD.2021.18
10. Fernandes AM, Marques JG, Bento A, Telles-Correia D. Mental illness among 500 people living homeless and referred for psychiatric evaluation in Lisbon, Portugal. CNS Spectr. (2021) 2021:1–10. doi: 10.1017/S1092852921000547
11. Laliberté V, Stergiopoulos V, Jacob B, Kurdyak P. Homelessness at discharge and its impact on psychiatric readmission and physician follow-up: a population-based cohort study. Epidemiol Ps2ychiatr Sci. (2019) 29:e52. doi: 10.1017/S2045796019000052
12. Fonseca Barbosa JC. Revolving Door in Severe Mental Disorders: A Systematic Review. Faculdade de Medicina da Universidade de Lisboa, Lisboa, Portugal. (2022).
13. Lichtenberg P, Levinson D, Sharshevsky Y, Feldman D, Lachman M. Clinical case management of revolving door patients - a semi-randomized study. Acta Psychiatr Scand. (2008) 117:449–54. doi: 10.1111/J.1600-0447.2008.01170.X
14. Berenson RA, Paulus RA, Kalman NS. Medicare's readmissions-reduction program–a positive alternative. N Engl J Med. (2012) 366:1364–6. doi: 10.1056/NEJMP1201268
15. Lin CH, Chan HY, Hsu CC, Chen FC. Time to rehospitalization in patients with bipolar mania discharged on long-acting injectable or oral antipsychotics. J Affect Disord. (2021) 279:292–8. doi: 10.1016/J.JAD.2020.10.023
16. Lin CH, Chen FC, Chan HY, Hsu CC. Time to rehospitalization in patients with schizophrenia receiving long-acting injectable antipsychotics or oral antipsychotics. Int J Neuropsychopharmacol. (2019) 22:541–7. doi: 10.1093/IJNP/PYZ035
17. Slade EP, Jahn DR, Regenold WT, Case BG. Association of electroconvulsive therapy with psychiatric readmissions in US hospitals. JAMA Psychiatry. (2017) 74:798–804. doi: 10.1001/JAMAPSYCHIATRY.2017.1378
18. Kocamer Sahin S, Demir B, Elboga G, Altindag A, Elmali E. The effects of maintenance electroconvulsive therapy on hospitalization rates. J Nerv Ment Dis. (2021) 209:155–8. doi: 10.1097/NMD.0000000000001278
19. Silva-dos-Santos A, Venda D, Sales MB, Velho MV, Gracias MJ. Bottom-up neuroanatomical pattern of symptom remission in melancholic depression after electroconvulsive therapy: a case report and literature review. Psychogeriatrics. (2021) 21:252–4. doi: 10.1111/psyg.12654
20. Silva-dos-Santos A, Bruno Sales M, Venda D. Symptomatic improvement of acute mania associated with a single session of electroconvulsive therapy: A proposed concept of neuroversion. Bipolar Disord. (2021) 23:844–6. doi: 10.1111/bdi.13107
21. Khatana SAM, Wadhera RK, Choi E, Groeneveld PW, Culhane DP, Kushel M, et al. Association of Homelessness with Hospital Readmissions-an Analysis of Three Large States. J Gen Intern Med. (2020) 35:2576–83. doi: 10.1007/S11606-020-05946-4
22. Vázquez JJ, Cala-Montoya CA, Berríos A. The vulnerability of women living homeless in Nicaragua: A comparison between homeless women and men in a low-income country. J Community Psychol. (2022) 50:2314–25. doi: 10.1002/JCOP.22777
23. Folsom DP, Hawthorne W, Lindamer L, Gilmer T, Bailey A, Golshan S, et al. Prevalence and risk factors for homelessness and utilization of mental health services among 10,340 patients with serious mental illness in a large public mental health system. Am J Psychiatry. (2005) 162:370–6. doi: 10.1176/APPI.AJP.162.2.370
24. Currie LB, Patterson ML, Moniruzzaman A, McCandless LC, Somers JM. Continuity of care among people experiencing homelessness and mental illness: does community follow-up reduce rehospitalization? Health Serv Res. (2018) 53:3400–15. doi: 10.1111/1475-6773.12992
25. Doran KM, Ragins KT, Iacomacci AL, Cunningham A, Jubanyik KJ, Jenq GY. The revolving hospital door: hospital readmissions among patients who are homeless. Med Care. (2013) 51:767–73. doi: 10.1097/MLR.0B013E31829FAFBB
26. Gama Marques J, Bento A. Marontology: Comorbidities of homeless people living with schizophrenia. Acta Med Port. (2020) 33:292. doi: 10.20344/AMP.13561
27. Lo E, Balasuriya L, Steiner JL. A street psychiatry rotation for medical trainees: humanizing the care of people experiencing homelessness. Acad Psychiatry. (2022) 46:248–53. doi: 10.1007/S40596-021-01461-8
28. Coleman EA, Parry C, Chalmers S, Min S. The care transitions intervention: results of a randomized controlled trial. Arch Intern Med. (2006) 166:1822–8. doi: 10.1001/archinte.166.17.1822
29. Voss R, Gardner R, Baier R, Butterfield K, Lehrman S, Gravenstein S. The care transitions intervention: translating from efficacy to effectiveness. Arch Intern Med. (2011) 171:1232–7. doi: 10.1001/ARCHINTERNMED.2011.278
30. Viggiano T, Pincus HA, Crystal S. Care transition interventions in mental health. Curr Opin Psychiatry. (2012) 25:551–8. doi: 10.1097/YCO.0b013e328358df75
31. Vigod SN, Kurdyak PA, Dennis CL, Leszcz T, Taylor VH, Blumberger DM, et al. Transitional interventions to reduce early psychiatric readmissions in adults: Systematic review. Br J Psychiatry. (2013) 202:187–94. doi: 10.1192/bjp.bp.112.115030
32. Mayer-Amberg N, Woltmann R, Walther S. An integrated care initiative to improve patient outcome in schizophrenia. Front Psychiatry. (2016) 6:e00184. doi: 10.3389/fpsyt.2015.00184
33. Stergiopoulos V, Gozdzik A, Nisenbaum R, Durbin J, Hwang SW, O'Campo P, et al. Bridging hospital and community care for homeless adults with mental health needs: outcomes of a brief interdisciplinary intervention. Can J Psychiatry. (2018) 63:774–84. doi: 10.1177/0706743718772539
34. Tomita A, Herman DB. The impact of critical time intervention in reducing psychiatric rehospitalization after hospital discharge. Psychiatr Serv. (2012) 63:935–7. doi: 10.1176/APPI.PS.201100468
35. Susser E, Valencia E, Conover S, Felix A, Tsai WY, Wyatt RJ. Preventing recurrent homelessness among mentally ill men: a “critical time” intervention after discharge from a shelter. Am J Public Health. (1997) 87:256–62. doi: 10.2105/AJPH.87.2.256
36. Gama Marques J. Super difficult patients with mental Illness: Homelessness, marontology and John Doe syndrome. Acta Med Port. (2021) 34:314. doi: 10.20344/amp.15868
Keywords: care transition, revolving door, homelessness, rehospitalization, Marontology
Citation: Bravo J, Buta FL, Talina M and Silva-dos-Santos A (2022) Avoiding revolving door and homelessness: The need to improve care transition interventions in psychiatry and mental health. Front. Psychiatry 13:1021926. doi: 10.3389/fpsyt.2022.1021926
Received: 17 August 2022; Accepted: 07 September 2022;
Published: 26 September 2022.
Edited by:
João Gama Marques, Centro Hospitalar Psiquiátrico de Lisboa, PortugalReviewed by:
Philip Timms, South London and Maudsley NHS Foundation Trust, United KingdomAntónio José Bento, Centro Hospitalar Psiquiátrico de Lisboa, Portugal
Nuno Borja-Santos, Hospital Prof. Doutor Fernando Fonseca, EPE, Portugal
Copyright © 2022 Bravo, Buta, Talina and Silva-dos-Santos. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Amílcar Silva-dos-Santos, YW1pbGNhcnNzJiN4MDAwNDA7Z21haWwuY29t