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Table 1 Tabulation and description of the studies used in the systematic review

From: Interventions to improve discharge from acute adult mental health inpatient care to the community: systematic review and narrative synthesis

IDAuthors and yearLocation and settingInterventionParticipantsMethodMain findingsMain aim/ problem to address
1Abraham et al. (2017)USA, 1 urban psychiatric hospitalPharmacist involvement to improve care co-ordination16 health professionals, 6 patients, 20 patient charts (SMI patients)Evaluation- interviews and observations of chartsIncreased pharmacist involvement in LAI care coordination may contribute to bridging gaps in medication adherence to optimize
treatment outcomes.
To support long-term medication adherence and patient outcomes
2Attfield et al. (2017)UK, 2 trustsDiagnostic-driven Integrated Care Pathways (ICPS)A random sample of 400 service usersRetrospective case comparison studyThe ICP Trust had a 13.5 day shorter average length of stay, (statistically significant). No significant differences in readmission or 7-day follow-up.Reducing unnecessary tests, interventions and duplication within the care process
3Bauer et al. (2012)Germany, 1 hospitalSMS-based
maintenance intervention
165 females. Eating disordersRCTSomewhat significant difference in readmission (depending on analysis). Significant difference in treatment utilisation.Maintain treatment
4Bennewith et al. (2014)UK, 3 inpatient wards in southwest England, mixed urban/ruralA contact-based intervention for people recently discharged (letters sent to sus)102 patients received a letter, 45 received all lettersPilot case study. Interviews, analysis of outcomes (readmission)Post-discharge, qualitative interviews with service users showed that most already felt adequately supported and the intervention added little to this.To reduce suicide post-discharge by providing social connectedness
5Bonsack et al. (2016)Switzerland, 1 psychiatric hospitalTransitional case management51 intervention, 51 controlRCTIncreased short-term rate of engagement with ambulatory care despite no differences
between the two groups after 3 months of follow-up. Intervention did not significantly reduce the rate of readmissions during the first year following discharge.
Improve engagement with care, reduce readmission
6Botha et al. (2018)South Africa, 1 hospital90-day transitional care intervention (four phone calls and one home visit, focusing on maintaining adherence, appointment reminders and psychoeducation.)60 male patientsRetrospective comparison to matched control groupNo effect on readmission rates in this setting.Bridge gap, reduce readmissions
7Chen (2014)USA, all of the community agencies providing CTI in NYC (4)Community support in critical time intervention (CTI)a time-limited, short-term psychosocial rehabilitation.
Program designed to facilitate the critical transition from
institutional to community settings
12 CTI workersInterviewsCTI workers self-identified as “extra support” to develop community ties that will help clients sustain stable housing. Propose a transient triangular relationship model, involving three dyadic relationships (worker-client, worker-primary support, primary support client).To facilitate effective transitional services and enhance continuity of care. Breaking the vicious cycle between institutionalization and homelessness
8D’Souza (2002)Australia, rural hospitalTelemedicine (psycho-educational programme and MDT videoconferencing post-discharge)51 (24 intervention, 27 control) male and femaleControlled studyMore side effects in control group, more treatment adherence and satisfaction in intervention group.Improve treatment adherence
9De Leo and Heller (2007)Australia, 1 psychiatric inpatient unitIntensive case management follow up of high risk people (ICM was weekly face-to-face contact with community case manager and telephone calls from counsellors)60 male service users with a history of suicide attemptsRCT (TAU or intervention)People in ICM had lower depression scores, suicidal ideation, QoL, more contact with services, better relationships with therapists and were satisfied with service.A solution to the reduced care following discharge that is linked to suicide.
10Exbrayat et al. (2017)France, single centreTelephone
follow-up 8,30 and 60 days post attempted suicide
436 patients (387 control patients who were matched from pre-intervention records)Controlled studyVery early telephone follow-up of our patients effectively reduced recidivism and seemed to be the only protective factor against repeated suicide attempt.To reduce suicide attempts post-discharge
11Forchuk et al. (2005)Canada, 26 wards, 4 hospitalsTransitional discharge model (TDM)390Randomised clinical trial using a cluster designCosts and quality of life were not significantly improved post-discharge compared with the control group. Although not predicted a priori, intervention subjects were discharged an average of 116 days earlier per person.Reduce bed occupancy, improve quality of life
12Forchuk et al. (2008)Canada, 1 hospitalIntervention to prevent homelessness- immediate assistance in accessing housing and assistance in paying their first and last month’s rent14 participants at risk of being discharged without housing (7 in intervention group)RCT, incl. interviewsAll intervention group maintained housing after 3 and 6 months. All but one individual in the control group remained homeless after 3 and 6 months. Results of this pilot were so dramatic that randomizing to the control group was discontinuedTo reduce discharge from inpatient wards to shelters or the street
13Forchuk et al. (2012)Canada, 6 hospitalsTransitional relationship model (TRM) (providing hospital staff involvement until a therapeutic relationship has been established with a community care provider as well as peer support.)No participant numbers as ethnographic analysis. 14 A wards, 12 B wards and 10 C wards.A quasi-experimental, action-oriented
research design
Staged large-scale implementation allowed for iterative improvements to the
model leading to positive outcomes. This study highlights the need to address work environment issues, particularly inter-professional teams.
To improve staff uptake of interventions
14Forchuk et al. (2013)Canada, all patients in Ontario at risk of homelessness, 1 acute care hospital, 1 territoryIntervention to prevent homelessness -
Pre-discharge assistance in securing housing
112 men and 107 women at risk of homelessness post-dischargeProgramme evaluation design- interviews, focus groupsThe results highlight several benefits of the intervention and show that homelessness can be reduced by connecting housing support, income support, and psychiatric care.To stop people being discharged to street or shelters
15Ghadiri Vasfi et al. (2015)Iran, 1 hospitalAftercare Services (three components: follow-up
Care (home visits or telephone follow-up), family psychoeducation, And social skills training for patients.)
120 patients (schizophrenia and bipolar) ages 15–65. 60 controlRCTThe cumulative number of hospitalizations during the follow-up period was 55 for the control group and 26 for the intervention group. Length of stay was significantly greater in the control group. Psychopathology was significantly less severe in intervention group compared with the controlReducing readmissions and length of stay
16Hampson et al. (2000)UK, 1 trust (North Nottingham and Hucknall)Community Link Team (CLT) to facilitate early discharge- team-based service offering intensive support during the day142 (all admissions to team in 12 month period)Retrospective comparisonMedian length of stay during CLT project was 19 days, a highly significant reduction from 36 days in the NABUS study. Cannot be attributed to team but justifies a RCT to test this hypothesis,To speed up discharge due to costs to provider and patients
17Hanrahan et al. (2014)USA, 1 hospitalTransitional care model (TCM)40 (20 control)RCTThe intervention group showed higher medical and psychiatric rehospitalisation than the control group. Emergency room use lower for intervention group but not statistically significant. Continuity of care with primary care appointments were significantly higher for the intervention group. The intervention group’s general health improved but was not significantReduce transition failures
18Hegedus et al. (2018)Switzerland, 2 wards, 1 hospitalShort transitional intervention in psychiatry (step)14 control, 15 interventionQuasi-experimental pilot study to determine the feasibility of the intervention,The intervention did not affect primary or secondary outcomes; however, it was shown to be feasible, and patients’ feedback highlighted the importance of post-discharge contact sessions.Prepare patients for situation outside of hospital
19Hengartner et al. (2015)Switzerland, 1 catchment area, which is an urban/suburban area of high-level resources near the city of ZurichPost-discharge network coordination3 patientsCase studies- narrative review and qualitative analysis of three patients who participated in the programCase reports revealed that patients’ social networks are small and their
relationships are commonly conflictual and unstable.
Reducing readmission, improving mental health and psychosocial functioning. Improve hospital discharge planning and to ease the transition
20Hengartner et al. (2016)Switzerland, 1 catchment area, which is an urban/suburban area of high-level resources near the city of ZurichPost-discharge network coordination151 patientsRCT using parallel group blockingIn the short-term, no significant effect emerged in any outcome. In the long term the two groups did not differ significantly with rate and duration of rehospitalisation. The intervention did not reduce psychiatric symptoms, did not improve social support, and did not improve quality of life.Reducing readmission, improving mental health and psychosocial functioning. Improve hospital discharge planning and to ease the transition
21Herman et al. (2011)USA, 2 transitional residences in hospital grounds metropolitan areaCritical Time Intervention to prevent homelessness150 previously homeless men and women with SMIRCTCTI group had less homelessness than TAUReduce homelessness following discharge
22Jenson et al. (2010)Canada, poor city, high unemployment, 1 acute ward and 1 community service provider within same regionCommunity-Based Discharge Planning (in-reach model- discharge planner based in community visits ward daily)36 service usersSingle group programme evaluation, analysis of admin data and interview with clientsReadmission rates were 40% lower in the year following
the change in service delivery model. This change was statistically significant.
To shift mental health services from institution to community
23Juven-Wetzler et al. (2012)Israel, 1 ward“Continuation of Care” model (continuing follow-up in the ward, by the same staff, instead of being referred to the outpatient department.)35 service usersPre and post within participant designThe number of hospitalizations in the 18 months following the index hospitalization was 1.79 _ 3.51 as compared to 4.67 _ 1.79 before the index hospitalization (p = 0.0002), and the number of days of hospitalization
18 months after was 24 _ 41.65 as compared to 119.71.
To reduce length of stay and readmission
24Kariel-Lauer (2000)Israel, 1 hospitalRe-entry group (short-term group meetings- psychoeducational approach)75 participants (42 in intervention) men and womenA controlled studyIntervention group had less readmissions, high rates of absorption into therapy and remaining in therapyReduce hospitalisations, increase compliance with outpatient appointments
25Kaspow and Rosenheck (2007)USA, 8 veteran medical centresCritical time intervention
Case management (a modification of the critical time intervention
(CTI) community case management model)
278 control cohort, 206 intervention cohortNonrandomized pre–post cohort design19% more days housed in each 90-day reporting period over the one-year follow-up and 14% fewer days in institutional settings. Veterans
In phase 2 also had 19% lower addiction severity index alcohol use scores,14% lower drug use scores
And 8% lower psychiatric problem scores
Reduce homelessness,
26Khaleghparast et al. (2013)Iran, 2 hospitalsDischarge planning (self-care training programme/nursing process model)46 service usersLongitudinal clinical trialThe intervention group had improved clinical symptoms and higher knowledge levels compared with control group.
Statistically significantly lower readmissions in the intervention group.
To increase patient knowledge, reduce clinical symptoms and rehospitalisation.
27Khanbhai et al. (2018)Australia, 1 medical centreDischarge checklist230 checklistsQuasi-experimental, pre–post intervention designThere was a small, but statistically non-significant, reduction in readmission rates.Reduce readmission
28Kidd et al. (2016)Canada, 1 large hospital in city‘Welcome Basket.’ (6 week peer support, contact on wards, basket of items, environmental support)23Evaluation- a mixed methods design, pre-post for quantitative outcomes, interviews and readmission ratesPre–post analysis indicated no change in psychiatric symptoms but improvement in community functioning, community integration, and quality of life. No difference in readmissionReduce suboptimal outcomes in first month, bridge gap
29Kisely et al. (2017)Australia, 1 hospital- intervention and control wards within itMotivational aftercare planning (motivational interviewing with advance directives)100 intervention plans, 197 control, 20 service user interviewsControlled before-and-after design, interviewsIntervention ward improved significantly (e.g. identification of triggers significantly increased from 52 to 94%, This did not occur in the control wards. Interviews showed improvements in experiences of discharge planning.To increase patient input into discharge planning, increase treatment plan following
30Lawn et al. (2008)Australia, 3 hospitalsPeer supportNo participant numbers in evaluationEvaluation methodology.Intervention at this stage of their recovery seems highly effective as an adjunct to mainstream mental health services. It has personal benefit to consumers and peers, substantial savings to systems, as well as much potential for encouraging mental health service culture and practice towards a greater recovery focus and improved collaboration with GPsTo reduce hospital avoidance and facilitate early discharge
31Lin et al. (2018)Taiwan, 1 hospitalNeeds-oriented hospital discharge planning for caregivers114 caregivers (of people with schizophrenia) 57 in each groupA quasi-experimental research designThe caregiver burden and health status of the experimental group improved more significantly compared with control group.Reducing readmission and improving medication adherence, reducing care giver burden
32Puschner et al. (2011)Germany, 5 hospitalsNeeds-oriented discharge planning intervention491Multicentre RCTNo effect of the intervention on outcomes.Reduce high utilisation of inpatient care
33Reynolds et al. (2004)Scotland, 1 unit, 3 wardsTransitional Discharge Model (ward nurse worked with SU until relationship built with community nurse, then support from service users)25 services user (14 control, 11 experimental)Randomised experimental designBoth control and experimental group demonstrated significant improvements in symptom severity and functional ability after 5 months. Usual treatment subjects in the control group were more than twice as likely to be re-admitted to hospital.Readmissions and not able to adapt to community, focus on need for relationships
34Rose et al. (2007)USA, 1 large urban medical centre, mostly African- American patientsTransitional care model a nurse-based in-home transitional care intervention10 service users (schizophrenia, bipolar)Evaluation- analysis of nurse logsOffers an alternative to patients who might otherwise be left poorly treated or untreated in the community setting.Lack of continuity of care and meet immediate post discharge needs of SU
35Sato et al. (2012)Japan, 5 hospitalsCommunity re-entry program. Discharge preparation program (psychosocial program for preparing long-term
hospitalized patients)
26 intervention, 23 control (schizophrenia)RCTThe program may be capable of promoting discharge of long-term hospitalized psychiatric patients.
There was no significant difference between both groups for number of patients discharged 6 months after end of program.
To reduce length of stay
36Scanlan et al. (2017)Australia, 3 geographical areas, large non-governmental mental health servicePeer-delivered, transitional and post-discharge support program38 service usersEvaluation, outcome measures, interviewsParticipants reported improvements in functional and clinical recovery and in the areas of intellectual, social and psychological wellness. Self-report of hospital readmissions suggested that there was a reduction in hospital bed days following the programReduce readmission, increase wellbeing
37Shaffer et al. (2015)USA, 6 community-based provider organizations within network of a not-for-profit, managed behavioural health care organizationBrief critical time intervention (a brief, three-month version of CTI)149 adults with readmission within 30 days, 224 controlA quasi-experimental investigationBCTI was associated with decreased early readmission rates,Reduce readmission
38Shaw et al. (2000)Scotland, 3 acute wards, 1 hospitalPharmacy discharge planning (receiving a baseline Pharmaceutical needs assessment, information about medicines and then a Pharmacy discharge plan sent to their community pharmacy)97 service usersControlled studyNo significant difference between the groups in baseline medicine knowledge. One week post-discharge, both groups showed
Significant improvement in knowledge of medication from baseline and was maintained at 12 weeks.
Fewer medication problems for the intervention group.
To reduce medicine-related problems that cause readmission
39Simpson et al. (2014)UK, 4 wards, inner city (London)Peer support46 service users 23 peer support 23 controlPilot randomised controlled trial with economic evaluationNo statistically significant benefits for peer support for hope or QoL, there is an indication that hope may be further increased in those in receipt of peer support. The total cost per case for the peer support was £2154 compared to £1922 for control.To increase hope and quality of life
40Smelson et al. (2010)USA, 1 acute inpatient psychiatric unitBrief Treatment Engagement (5 h per week of services- assertive community treatment using BCTI, peer support, dual recovery therapy)102 veterans, (56 control)Prospective randomized trial69%
Of intervention participants attended an outpatient appointment within 14 days of discharge, compared to only 33% of control. Intervention participants were also significantly more likely to be engaged in outpatient services at the end of the intervention period.
Treatment engagement
41Taylor et al. (2014)USA, 1 large psychiatric hospitalBrief care management
Intervention (brief interview prior to discharge)
87 intervention, 108 control, 195 totalControlled studyIndividuals in the control group were more likely to be readmitted within 30 days of an index readmission than individuals in the intervention group.Increase aftercare engagement, reduce readmissions
42Tomita et al. (2012)USA, 2 New York City hospitalsCritical time intervention (CTI)150 total previously homeless men and womenRCTAt the end of the follow-up period, psychiatric re-hospitalization was significantly lower for the group assigned to CTI compared with the usual services group.Reducing readmission
43Virgolesi et al. (2017)Italy, 3 hospitals in RomeNursing discharge programme (a short-term nursing discharge programme with follow-up phone calls 7–10 days)135 patientsProspective correlational designThe interpersonal and educational nursing intervention improves adherence to a treatment plan.Medication adherence and patient satisfaction
44Walker et al. (2000)UK, 3 wards (2 control)Discharge co-ordinators343, 119 intervention, 224 controlControlled cohort studyNo differences in outcomes (readmission, LoS, mental health status, satisfaction). More satisfaction for those without interventionImprove communication between primary and secondary care
45Zheng and Arthur (2005)China, 1 large hospital in BeijingFamily education101 patients (schizophrenia)RCT pre-test, post-testSignificant improvement in knowledge about Schizophrenia in the experimental group. Significant difference in symptom scores and functioning at 9 months after discharge.Knowledge about condition and rehospitalisation.
There is a need for culturally sensitive family treatments offered by nurses