title: Lessons learned from implementing a pilot RCT of transitional care model for individuals with serious mental illness.
abstract: We adapted an evidence-based transitional care model for older adults being released from acute care hospitals for patients with serious mental illness and medical co-morbidities being discharged from two psychiatric units of an acute care hospital (TCare) and evaluated implementation issues. An advisory group (AG) of community stakeholders assessed barriers and facilitators of a 90-day T-Care intervention delivered by a psychiatric nurse practitioner (NP) in the context of conducting a pilot randomized controlled trial. Minutes of AG and case narratives by NP of 20 intervention participants were content analyzed. Patients with immediate and pressing physical health problems were most receptive and actively utilized the service. Provider barriers consisted of communication and privacy issues making it difficult to contact patients in mental health facilities. In contrast, the NP was accepted and valued in the physical health arena. Psychosocial needs and relationship issues were demanding, and we recommend a team approach for TCare with the addition of a social worker, peer provider, and consulting psychiatrist for severely mentally ill patients being released from an acute physical health hospitalization.
authors.affiliation: University of Pennsylvania School of Social Policy Practice, Center for Mental Health Policy and Services Research. Electronic address: solomonp@sp2.upenn.edu.
authors.forename: Phyllis
authors.initials: P
authors.lastname: Solomon
authors.affiliation: University of Pennsylvania School of Nursing, Center for Health Outcomes and Policy Research. Electronic address: nancyp@nursing.upenn.edu.
authors.forename: Nancy P
authors.initials: NP
authors.lastname: Hanrahan
authors.affiliation: Philadelphia Department of Behavioral Health and Intellectual Disability Service; University of Pennsylvania School of Medicine, Center for Mental Health Policy and Services Research. Electronic address: Matthew.hurford@phil.gov.
authors.forename: Matthew
authors.initials: M
authors.lastname: Hurford
authors.affiliation: University of Pennsylvania School of Nursing, Center for Health Outcomes and Policy Research. Electronic address: mdecs@nursing.upenn.edu.
authors.forename: Marissa
authors.initials: M
authors.lastname: DeCesaris
authors.affiliation: University of Pennsylvania School of Nursing, Center for Health Outcomes and Policy Research. Electronic address: lakeetra@nursing.upenn.edu.
authors.forename: LaKeetra
authors.initials: L
authors.lastname: Josey
mesh_terms: D000328:Adult; D000359:Aftercare; D003131:Combined Modality Therapy; D015897:Comorbidity; D003299:Cooperative Behavior; D055318:Evidence-Based Nursing; D005260:Female; D006284:Health Plan Implementation; D006801:Humans; D033183:Interdisciplinary Communication; D008297:Male; D001523:Mental Disorders / Q000175:diagnosis / Q000451:nursing* / Q000523:psychology; D008875:Middle Aged; D016294:Models, Nursing; D020380:Needs Assessment; D009722:Nurse Practitioners; D010351:Patient Discharge; D010865:Pilot Projects; D011619:Psychotropic Drugs / Q000627:therapeutic use; D000069341:Transitional Care
chemical_list: D011619:Psychotropic Drugs