title: A pilot randomized control trial: testing a transitional care model for acute psychiatric conditions.
abstract: OBJECTIVE
  People with multiple and persistent mental and physical health problems have high rates of transition failures when transferring from a hospital level of care to home. The transitional care model (TCM) is evidence-based and demonstrated to improve posthospital outcomes for elderly with physical health conditions, but it has not been studied in the population with serious mental illness.
  
  
  METHODS
  Using a randomized controlled design, 40 inpatients from two general hospital psychiatric units were recruited and randomly assigned to an intervention group (n = 20) that received the TCM intervention that was delivered by a psychiatric nurse practitioner for 90 days posthospitalization, or a control group (n = 20) that received usual care. Outcomes were as follows: service utilization, health-related quality of life, and continuity of care.
  
  
  RESULTS
  The intervention group showed higher medical and psychiatric rehospitalization than the control group (p = .054). Emergency room use was lower for intervention group but not statistically significant. Continuity of care with primary care appointments were significantly higher for the intervention group (p = .023). The intervention group's general health improved but was not statistically significant compared with controls.
  
  
  CONCLUSIONS
  A transitional care intervention is recommended; however, the model needs to be modified from a single nurse to a multidisciplinary team with expertise from a psychiatric nurse practitioner, a social worker, and a peer support specialist. A team approach can best manage the complex physical/mental health conditions and complicated social needs of the population with serious mental illness.
authors.affiliation: Nancy P. Hanrahan, PhD, RN, FAAN, University of Pennsylvania School of Nursing, Philadelphia, PA, USA nancyp@nursing.upenn.edu.
authors.forename: Nancy P
authors.initials: NP
authors.lastname: Hanrahan
authors.affiliation: Phyllis Solomon, PhD, University of Pennsylvania School of Social Policy & Practice, Philadelphia, PA, USA.
authors.forename: Phyllis
authors.initials: P
authors.lastname: Solomon
authors.affiliation: Matthew O. Hurford, MD, Philadelphia Department of Behavioral Health and Intellectual Disability Services, University of Pennsylvania School of Medicine, Philadelphia, PA, USA.
authors.forename: Matthew O
authors.initials: MO
authors.lastname: Hurford
mesh_terms: D000208:Acute Disease; D000293:Adolescent; D000328:Adult; D003266:Continuity of Patient Care / Q000458:organization & administration*; D005260:Female; D006699:Home Care Services / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D001523:Mental Disorders / Q000628:therapy*; D008875:Middle Aged; D010359:Patient Readmission; D015143:Philadelphia; D010865:Pilot Projects; D011568:Psychiatric Nursing / Q000379:methods*; D011788:Quality of Life / Q000523:psychology; D055815:Young Adult
keywords: TCM; advanced practice nurse; chronic care; mental illness; psychiatric hospitalization; psychiatric nurse practitioner; transitional care model; translational research