Readmission Patterns and Effectiveness of Transitional Care Among Medicaid Patients With Schizophrenia and Medical Comorbidity.
BACKGROUND
Patients with chronic medical and mental health comorbidities are at increased risk of hospital admission, but little is known about their hospital utilization patterns or whether nurse-directed transitional care interventions have any appreciable impact on future hospitalizations.


METHODS
Using paid Medicaid claims and a care management database, we examined patterns of hospital utilization for adults with multiple chronic conditions where one of the conditions was schizophrenia. Patients were enrolled in Community Care of North Carolina's medical home program and were discharged from 100 different hospitals throughout the state from July 1, 2010 through June 30, 2011. We examined readmission rates after psychiatric and nonpsychiatric hospital discharges, and we compared patients who received community-based, nurse-directed, transitional care management services to patients who received usual care.


RESULTS
A total of 1,717 patients were included in the final analysis. Patients in this study experienced 980 readmissions over the course of 1 year, with 20% of readmissions for a different reason than the primary hospitalization, and 36% of readmissions occurring at a different hospital. Controlling for demographic, clinical, and hospital characteristics, patients receiving transitional care (n = 1,104) were as much as 30% less likely to experience a readmission during the year following discharge compared to patients receiving usual care (n = 613).


CONCLUSIONS
This descriptive study reports on a nonrandomized intervention and its impact on service utilization for Medicaid patients with complex illnesses in North Carolina.


CONCLUSIONS
Regardless of the reason for hospitalization, patients with chronic medical and psychiatric conditions may benefit from transitional care support that addresses both conditions. This holds true even when the patient is already receiving intensive outpatient psychiatric care.
assistant director, Program Evaluation, Community Care of North Carolina, Raleigh, North Carolina cjackson@n3cn.org.
Carlos
C
Jackson
senior vice president, Informatics and Evaluation, Community Care of North Carolina, Raleigh, North Carolina.
Annette
A
DuBard
director, Behavioral Health, Duke University Health System; director, Duke Area Health Education Center program, Duke University School of Medicine, Durham, North Carolina.
Marvin
M
Swartz
director, Behavioral Health Integration, Community Care of North Carolina, Raleigh, North Carolina.
Amelia
A
Mahan
assistant director, Pharmacy Operations and Payer Programs, Community Care of North Carolina, Raleigh, North Carolina.
Jerry
J
McKee
associate director, Behavioral Health Pharmacy Programs, Community Care of North Carolina, Raleigh, North Carolina.
Theo
T
Pikoulas
senior policy associate, Massachusetts Health Policy Commission, Boston, Massachusetts.
Kathleen
K
Moran
medical director, Southlight, Inc., Raleigh, North Carolina.
Mike
M
Lancaster
D000328:Adult; D015897:Comorbidity; D005260:Female; D006801:Humans; D008297:Male; D008484:Medicaid; D009657:North Carolina; D010359:Patient Readmission / Q000706:statistics & numerical data*; D018802:Patient-Centered Care; D012189:Retrospective Studies; D012559:Schizophrenia / Q000628:therapy*; D000069341:Transitional Care / Q000458:organization & administration*; D014481:United States