Transitional care programs to improve the post-discharge experience of patients with multiple chronic conditions and co-occurring serious mental illness: A scoping review - 09/12/24
, Kathy Sliwinski c
, Kelvin Amenyedor d
, J. Margo Brooks Carthon a, b 
Abstract |
The transition from hospital to home can be especially challenging for those with multiple chronic conditions and co-occurring serious mental illness (SMI). This population tends to be Medicaid-insured and disproportionately experiences health-related social needs. The aim of this scoping review was to identify the elements and outcomes of hospital-to-home transitional care programs for people diagnosed with SMI. A scoping review was conducted using Arksey and O’Malley's methodology. Three databases were searched; ten articles describing eight transitional care programs published from 2013 to 2024 met eligibility criteria. Five programs focused on patients being discharged from a psychiatric admission. Five of the interventions were delivered in the home. Intervention components included coaching services, medication management, psychiatric providers, and counseling. Program lengths ranged from one month to 90 days post-hospitalization. These programs evaluated quality of life, psychiatric symptoms, medication adherence, readmissions, and emergency department utilization. Notably, few programs appeared to directly address the unmet social needs of participants. While the focus and components of each transitional care program varied, there were overall positive improvements for participants in terms of improved quality of life, increased share decision making, and connections to primary and specialty care providers.
Le texte complet de cet article est disponible en PDF.Highlights |
• | Transitions are challenging for patients with SMI and chronic medical conditions. |
• | Few programs address their unique needs. |
• | Those that do focus on coaching, medication management, and counseling. |
• | Programs improved quality of life, medication adherence, but had mixed on readmission results. |
• | Program varied, but few addressed health-related social needs. |
Keywords : Serious mental illness, Transitional care, Medicaid, Multiple chronic conditions
Plan
Vol 91
P. 106-114 - novembre 2024 Retour au numéroBienvenue sur EM-consulte, la référence des professionnels de santé.
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