Reduce 30-day readmission rate for patients with chronic mental health problems

The metrics of readmission rates is indicative of several factors such as mental health care quality ( Donisi, et al. , 2016), comorbidity (Reif, Acevedo, Garnick, & Fullerton, 2017) and diagnoses (Hesslin & Weis, 2015). A major concern of readmission is the financial burden to society at large (Hesslin & Weis, 2015), institutions ( Benjenk & Chen, 2018 ) and individuals (Hesslin & Weis, 2015). Readmission also represents a substantial increase in the nursing burden (Hesslin & Weis, 2015). With the global increase of mental health diagnoses for varying reasons (e.g. drug use, change in diagnostic criteria), it becomes more important to delineate factors that influence readmission rates and to devise interventions and prevention methods to decrease such (Morris, Ghose, Williams, Brown, & Khan, 2017). The aim of this analysis is to identify policies and legislations that are currently underway to reduce the rate of 30-day readmissions in mentally ill adults. 

Upon completion of this analysis the reader will be able to identify the policies and/or legislations in place to reduce 30-day readmission for patients with chronic mental illness, strategies that are being implemented to address the issue, the public health and financial burden. 

Literature Review 

Prevalence of Mental health 

For the purposes of this paper, the term mental health is used as a general term to encompass mood disorders (MD) such as major depression disorder and bipolar disorder (BD), substance use/abuse disorders (SUD), schizophrenia, and other psychotic disorders (Hesslin & Weis, 2015; Regier, 1993). Steel et al., (2014) estimate a global lifetime prevalence of mental health disorder of about 20%, with a wide variability in gender, regions, and social economic class. This is a striking increase over previous estimates (Spitzer, Endicott, & Robins, 1978). Changes in diagnostic criteria (particularly DSM III through V) as well as changing global situations have been blamed for this increase (Steel et al., 2014). According to Hesslin and Weis (2015) and Regier (1993), approximately 25% of Americans experience some form of mental disorder, with 25-60% being classified as moderate to severe and requiring hospitalization. According to Owens et al. (2019), this equated to 55 million Americans with a principal diagnosis of MD, SUD or schizophrenia in 2016. 

Admission and Readmission Prevalence 

The Healthcare Cost and Utilization Project (HCUP) is a federally funded entity operated by the Agency for Healthcare Research and Quality with the sole purpose of collecting, collating and analyzing hospital care data since 1988. All statistics reported here are based on data reported through this organization. 

According to Owens et al. (2019), in 2016, approximately 6% of all hospital admissions could be attributed to Major Depression, Substance Use Disorder, or schizophrenia. These patients were predominantly young -18 -44 (49%) and 45 - 64 (35%), on Medicare (41%), and urban (86%). There was no significant difference in gender (female, 46%). The majority of these specific diagnoses were depression, alcohol-related disorder, schizophrenia, and bipolar (187, 133, 131, 90 per 100,000 population respectively). Studies suggest that increased hospital admissions for initial treatments, within the last 20 years, is caused mainly by the decreased availability of outpatient services for mental health and substance use (Morris, et al., 2015) and in some states, a restriction to inpatient benefits. The ACA has made it possible for millions of Americans to receive coverage for mental health, but some insurance companies still put limitations on the number of covered days for inpatient per year. This causes patients to be discharged before being fully stabilized. Obviously, readmission rates would also be affected by increased initial visits. According to Bailey et al., (2019), readmission is defined as the unintentional readmission for any reason, to a hospital within a limited time frame (usually 30 days) after initial release. MD, SUD and schizophrenia are ranked as the 6 th most prevalent cause for 30-day readmission, with a rate of 16.8%. The majority of these are SUDs (Owens et al., 2019). 

Financial Cost of Readmission 

According to Hesslin and Weis (2015), a large majority of Medicare and Medicaid recipients are registered disabled for mental health or substance use reasons, for example, “approximately 37 percent of all disabled Medicare beneficiaries had a severe mental disorder” (p.1). This represents a considerable burden to the public taxpayer. This is compounded by Emergency visits by psychiatric patients seeking initial treatments. According to Morris et al., (2017), MD, SUD and schizophrenia account for more than 40% of emergency visits which, according to Owens et al., (2019), translates into over $15 billion financed by taxpayers. 

Some of this financial burden is transferred to the hospitals themselves. The 

Hospital Readmissions Reduction Program (HRRP) is a federally developed program which issues financial penalties to hospitals based on their 30-day readmission rates (Bailey et.al., 2019). While psychiatric hospitals and units are exempted from these penalties, emergency departments are not, and as previously noted psychiatric diagnoses account for over 40% of their admissions ( Benjenk & Chen, 2018; Morris et al., 2017). Additionally, almost 30% of patients readmitted for physical health conditions have comorbid MD, SUD or schizophrenia ( Benjenk & Chen, 2018) . The idea of HRRP is that much of readmission could be attributed to poor medical care and/or poor post discharge maintenance, much of which can be controlled by hospital protocol ( Benjenk & Chen, 2018) . Indeed, this philosophy appears to be justified, as hospital protocol adjustments to financial penalties have resulted in an almost 5% decrease in 30-day readmissions since 2007 ( Benjenk & Chen, 2018). However, the 30-day readmission rates for mood disorders (15%) and schizophrenia (22%) remain high ( Hesslin & Weis, 2015). 

Current policy/legislation 

The Mental Health Parity and Addiction Equity Act (MHPAEA) was put into place in 2008 to prevent health insurance companies from placing more emphasis on health benefits and to place the same emphasis on mental health and substance abuse (cms.gov, 2020). The patient protection and Affordable Care Act amended the MHPAEA to include group health plans and individual coverage (cms.gov, 2020). 

The Community Preventive Services Task Force (CPSTF) recommends mental health benefits legislation, with particularly emphasis on comprehensive parity legislation (thecommunityguide.org, 2020). This legislation aims to improve financial protection and increase appropriate utilization of mental health services for individuals with mental health conditions (thecommunityguide.org, 2020). There is substantial evidence that mental health benefits legislation is associated with increased access to mental health care, increased diagnosis of mental health conditions, reduced prevalence of unmanaged mental health and reduced suicide rates (thecommunityguide.org, 2020). Mental health benefits legislation comprises of changing regulations for mental health insurance coverage to improve financial protection thereby decreasing the financial burden and increasing access to mental health and substance abuse services (thecommunityguide.org, 2020). 

According to communityguide.org (2020), in the United States, insurance benefits for mental health services have been substantially less compare to physical health services. Several state and federal initiatives have worked to address this issue by increasing parity or equality for mental health coverage (thecommunityguide.org, 2020). Forty-nine states as well as the District of Columbia have enacted mandated legislations. While at the federal level, the 1996 Mental Health Parity Act, the 2008 Mental Health Parity and Addiction Equity Act, and the Affordable Care Act have all led to increasingly stronger parity requirements (thecommunityguide.org, 2020). Current provisions of the ACA require that state Medicaid programs and insurance plans cover both mental health and substance abuse as one of ten categories of essential health benefits (thecommunityguide.org, 2020). 

Policy Descriptions for Specific Populations 

Over the years, the government has expended a lot of effort to reduce hospital readmissions as well as improve the quality of care for patients with chronic mental health issues. This section, however, focuses on the main three; the 1996 Mental Health Parity Act, the 2008 Mental Health Parity and Addiction Equity Act, and the Affordable Care Act (ACA). Note two things; first, the Affordable Care Act was built on top of previous policy implementations and as an attempt to nationalize health care. Secondly, describing the three different policy implementations to the necessary depth would push this paper outside its scope. Therefore, the policy descriptions and implications will be limited to a brief overview of the first two and a comprehensive review of the Affordable Care Act in the context of reducing 30-day readmissions. However, the scope is still wide to prevent an in-depth discussion. Therefore, the discussion will be made using a specific patient population: mental health care for older adults. 

The Mental Health Parity Act, signed into law in 1996, was an attempt to reduce the prevalence of mental health conditions across the country. As a result, it targeted group health plans and insurance health issuers with a requirement of an annual or lifetime dollar limit on mental health benefits to be equal to, if not more than surgical and medical benefits (Thalmayer et al., 2017). The law, however, failed in its objective as well as its mission. The positive part was the rider on the Troubled Asset Relief Program (TARP) that prohibited insurance companies offering mental health coverage from increasing the cost of mental health care, such as limiting the number of visits, co-insurance, co-pays, and even the number of days covered by the insurance. This rider legislation was the work of Pete Domenici, Senator Paul Wellstone, and his successors who fought hard to ensure mental health parity was enacted at the federal level. 

The Mental Health Parity Act (MPHA) was later superseded by the Mental Health Parity and Addiction Equity Act (MHPAEA). President George W. Bush signed it into law in October 2008. The purpose of the MHPAEA was mainly fixing the loopholes insurance providers and issuers exploited in the MPHA. For instance, the insurance benefits on mental health were guaranteed to not be more restrictive than those benefits the issuers afforded under medical and surgical coverage. The challenge to the implementation of MHPAEA, however, was carved out health benefits. According to Ettner et al. (2016), carve out health benefits are mental health benefits that employers purchase and separate them from medical benefits. The vendor, however, would be different from the medical and surgical benefits vendors. The law, therefore, required a carve-out vendor to establish parity with the benefits provided by separate vendors. This creates numerous problems because the law would be cutting into the profit margins of the carve-out vendors. Another challenge with the implementation was that there were no mechanisms to monitor compliance and regulate the implementation of the legislation. 

The two legislations, their challenges, and lessons learned to form the foundation for the Patient Protection and Accordable Care Act that was introduced in 2010. It can, therefore, be said that the Affordable Care Act was not a new piece of legislation but an extension of previous works. For instance, the ACA fixed two prominent issues with each of the previous legislation; MHPA and MHPAEA. First, the ACA abolished the limits on coverage, especially the length of stay in a hospital or coverage for chronic conditions, such as mental health complications, cancer, and diabetes, among others. Secondly, part of the reason why the Affordable Care Act has been successful is due to the comprehensive oversight into compliance, implementation, and maintenance of the provisions. 

Role of the APRN in Assisting with or Refuting the Policy 

APRNs assist with the Affordable Care Act indirectly through their roles as the leaders and drivers of Patient-Centered Medical Homes (PCMH). The PCMH is a care model initially introduced in the 1960s to help manage and coordinate care for chronic conditions in children (Bartels & Naslund, 2015). The PCMH is similar to the chronic care model in that to deliver quality health care, providers (such as RNs and APRNs) would require to assess patient needs, coordinate care across different settings (such as interdisciplinary teams), and community resources. After ACA was passed, the PCMH model became critical to improved health care delivery at lower costs. Besides, there are specific provisions in the Affordable Care Act that facilitate these objectives. For instance, federal stimulus funds as incentives and electronic health information technology have been critical to facilitating medical home delivery. The role of the APRN has, therefore, evolved to encompass multiple responsibilities, especially in problem identification and resolution through evidence-based practice. 

Take mental health care among older adults as an example. Geriatric patients, when compared to young adults, are less likely to intentionally visit mental health care providers for their mental health problems. On the other hand, they are very keen to visit their primary care physicians and make follow-ups and referrals. Therefore, any mental health care they receive is more likely to come from their primary care physicians (Bartels & Naslund, 2015). That mental health care, however, is inadequate because the main intervention is a prescription for antidepressants or other medication for mental health problems. There are different reasons for mental health care for geriatric patients has deteriorated. First, older adults cannot afford the costs of mental health care due to limited resources and low incomes ( Keynejad et al., 2018) . Secondly, there is an urgent need for mental health professionals specializing in geriatric mental health. Lastly, accessing health care services is difficult due to mobility limitations as well as mental health problems stigma (Reif et al., 2017). This is a problem identified that APRNs can contribute to solving 

The solution comes in the form of principal components of PCMHs. According to Bartels & Naslund (2015), patient-centered medical homes are built for the purpose of delivering patient-centered, comprehensive, and coordinated care for all patients, including the mental health care needs of the geriatric patients. Three solutions are apparent. First, if the problem is mobility or lack of resources to access medical health care, APRNs could schedule the geriatric patient's mental health check-ups and treatments to coincide with the regular visits to the primary care physicians. This is part of the care coordination model that is central to the role played by APRNs in their normal duties. On the other hand, if the problem financial limitations, then the ACA protects them by ensuring they are insured and provided much-needed care. However, all these interventions would be useless if the geriatric patients are afraid to seek mental health care services due to stigma. Solving this complication requires a community intervention where the APRNs bring together professionals, community members, and interdisciplinary teams to bring care to individual homes. Such collaborative care ensured integrated mental health and primary care provision. According to Bartels & Naslund (2015), there is more to patient-centered care than described briefly in this section. As shown above, the policy is not comprehensive enough to cover all situations. ACA makes it affordable to get insurance and get access to medical care. However, when the target population is reluctant to seek health care due to external factors, it is up to the APRNs to step in, solve the emerging issues, and publish the results. When policymakers look for areas to improve on or modify, the APRN published results become valuable resources in scaling the solutions. 

How ACA Influences Clinical Practice and Usage to Promote Best Outcomes 

It is impossible to exhaust how the Affordable Care Act has influenced clinical practice and helped promote the best outcomes. However, this section will focus only on a small set of provisions. According to Bartels & Naslund (2015), the ACA aimed to improve patient outcomes (quality of care) and reduce costs by targeting hospital readmission rates. The Hospital Readmission Program was implemented where hospitals with high readmission rates within a month would incur financial penalties (Roberts et al., 2018; Myers et al., 2020). Note that it is impossible for a hospital to reduce its readmission rates to zero. Therefore, the aim of the provision was to provide hospital administration incentives to minimize the readmission rates lower than a specific metric, such as projections. The provision, however, has led to major and minor changes in clinical practice at different levels of the organizations. 

For instance, there are proposals that bundled payments for total patient care. Such a proposal has the potential of reducing readmission by focusing on improving patient outcomes. If a patient is admitted to a hospital and gets all their health care needs to be met (including those that they did not know about), then they are less likely to be readmitted. As a consequence, their health outcomes would improve. While delivering total care, hospitals could go as far as providing preventative health care services to reduce the probability of the patient returning unless it is for their routine check-ups or emergencies. Achieving total care, however, is what impacts clinical practice. For instance, total care could be implemented, ensuring transitions are as smooth as possible. When the patient handoff is done from the hospitals to home and community care professionals, it becomes essential that the patient's needs are adequately communicated and met. It should be noted, however, that the greatest accomplishments made by the ACA provisions on readmissions is aligned interests. Though hospitals promote best outcomes and patients benefit, they do it mainly to avoid the financial penalties. 

The other clinical impact ACA provisions have had on reducing hospital readmissions is the growth of research and evidence-based practice to efficiently improve patient outcomes, in and outside the hospital. Bartels & Naslund (2015) give an example of an EBP transition protocol that has significantly reduced patient readmissions. First, patient transition services are stated over 24 hours before the actual discharge. Secondly, post-discharge follow-up is carried out immediately where the patients, family, and other primary caregivers are educated on all pertinent facts and get all their questions answered. Thirdly, the discharged patients are immediately linked to outpatient providers for continued care, such as home or community-based care programs. Fourthly, there is a comprehensive education session where medication is reviewed, reconciled, and any support and adjustments made. This becomes essential for self-managed patients of conditions like diabetes, where the burden of daily care lies with the patient. Finally, it is critical to organize post-discharge refills for all applicable prescriptions. Failure to do so would increase readmission rates when the patients finish their prescriptions before the recommended time and cannot refill them. 

How Interprofessional Teams can Use ACA to Coordinate Care for Geriatric Patients 

As described in the previous section, the Affordable Care Act has provisions that help reduce the 30-day readmission rate for patients with chronic mental health problems. Geriatric patients are especially vulnerable to other patient populations. According to Bartels & Naslund (2015), mental health problems affect adults older than 65 years disproportionately, especially if the conditions are chronic. These adults are also more likely to be Medicare-only beneficiaries and have both chronic physical as well as mental health conditions. Furthermore, their per capita share of health costs is significantly greater than that of other patients. The situation worsens, however, due to the fact that medical screening, diagnosis, and treatment, and monitoring of mental health conditions are highly variable coupled with other barriers to health care (Bartels & Naslund, 2015). The total outcome is that readmission rates for these patients would increase and, in turn, lower the financial benefits hospitals stand to gain from ACA provisions. 

Therefore, interprofessional teams could use the Affordable Care Act to ensure coordinated and comprehensive care for geriatric patients with chronic mental health conditions in the following ways. First, positive patient outcomes can be achieved by integrating care between different primary care providers. The Affordable Care Act supports this solution through different options. Behavioral health organizations, according to Bartels & Naslund (2015), integrated care through shared financing and co-located facilities to enhance access to quality care. However, such models are only successful if the partnering organizations are financially aligned when providing different health services, physical or mental. Care coordination between these organizations for quality support and service delivery is the primary responsibility of interprofessional teams. 

Secondly, there are ACA provisions that support Medicaid specialty health homes for patients with chronic mental health conditions, especially older adults. These specialty providers are more likely to implement the total care model. When patients visit, the providers assess both the physical and mental needs and create an integrated health care plan to address them. These providers could also extend the total care paradigm to community settings and target specific individuals or demographics. Therefore, the incorporation of primary and mental health care services has the potential to reduce patient readmission for both chronic physical and mental health conditions. Similar to the behavioral health organizations, it is the responsibility of the associated interdisciplinary teams to use the ACA provisions to ensure coordinated and comprehensive care for different populations, such as geriatric patients with chronic mental health problems. 

Conclusion 

Upon completion of this analysis, the reader will be able to understand the policies and/or legislation in place that could help to reduce 30-day readmission for patients with chronic mental illness, strategies that are being implemented to address the issue, the public health, and financial burden. Two strategies were discussed extensively. First, the Affordable Care Act has transformed clinical practice and driven it towards total care, where physical and mental health care needs are met with every visit. Total care relies on the ability of the interprofessional teams to coordinate care across the continuum. Secondly, health care providers could integrate mental and physical health care services by co-location or shared financing models. The strategy, however, only works when all the partnering organizations align financially. 

References 

Acevedo, A., Garnick, D.W., Fullerton, C., & Reif, S. (2017). Reducing behavioral inpatient readmissions for people with substance use disorders: Do follow-up services matter? Psychiatr Serv, 68 (8): 810–818. doi: 10.1176/appi.ps.201600339. 

Bailey, M.K., Weiss, A. J., Barrett, M.S., & Jiang, H. J. (2019). Characteristics of 30-Day all-cause hospital readmissions, 2010–2016. HCUP Statistical Brief #248. Rockville, MD: Agency for Healthcare Research and Quality 

Bartels, S. J., Gill, L., & Naslund, J. A. (2015). The Affordable Care Act, accountable care organizations, and mental health care for older adults: Implications and opportunities. 

Benjenk, I. & Chen, J. (2017). Effective mental health interventions to reduce hospital readmission rates: a systematic review. J Hosp Manag Health Policy, 2 (45) doi: 10.21037/jhmhp.2018.08.05 

Brandt, L., & Popejoy, L. (2020). Use of sensemaking as a pedagogical approach to teach clinical ethics: An integrative review. International Journal of Ethics Education , 1-15. https://doi.org/10.1007/s40889-020-00089-w 

Carper, B.A. (1978) Fundamental patterns of knowing in nursing.  Advances in Nursing Science , 1(1), 13-24.   

Donisi, V., Tedeschi, F., Wahlbeck, K., Haaramo, P., & Amaddeo, F. (2016) . Pre-discharge factors predicting readmissions of psychiatric patients: a systematic review of the literature. BMC Psychiatry 16 , 449. doi: 10.1186/s12888-016-1114-0 

Ettner, S. L., Harwood, J. M., Thalmayer, A., Ong, M. K., Xu, H., Bresolin, M. J., ... & Azocar, F. (2016). The Mental Health Parity and Addiction Equity Act evaluation study: Impact on specialty behavioral health utilization and expenditures among “carve-out” enrollees. Journal of health economics, 50, 131-143. 

Guide to Community Preventive Services. Mental Health: Mental Health Benefits Legislation. https://www.thecommunityguide.org/findings/mental-health-mental-health-benefits-legislation. Page last updated: August 04, 2020. Page accessed: August 26, 2020 

Heslin, K.C. & Weiss, A.J. (2015). Hospital readmissions involving psychiatric disorders, 2012. HCUP Statistical Brief #189. Rockville, MD: Agency for Healthcare Research and Quality 

Johansen, M. L., & O'Brien, J. L. (2016). Decision making in nursing practice: a concept analysis. Nursing forum , 51(1), 40-48. Doi:10.1111/nuf.12119 

Keynejad, R. C., Dua, T., Barbui, C., & Thornicroft, G. (2018). WHO Mental Health Gap Action Programme (mhGAP) Intervention Guide: a systematic review of evidence from low and middle-income countries. Evidence-based mental health, 21(1), 30-34. 

Morris, D.W., Ghose, S., Williams, E., Brown, K., & Khan, F. (2018). Evaluating psychiatric readmissions in the emergency department of a large public hospital. Neuropsychiatric Disease and Treatment , 14, 671—679. doi: 10.2147/NDT.S143004 

Myers, L. C., Faridi, M. K., Hasegawa, K., Hanania, N. A., & Camargo Jr, C. A. (2020). The Hospital Readmissions Reduction Program and readmissions for chronic obstructive pulmonary disease, 2006–2015. Annals of the American Thoracic Society, 17(4), 450-456. 

Owens, P.L., Fingar, K., McDermott, K.W., Muhuri, P.K., & Heslin, K.C. (2019). Inpatient stays involving mental and substance use disorders, 2016. HCUP Statistical Brief #249. Rockville, MD: Agency for Healthcare Research and Quality 

Puls, S.E., Guerrero, K.S., & Andrew, D.A. (2014). Facilitating safe patient transition of care: A qualitative systematic review. Journal of Nursing Education and Practice, 4 (6), 37-52. DOI: 10.5430/jnep.v4n6p37 

Regier, D. (1993). The de Facto US mental and addictive disorders service system: Epidemiologic catchment area prospective 1-year prevalence rates of disorders and services. Archives of General Psychiatry, 50 (2), 85–94 

Reif, S., Acevedo, A., Garnick, D. W., & Fullerton, C. A. (2017). Reducing behavioral health inpatient readmissions for people with substance use disorders: do follow-up services matter?. Psychiatric services, 68(8), 810-818. 

Roberts, E. T., Zaslavsky, A. M., Barnett, M. L., Landon, B. E., Ding, L., & McWilliams, J. M. (2018). Assessment of the effect of adjustment for patient characteristics on hospital readmission rates: implications for pay for performance. JAMA internal medicine, 178(11), 1498-1507. 

Spitzer, R.L ., Endicott, J ., & Robins. E . (1978). Research diagnostic criteria: rationale and reliability. Arch Gen Psychiatry , 35 (6), 773-82. 

Steel , Z., Marnane , C., Iranpour , C., Chey , T., Jackson , J.W., Patel , V., & Silove , D. (2014). The global prevalence of common mental disorders: a systematic review and meta-analysis 1980–2013 International Journal of Epidemiology , 43(2), 476–493. doi:10.1093/ije/dyu038 

The Mental Health Parity and Addiction Equity Act (MHPAEA), 2020. Retrieved from 

https://www.cms.gov/CCIIO/Programs-and-Initiatives/Other-Insurance-Protections/mhpaea_factsheet#:~:text=The%20Paul%20Wellstone%20and%20Pete,favorable%20benefit%20limitations%20on%20those 

Thalmayer, A. G., Friedman, S. A., Azocar, F., Harwood, J. M., & Ettner, S. L. (2017). The Mental Health Parity and Addiction Equity Act (MHPAEA) evaluation study: impact on quantitative treatment limits. Psychiatric services, 68(5), 435-442.