Results Summary
What was the research about?
Transitional care clinics treat patients with a mental illness for 90 days after a hospital stay. The clinics also connect patients to mental health services for ongoing care. Getting effective transitional care can keep patients from going back to the hospital.
In this study, the research team looked to see if an engagement-focused care program improved quality of life and care for patients at a transitional care clinic. In the program, patients had coaching in shared decision making. Shared decision making is a process where patients and doctors make decisions together based on the patient’s individual needs. To support shared decision making between patients and doctors, the coaches in the program
- Helped patients identify their care goals
- Taught patients how to work with their doctor to make a care plan based on their individual needs
Patients in the program also attended a group visit when they first came to the clinic to allow them to get care more quickly.
What were the results?
Quality of life increased more for patients in the program than for those who only got usual care at the end of transitional care. Patients in the program and those getting usual care only were both satisfied with their care. But patients getting usual care only were more satisfied than those in the program. Many patients in the program getting usual care only said they wanted to be involved in some shared decision making.
The study did not find differences between the patients in the program and those getting usual care in
- How often patients went to their appointments
- Mental health symptoms
- Number of hospital and emergency room, or ER, visits after leaving transitional care
- Patient and doctor ratings of the doctor’s communication skills
Who was in the study?
The study included 326 patients getting mental health transitional care after a hospital stay or ER visit in Bexar County, Texas. Of these, 49 percent were Hispanic, 41 percent were white, and 7 percent were African American. The average age was 38, and 55 percent were women.
What did the research team do?
The research team assigned patients by chance to get usual care only or usual care plus the program. Usual care included making sure the patients’ doctors worked together and patients got the right medicines and therapy.
Patients took surveys when the study began, when they left the transitional care clinic, and six months later. The research team also checked medical records to see if patients went to their appointments. Both patients and doctors rated the doctor’s communication skills after appointments. After patients left the clinic, the team called them monthly to learn how often they went to a hospital or ER.
Patients and clinicians on an advisory board and in focus groups helped design the study.
What were the limits of the study?
Of the patients in the program, 38 percent didn’t go to any coaching appointments. Results might be different if more patients went to these appointments. In addition, this study included patients at only one clinic. Results might be different in other locations or settings. The usual care given at this clinic was more thorough than usual care at most clinics. The quality of the usual care might have made it hard to improve care.
Future studies could see if the program works at other clinics and look at ways to get more patients to go to coaching appointments.
How can people use the results?
Transitional care clinics may want to use an engagement-focused care program to improve patients’ quality of life. Researchers can use results from this study to explore other ways to improve mental health transitional care.
Professional Abstract
Objective
To assess the effectiveness of engagement-focused care (EFC) in addition to usual care, compared with usual care only, in improving quality of life (QOL) and appointment attendance for patients at a behavioral health transitional care clinic (TCC)
Study Design
| Design Elements | Description |
|---|---|
| Design | Randomized controlled trial |
| Population | 326 individuals receiving care at a behavioral health TCC after discharge from a hospital or ED |
| Interventions/ Comparators |
|
| Outcomes |
Primary: QOL, appointment attendance Secondary: psychiatric symptomatology, mental health service use, patient preference for SDM, patient and physician ratings of physician’s communication skills, patient satisfaction |
| Timeframe | 9-month follow-up for primary outcomes |
This randomized controlled trial examined whether EFC plus usual care would improve QOL, appointment attendance, and other aspects of care for patients at a behavioral health TCC after a hospitalization or an emergency department (ED) visit.
The research team randomly assigned participants to receive either usual care only or EFC plus usual care. Usual care included medication management, care coordination, in-home visits, and psychotherapy. EFC included the following:
- Coaching for shared decision making (SDM): In SDM, patients and physicians make treatment decisions together based on the patient’s individual needs. Licensed counselors and peer specialists coached patients to identify their care goals, develop strategies for working with their physician to develop individualized treatment plans, and become active partners in selecting and evaluating their care. Coaches met with patients before and after each physician visit. Patients also had access to SDM videos and other tools.
- Group intake: Patients attended group intake appointments designed to offer quicker access to services than the usual individual intake process.
Study participants were patients receiving care at one behavioral health TCC in Bexar County, Texas, after discharge from a hospital or ED. Of the 326 participants, 49% were Hispanic, 41% were white, and 7% were African American. The average age was 38, and 55% were female. The research team collected self-report data through questionnaires when the study began, at the time of discharge from the TCC three months later, and then six months later. Patients and physicians gave ratings of the physician’s communication skills immediately after appointments. In addition, the team conducted a medical records review to identify missed appointments and called participants monthly to assess service use.
Patients and clinicians gave input on the study through a community advisory board and focus groups.
Results
Although the difference in QOL between groups was small, the research team found greater improvement in QOL for the EFC group than the usual care group at the time of discharge from transitional care (p<0.04) but not at other times. The groups did not differ in appointment attendance.
The usual care group reported higher satisfaction with treatment than the EFC group (p<0.004), although both groups reported high satisfaction. Psychiatric symptoms decreased for both groups, and the groups did not differ in symptomology or service use after discharge.
An equally high proportion of participants in both groups reported wanting to engage in at least some SDM with their physician (91%), and this proportion remained stable over time. Patients’ and providers’ ratings of the physician’s communication skills converged over time for both groups.
Limitations
In the EFC group, 38% of patients attended no SDM coaching appointments, which made it more difficult to identify differences between the two groups. This study included patients from one TCC, limiting generalizability. The usual care given at this TCC was more intensive than usual care at most clinics, which may also have made it difficult to find differences between the two groups.
Conclusions and Relevance
Compared with the usual care group, the EFC group had higher QOL at the time of TCC discharge. However, EFC did not improve in any other examined outcomes over usual care only, and patients receiving usual care only reported higher satisfaction with their care.
Future Research Needs
Future studies could examine other effective ways to engage patients in their care to improve care outcomes.
Final Research Report
View this project's final research report.
Journal Citations
Results of This Project
Related Journal Citations
Peer-Review Summary
Peer review of PCORI-funded research helps make sure the report presents complete, balanced, and useful information about the research. It also assesses how the project addressed PCORI’s Methodology Standards. During peer review, experts read a draft report of the research and provide comments about the report. These experts may include a scientist focused on the research topic, a specialist in research methods, a patient or caregiver, and a healthcare professional. These reviewers cannot have conflicts of interest with the study.
The peer reviewers point out where the draft report may need revision. For example, they may suggest ways to improve descriptions of the conduct of the study or to clarify the connection between results and conclusions. Sometimes, awardees revise their draft reports twice or more to address all of the reviewers’ comments.
Peer reviewers commented and the researchers made changes or provided responses. Those comments and responses included the following:
- Because so many patients were lost to follow-up, the reviewers requested that the researchers reanalyze the data including all patients with an initial assessment, even if patients did not have outcome data. The researchers responded that they chose their mixed-model approach specifically to deal with the expected missing data. The researchers stated that they required only that a person have a baseline and one post-baseline assessment for inclusion in the analyzed sample; the researchers did not require complete data for inclusion. As reviewers requested, the researchers did run additional analyses on primary outcomes and any significant secondary outcomes including all people with baseline data, but they kept the original primary analyses, as well.
- The reviewers asked the researchers to expand the discussion of limitations. The researchers added a limitation related to the large amount of missing outcome data. Researchers said that due to missing data, the sample they analyzed could have been systematically different from the original study sample. The investigators also stated that replication of the study results might be difficult because the study did not follow a framework for an intention-to-treat analysis because the analyzed sample did not include all the patients randomly assigned to the group receiving the intervention.
- The reviewers also argued that randomizing patients before obtaining full informed consent is a study limitation. Randomizing before consent could preclude a true intention-to-treat analysis because some randomized patients might choose not to participate in the study, the reviewers said. The researchers explained that if they had randomized after initial data collection, they would have captured only those patients motivated to engage in transitional care. Therefore, researchers thought they would not get a truly representative sample of the population if they had randomized at this later stage.
- The reviewers questioned the significance of evaluating joint intake versus individual intake appointments within the transitional care center training. The researchers noted that many of their stakeholders considered this question to be very important because joint intake procedures could speed access to services.