What was the research about?
Many people go to emergency rooms, or ERs, for urgent mental health problems. Getting follow-up mental health care after leaving the ER can improve people’s health. But less than half of people get follow-up care.
Care management helps patients get follow-up care and resources that can improve their health and quality of life. But not enough mental health professionals are available to offer care management to everyone who needs it. In this study, the research team compared care management delivered by
- Professionals, such as nurses, social workers, or counselors
- Peers recovering from a mental health problem
The research team looked at how often people who visited an ER for a mental health problem in the two groups got follow-up mental health care at a clinic.
What were the results?
People with professional care managers were more likely to have a follow-up mental health visit within one month after they left the ER than people with peer care managers.
People with professional and peer care managers didn’t differ in the number of follow-up visits they attended or in new admissions to the ER or hospital within six months.
Who was in the study?
The study included 326 adults who received mental health care in one of eight ERs in South Carolina. Of these patients, 53 percent were White, 40 percent were Black, and 7 percent were another race; 19 percent were Hispanic. The average patient age was 35, and 54 percent were men.
What did the research team do?
The research team assigned patients by chance to work with either a professional or a peer care manager. The team trained all care managers. Care managers met with each patient during or shortly after their ER visit. Care managers talked with patients about barriers to getting care. They helped patients set goals to overcome those barriers. Patients and care managers also talked about their roles in the recovery process. Care managers met with patients monthly for five months and then called every month for six months.
To see how often patients received care after leaving the ER, the research team looked at patient health records up to six months.
Patients, healthcare providers, health insurers, and patient advocates helped plan and conduct the study.
What were the limits of the study?
Fewer people enrolled in the study than planned. Findings may have differed if more people had enrolled in the study. ERs differed in what peer managers could do and how they were supervised, which may have affected the results. Because the study didn’t compare professional and peer care management with usual care, the research team can’t say for sure if care management or something else led to follow-up visits.
Future research could look at reasons, like differences in training, for differences in how care managers provided care.
How can people use the results?
Healthcare providers can use the results when considering ways to help people with mental health problems get follow-up care after leaving the ER.
To assess the effectiveness of two types of mental healthcare management in predicting rates of follow-up outpatient care after a mental health-related visit to the emergency department (ED)
|Design||Randomized controlled trial|
|Population||326 adults ages 18 and older admitted to 1 of 8 EDs for a mental illness|
Primary: at least one outpatient visit at a community mental health center within 30 days after ED discharge
Secondary: proportion of outpatient visits attended, number of ED readmissions, number of all-cause inpatient admissions within 6 months of ED discharge
|Timeframe||30-day follow-up for primary outcome|
This randomized controlled trial compared how care management delivered by professional versus peer care managers predicted rates of follow-up outpatient mental health care. Professional care managers included nurses, social workers, or counselors. Peer care managers were people recovering from a mental illness. All care managers received training to deliver the Coordination, Access, Referral and Evaluation intervention, a care management program designed to improve patient follow-up and treatment engagement in outpatient mental health settings.
Researchers randomly assigned either a professional or a peer care manager to patients upon admission to the ED for a mental illness or within 48 hours of discharge. An initial follow-up visit took place at a community mental health center within two weeks of discharge. Care managers worked with patients to examine the reasons for the ED visit, identify barriers to care, and review patient and care manager roles in the recovery process. Monthly follow-ups occurred in person for the next five months and via phone for six months after that. Care managers monitored patients’ follow-up outpatient care and helped patients set goals to overcome barriers to care.
The study included 326 adults who had been admitted to one of eight EDs in South Carolina for a mental illness. Of the patients, 53% were White, 40% were Black, and 7% were another race; 19% were Hispanic. The average patient age was 35, and 54% were male.
To assess outcomes, researchers reviewed health records from the state’s integrated data system six months after study enrollment.
An advisory board comprising healthcare providers, health insurers, and patient advocates assisted with study planning and implementation. Patients, advocates, and policy makers oversaw day-to-day study activities.
Compared with patients who saw peer care managers, patients who saw professional care managers were more likely to have at least one outpatient visit within 30 days after ED discharge (55% vs. 43%, p=0.03).
Patients in the two care manager groups did not differ significantly in the number of follow-up visits they attended or new admissions to the ED or a hospital within six months.
The sample size was smaller than planned. Findings may have differed if more patients had enrolled in the study. Differences in practice and supervision requirements for peer managers across sites may have affected care managers’ ability to link participants with outpatient services, leading to variation across sites. Without a control group receiving usual care, this study cannot establish with certainty that care management, regardless of provider type, facilitated follow-up outpatient care after ED discharge.
Conclusions and Relevance
In this study, professional care managers achieved higher rates of outpatient follow-up care after discharge from the ED than peer care managers.
Future Research Needs
Future research could further examine reasons behind differences in care quality or outcomes, such as variations in training or scope of practice.
Final Research Report
View this project's final research report.
Related Journal Citations
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:
- The reviewers noted that although the study went through modification of the study aims and analyses due to poor accrual and follow-up rates; the researchers did not seem to consider the study modifications in their rationale for the project. The researchers modified the background of the final report to better explain the importance of sociodemographic and contextual factors in developing interventions for postemergency department follow-up mental health care, aligning the background section better with the rest of the report.
- The reviewers expressed concern about the reporting and handling of missing data, noting that the quantitative portion of the study began with 326 participants but only 316 were in the data analysis, suggesting a violation of the intention-to-treat principle of analysis. The researchers explained that after participants provided informed consent and were assigned to one of the two study arms, 10 informed consent forms were not returned to the study team from the emergency departments where the researchers recruited the patients from, so these 10 patients could not be included in either the intervention or analysis.
- The reviewers said it was not clear how the study integrated findings from its quantitative and qualitative portions. The researchers said that for their revised protocol, the qualitative portion of the study focused on what in general helped or hindered patients’ engagement with treatment after emergency department discharge, rather than focusing on how the effect of the type of provider who helped serve as an intermediary to future services. The researchers said it was not possible to formally integrate findings from the qualitative and quantitative study components because the quantitative intervention was complete when the modified qualitative protocol was developed.
- The reviewers asked how the study handled missing data at the six-month point for the number of emergency department readmissions and inpatient visits and asked what strategies researchers used to promote study retention. The researchers said that they used statistical techniques, including multiple imputation, to account for the missing data but said there were no significant differences between patients with and without missing sixth-month data.
- For the qualitative portion of the study, the reviewers asked if the variation in interview length, 15-60 minutes, was a problem. The researchers said they were limited by the time that participants were able to provide, but the researchers felt that they had enough participant interviews to reach thematic saturation, despite the interviews’ short length.
Conflict of Interest Disclosures
Patient / Caregiver Partners
No information provided by awardee.
Other Stakeholder Partners
- Meera Narasimhan, University of South Carolina
- John Magill, South Carolina Department of Mental Health
Study Registration Information
- Has Results