Transitional Care Clinics Aim to Reduce ED Visits for Mentally Ill Patients

Emergency departments (EDs) are a common destination for people with serious mental illness (SMI), even though these urgent care settings are costly and overburdened. Some healthcare systems are implementing transitional care clinics (TCCs) to help keep these mentally ill patients out of the ED.

Last month, a poll by the American College of Emergency Physicians (ACEP) found that a concerning amount of emergency physicians reported that psychiatric patients faced long wait times and a shortage of inpatient beds. More than half (52%) of the ED doctors surveyed said that the mental health system where they practice has worsened in the past year, and 21% said patients stay in the ED for 2 to 5 days waiting for an inpatient bed.

“Psychiatric patients wait in the emergency department for hours and even days for a bed, which delays the psychiatric care they so desperately need,” said Rebecca Parker, MD, FACEP, the president of ACEP, in a press release announcing the poll findings. “It also leads to delays in care and diminished resources for other emergency patients. The emergency department has become the dumping ground for these vulnerable patients who have been abandoned by every other part of the health care system."

In response, some healthcare systems have turned to TCCs to help alleviate the burden on EDs. As its name suggests, the TCC is a short-term resource targeting patients with SMI after they have been discharged from a hospital but before they can find regular mental healthcare, which can sometimes take weeks or months.

One example is the TCC at the University of Texas Health Science Center at San Antonio. In this program, clinic appointments are scheduled while patients are still in the hospital, and most occur within a few days of discharge. Patients then meet with psychiatrists who prescribe medication and counselors who make home visits. During these visits, the therapists use cognitive adaption training to teach skills that can help patients adhere to their medication regimen or perform other daily tasks. Care coordinators also help patients access community-based resources that provide insurance, housing, or other social services.

So far, there is some evidence that the TCC model keeps patients with SMI out of the ED. A study in the Community Mental Health Journal found that having a TCC appointment within 3 days of discharge was associated with significantly longer time in the community without returning to the ED.

In addition, the TCC in San Antonio is experimenting with an intervention that includes shared decision making (SDM), which engages patients by asking about their personal goals, discussing treatment options, and providing educational resources to help them make decisions about their own care. In 2013, the clinic was awarded a $1.3 million study grant from the Patient-Centered Outcomes Research Institute. The study will compare the outcomes for patients receiving standard care and those receiving engagement-focused treatment, which emphasizes SDM principles.

The results of the study have not yet been published, but researchers hypothesize that patients receiving the SDM intervention will exhibit greater quality of life, attendance at appointments, and involvement in decision making, compared to the patients receiving standard care. According to a description of the study, engagement-focused treatment is designed to reduce rehospitalizations by teaching recently discharged individuals with SMI “how to be good consumers of mental health treatments going forward.”