Abstract
Individuals with mental illness are considered a vulnerable population and are at an increased risk for all-cause 30-day inpatient readmissions. The risk for 30-day readmission is increased for individuals with mental illness and co-occurring cardiometabolic conditions compared to those without mental illness. The purpose of this quality improvement project is to reduce 30-day readmissions and improve continuity of care for patients with comorbid cardiometabolic risk in the inpatient psychiatric hospital setting. Patients participating in the Re-engineered Discharge Program (RED) were screened for metabolic syndrome (MetS) risk, if positive, they received a MetS education focused bridge strategy and primary care provider (PCP) follow-up care to address physical and mental health concerns post-discharge. Limitations allowed for the following data to be collected: (a) 30-day readmission rates, (b) positive or negative screen for MetS risk, and (c) interventions provided. In October 2020, 14 of those screened (N=51) met criteria, 13 received interventions, and one declined participation. In November 2020, 7 of the (N=35) project participants received interventions. Collected data did not show a relationship between project interventions and a reduction in 30-day readmissions. Data did show high rates of participation in project, 95% of individuals identified as high-risk participated in project interventions. The average wait time for a PCP appointment in the project site area was seven to ten days compared to six to eight weeks for an outpatient psychiatry appointment. The project PCP interventions will have a sustained future impact on improving continuity of care for patients as the interventions were adopted as a standard of care for all patients who enter the RED program.
Keywords: thirty-day inpatient psychiatric readmissions, metabolic syndrome, continuity of care