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Best Practices

Created on December 05, 2017

“Insanity is doing things the way we’ve always done them and expecting different results.”
Albert Einstein

Hospital readmission rates for a mental illness or an addiction is a priority indicator for the Quality Improvement Plans (QIPs). This indicator measures the rate of psychiatric (mental health and addiction) discharges that are followed within 30 days by another mental health and addiction admission.

Below are best practices for managing and improving this indicator. They are graded according to Type of Evidence. Evidence-informed best practices are based on high-quality evidence; they can optimize outcomes and should be implemented into practice where possible.

To help you move from best evidence to best practice, you can refer to:

Or browse the interactive table below for some key change ideas on how to improve readmissions for mental illness or an addiction.

  1. Baiden P; den Dunnen W; Stewart SL. (2013).
    Discharge of adolescents with mental health problems against medical advice: findings from adult mental health inpatient facilities across Ontario, Canada.
    Psychiatry Research. 210(3):1161-1167.

  2. Barron, Gary R S.(2016).
    The Alberta Mental Health Act 2010 and Revolving Door Syndrome: Control, Care, and Identity in Making up People.
    Canadian Review of Sociology. 53(3):290-315.

  3. Bradshaw LE; Goldberg SE; Lewis SA; Whittamore K; Gladman JR; Jones RG; Harwood RH. (2013).
    Six-month outcomes following an emergency hospital admission for older adults with co-morbid mental health problems indicate complexity of care needs.
    Age & Ageing. 42(5):582-588.

  4. Canadian Institute for Health Information (CIHI).
    Depression in Ontario: What Predicts a First Mental Health Rehospitalization?
    Ottawa, ON: CIHI; 2010.

  5. Canadian Institute for Health Information (CIHI).
    Health Indicators Interactive Tool.
    Ottawa, ON: CIHI; 2016.
    Retrieved from: https://yourhealthsystem.cihi.ca/epub/?language=en

  6. Figueroa JF; Joynt KE; Zhou X; Orav EJ; Jha AK. (2017).
    Safety-net Hospitals Face More Barriers Yet Use Fewer Strategies to Reduce Readmissions.
    Medical Care. 55(3):229-235.

  7. Government of Canada.
    The Human Face of Mental Health and Mental Illness in Canada.
    Minister of Public Works and Government Services Canada, 2006.
    Retrieved from: http://www.phac-aspc.gc.ca/publicat/human-humain06/pdf/human_face_e.pdf

  8. Greenwald JL; Cronin PR; Carballo V; Danaei G; Choy G. (2017).
    A Novel Model for Predicting Rehospitalization Risk Incorporating Physical Function, Cognitive Status, and Psychosocial Support Using Natural Language Processing.
    Medical Care. 55(3):261-266.

  9. Guerin K. (2010).
    Factors affecting mental health readmissions.
    Canadian Medical Association Journal: 182 (7); E291.

  10. Health Quality Ontario (HQO).
    Taking Stock a report on the quality of mental health and addictions services in Ontario.
    Toronto, ON; 2015.
    Retrieved from: http://www.hqontario.ca/Portals/0/Documents/pr/theme-report-taking-stock-en.pdf

  11. Hinami K; Smith J; Deamant CD; DuBeshter K; Trick WE. (2015).
    When do patient-reported outcome measures inform readmission risk?
    Journal of Hospital Medicine (Online). 10(5):294-300.

  12. McAnanama EP; Rogosin-Rose ML; Scott EA; Joffe RT; Kelner M. (1999).
    Discharge planning in mental health: the relevance of cognition to community living.
    American Journal of Occupational Therapy. 53(2):129-135.

  13. Richards B; Madden B; Cockburn T. (2015)
    Untangling the surrogacy web and exploring legal duties following the discharge of mental health patients.
    Journal of Bioethical Inquiry. 12(1):25-29.

  14. Sarwer DB. (2014).
    Decreasing readmission through psychological evaluation and treatment. [Review].
    Surgery for Obesity & Related Diseases. 10(3):389-391.

  15. Simpson A; Flood C; Rowe J; Quigley J; Henry S; Hall C; Evans R; Sherman P; Bowers L. (2014).
    Results of a pilot randomised controlled trial to measure the clinical and cost effectiveness of peer support in increasing hope and quality of life in mental health patients discharged from hospital in the UK.
    BMC Psychiatry. 14:30.

  16. Vigod SN, Kurdyak PA, Dennis CL, Leszcz T, Taylor VH, Blumberger DM, et al. (2013).
    Transitional interventions to reduce early psychiatric readmissions in adults: systematic review.
    British Journal of Psychiatry: 202(3):187-194.

  17. World Health Organization.
    Global Burden of Mental Disorders and the Need for a Comprehensive, Coordinated Response from Health and Social Sectors at the Country Level.
    Report by the Secretariat for the Sixty-fifth World

  18. Health Assembly (document A65/10).
    Geneva: World Health Organization, 2012.
    Retrieved from: http://apps.who.int/iris/handle/10665/78898

Measurement

Created on December 05, 2017

“While all changes do not lead to improvement, all improvement requires change”
Institute for Healthcare Improvement

How do we know if a change is an improvement? Measurement is a critical step in QI to assess the impact of a change. Quality indicators are used in the QIPs to measure how well something is performing. There are three types of quality indicators used to measure QI efforts:

  • Outcome Indicators: capture clinical outcomes and or system performance,
  • Process Indicators: track the processes that measure whether the system is working as planned, and
  • Balancing Indicators: ensure that changing one part of the system does not cause new problems in another.

Indicator

Hospital readmission rates for a mental illness or an addiction

Topic Mental Health and Addiction
Quality Dimension Effective
Type of Indicator Outcome
Measure Rate per 100 discharges
Data Source Discharge Abstract Database (DAD), Ontario Mental Health Reporting System (OMHRS), Registered Persons Database (RPDB)
Data Collection Instrument Data provided to HQO by the Ministry of Health and Long-Term Care (MOHLTC)
How to Calculate The # of patients readmitted within 30 days of discharge divided by the number of patients discharged during the study period.
Target Lower is better
Range 0 – 100%
HQO Reporting Tool Quality Improvement Plans (QIPs)

This data can be presented using Run Charts to track improvement over time. To read more about general measurement in QI refer to Measurement for Quality Improvement or the QI Getting Started Section.

Tools & Resources

Created on December 05, 2017

Health Quality Ontario’s Tools and Resources


Other Tools and Resources

Mental Health and Addictions
Transitions

Background

Created on December 05, 2017

Issue

Ontarians can access mental health and addictions services through various types of providers in the community, in the primary care setting and in hospitals. A wide range of services are provided in the community, but data are not systematically collected on the effectiveness of these services and supports. Being admitted to a hospital for a mental illness can be very disruptive to an individual’s life and can be one of the most expensive forms of hospital based treatment (CIHI, 2010). A 30-day readmission for mental health or an addiction can occur due to issues such as poor access to adequate community-based aftercare and/or challenges in medication adherence and self-care (Vigod et al. 2013). The majority of readmissions happen from general rather than psychiatric facilities (CIHI 2010; Guerin, 2010) and is generally indicative of a negative clinical outcome or lack of services (CIHI 2010; Vigod et al. 2013).


Call to Action

In Ontario, about five people per 1,000 are hospitalized for a mental illness or addiction in a year, a rate that has remained relatively stable in recent years, and more than 12% of people admitted to hospital for mental illness or addiction get readmitted within 30 days (CIHI 2016; HQO 2015). When considered by diagnosis (Figure 1) we see that schizophrenia / psychosis have the highest readmission rate within 30 days at 12.5% followed by mood disorders (9.3%), anxiety disorders (7.9%) and substance abuse (7.4%) (HQO 2015).

FIGURE 1. Hospital readmission rate within 30 days for a mental illness or addiction per 100 population aged 16 years and older, by diagnosis, in Ontario, 2012/13

Source : Discharge Abstract Database, Ontario Mental Health Reporting System, National Ambulatory Care Reporting System, Registered Persons Database and Citizenship and Immigration Canada Database, provided by the Institute for Clinical Evaluative Sciences.

If people do not have access to needed supports and care in the community after being hospitalized, they could end up being readmitted to hospital. Better understanding the risk factors associated with hospital readmission among those who have mental health issues and/or addictions problems can help to identify the most vulnerable individuals and can facilitate system-level management and treatment planning over the course of the illness (CIHI 2010; HQO 2015).

  1. Canadian Institute for Health Information (CIHI).
    Depression in Ontario: What Predicts a First Mental Health Rehospitalization?
    Ottawa, ON: CIHI; 2010.

  2. Canadian Institute for Health Information (CIHI).
    Health Indicators Interactive Tool.
    Ottawa, ON: CIHI; 2016.
    Retrieved from: https://yourhealthsystem.cihi.ca/epub/?language=en

  3. Guerin K. (2010).
    Factors affecting mental health readmissions.
    Canadian Medical Association Journal: 182 (7); E291.

  4. Health Quality Ontario (HQO).
    Taking Stock A report on the quality of mental health and addictions services in Ontario.
    Toronto, ON; 2015.
    Retrieved from: http://www.hqontario.ca/Portals/0/Documents/pr/theme-report-taking-stock-en.pdf

  5. Vigod SN, Kurdyak PA, Dennis CL, Leszcz T, Taylor VH, Blumberger DM, et al. (2013).
    Transitional interventions to reduce early psychiatric readmissions in adults: systematic review.
    British Journal of Psychiatry: 202(3):187-194.