Adapting Critical Time Intervention to Support Inpatient Medical Care Transition

For adults with schizophrenia, the transition from hospital inpatient to outpatient care
poses substantial risks of treatment disengagement. Traditional case management approaches
for patients with schizophrenia have involved telephonic follow-up after discharge from
inpatient mental health care and have yielded poor results. Much less information exists
regarding outcomes for patients with schizophrenia discharged following inpatient medical
care. Given that these patients often have difficulty accessing and adhering to medical
treatments, patients with schizophrenia who are admitted to a hospital for treatment of a
medical condition are especially vulnerable to failed care transitions. Intensive
interventions involving home visits, social support, motivational interviewing, and
accompanying patients to outpatient appointments have shown positive results for patients
discharged following inpatient mental health care, and may therefore be effective for
patients with schizophrenia discharged following inpatient medical care. Critical Time
Intervention (CTI) is a novel evidence based time-limited intervention that involves ongoing
community-based contacts with patients from trained care managers to facilitate connections
to aftercare providers and community and support systems following hospital discharge. This
pilot study will adapt CTI for use with patients with schizophrenia who are admitted to one
of 2 safety net hospitals in Bronx, New York, for treatment of ambulatory care sensitive
conditions (medical conditions for which appropriate ambulatory care should limit the need
for inpatient treatment). We will randomize 80 eligible inpatients to receive either: 1)
treatment as usual (TAU) (n=40); or 2) CTI and TAU (n=40). During a 3-month period prior to
randomization, an Adaptation Team of research and hospital staff will review data from
qualitative interviews of clinical staff and patients to identify factors likely to
facilitate and impede CTI implementation. The team will then adapt the CTI to increase the
likelihood of successful implementation. In the randomization phase, participants assigned to
CTI will meet with a CTI care manger during their inpatient stay and over a 3-month period
following hospital discharge. CTI care managers will assess and address patient needs and
barriers to outpatient medical and mental health care and provide support and assistance with
medical and mental health care management. For quantitative analyses, the primary outcome
measures will be all-cause hospital readmissions at 7 and 30 days following discharge.
Secondary outcomes will include follow-up with medical and mental health outpatient care at 7
and 30 days following hospital discharge. Patients receiving CTI will also be assessed to
evaluate satisfaction with CTI services, psychiatric symptoms, community function, and
involvement in medical care decisions. The proposed study will test whether a time-limited
novel intervention helps overcome common barriers to adherence with outpatient medical and
mental health care and reduces hospital readmissions for a vulnerable population.

Inclusion Criteria:

- Age 21 to 64 years old

- Diagnosis of schizophrenia

- Admitted to medical unit at collaborating hospital

- Admission diagnosis of Ambulatory Care Sensitive Condition

Exclusion Criteria:

- Not enrolled in Healthfirst Medicaid Managed Care plan for 12 months prior to
admission