Postdisharge Follow-Up: Research and Practice Disconnect

In this month's issue Stein and colleagues show that only 30% and 49% of Medicaid-enrolled adults hospitalized for psychiatric care in one mid-Atlantic state received aftercare within seven and 30 days of discharge, respectively. African Americans, those with co-occurring disorders, and those discharged against medical advice had increased risk of lack of timely aftercare. The authors concluded, "Efforts to improve follow-up utilization should target higher-risk individuals while developing and evaluating interventions to address specific barriers among these groups."

These findings come as no surprise. Many studies have documented risk factors for poor aftercare, and broad searches of academic and "grey literature" still yield typical ranges from 41% to 96% for 30-day follow-up (even lower for seven-day follow-up)—values that vary unacceptably. Even so, in the context of performance report cards, some providers are reporting very high follow-up rates (up to 100% for the 30-day indicator).

There is a marked disconnect between research and practice here. Clearly some organizations have found ways to improve follow-up rates. However, only a few quality improvement projects are reported. They rarely describe how the aftercare levels were achieved, and rigor is suboptimal, limiting validity, generalizability, and opportunities for best practice dissemination. In addition, much research on the topic remains descriptive (analyses of administrative data); such studies are also very limited for illuminating the mechanisms that produce better follow-up. Although these analyses will continue to be helpful for monitoring, substantial improvement of practice will depend on rigorous studies of innovative interventions.

The attachment of timely aftercare to the performance imperative seems to have motivated improvement in some organizations but not all. We may also need to shift away from a focus on those "at risk" toward greater recognition that a psychiatric hospitalization is a very serious event, sufficient in itself to justify everyone's being seen within a short time after discharge, regardless of individual characteristics. It may be that we need to "up the ante" by attaching timely aftercare to the patient safety imperative. This is not unreasonable given the evidence that postdischarge suicides tend to cluster in the first week. For example, it may be necessary to define timely aftercare as a universal standard of care for all psychiatric admissions and to define failure to provide aftercare as a health care error (of omission). In research, we probably need to spend less time describing levels of and risk factors for poor aftercare and more time designing and testing innovative interventions aimed at ensuring universal follow-up for all persons admitted for a psychiatric illness and documenting their outcomes.