Health care utilization and cost after discharge from a mental health hospital; an RCT comparing community residential aftercare and treatment as usual

Most psychiatric inpatients can be discharged without comprehensive follow-up, yet patients with severe mental illness (SMI) often need long-term aftercare [1]. This is a particularly vulnerable group, as patients with SMI have a 10–25 year shorter life expectancy than the general population [2]. Furthermore, a Danish population-based cohort study found increased risk of hospitalisations and rehospitalisation within 30 days for patients with SMI compared with the general population [3].

The duration of hospital stays is a major driver for health costs [4] and most Western countries have shifted more mental health care towards community-based settings [5]. However, it is a challenge to provide timely community services for patients who are ready for discharge from mental health hospitals. A study in the UK in 2005 found that the proportion of discharges classified as “delayed” varied from 4 to 16% of all hospital beds [6]. A study from Norway in 2013 found that 7% of all patients in mental health hospitals were ready for discharge, but were still waiting for municipal services to take over, mainly to provide sheltered housing [7]. A review of 35 studies, mostly from general hospitals, on delayed discharge [8] found that the average cost of one extra day per patient was between £200 and £565.

Early psychiatric readmission serves as a negative quality of care indicator in the mental health services [9, 10]. Some studies report that short inpatient treatment stays (< 28 days) increase readmission rates [11‐13]. In contrast, a Cochrane review from six randomised studies did not find evidence suggesting that short-stay hospitalisation (< 28 days), compared to long stay (> 28 days), encouraged a ‘revolving door’ pattern of admission to hospital [14].

Community based residential mental health services can serve as an alternative to both inpatient admissions (step-up) and aftercare (step-down). A review from 2013 [15] evaluated such services for acute [16‐18] and sub-acute admissions (step-up) [19] and concluded that these step-up residential community services offered a cost-effective alternative to hospital based inpatient services. Similarly, a few studies have evaluated community-based services in the form of residential aftercare after hospital stays (step-down) [20‐23]. An RCT study on inpatient treatment for substance use disorders compared the effects of two types of community-based, residential treatment programs among justice involved persons with dual diagnosis and reported significant reductions in psychiatric severity for those assigned to residential conditions [23]. An observational study found that a staffed residential step-down facility with a comprehensive program improved symptoms and functioning for persons with psychosis or mood disorder [21].

Taken together, this indicates that patients ready for discharge could be discharged as early as possible to a community residential service, without the shorter stay leading to increased risk of readmission [14], and the costs would be reduced [8]. To make this happen for in-patients with SMI, there is a need for improved collaboration and communication between service levels [24, 25] as well as services that can receive patients who need community services after their hospital stay [20].

There is, however, still a need for studies on the effect and costs of residential aftercare services in the community. One type not previously investigated, is residential aftercare services that do not offer organised in-house activities. Offering organised in-house activities may substitute for future local activities and integration in the local community. Thus, not offering in-house activities could potentially help patients use community services more actively and promote more independent living. The reason being that the patients would have to orient themselves more towards the activities in the community during the stay [26].

The aim of this RCT study was to investigate use of community and specialist mental health care services and costs in patients with severe mental illness (SMI) the first 12 months after discharge from a mental health hospital (MHH), comparing community residential aftercare (CRA) and treatment as usual.

This was an open parallel group randomised controlled trial including patients from January 2013 to April 2015. It was approved by the Committee for Medical and Health Research Ethics in Central Norway (2011/1770) and was registered in clinicaltrials.gov (NCT01719354).

This is the first RCT study on the effect of discharge for patients with SMI to a community residential aftercare facility (CRA) with no organised in-house activities or on-site treatment. The differences in utilisation and cost during 12 months were in favour of the intervention group, but mostly with p-values above the conventional cut-off p < 0.05. The confidence intervals were wide, meaning that there was imprecision in the estimates. Thus, no final conclusion on the effect of the CRA can be made based on this study.

However, the study gives indication of a potential effect of discharging patient in need of community aftercare to the CRA. The best estimates for this potential based on the present study is that it can reduce the use of hourly based community mental health services with 29% (22 h), with a cost saving of 29% (1845 EUR) for each patient compared to usual care. The total number of inpatient days for one year was the same (66 days), but the number of inpatient days in the mental health hospital was 54% (13 days) lower. Importantly, although using less services, the point estimate for the number of inpatient admissions and readmissions was respectively 18% (− 0.9 admissions) and 42% (− 0.8 readmissions) lower in the intervention group indicating at least no major worsening in the intervention group.

Considering possible mechanisms and explanations for the direction of the observed effect, it seems that the CRA is successful in facilitating independent living which, in turn, leads to less mental health service use. Even if a stay at the CRA does not reduce the total number of inpatient days during the first year, spending more time in residential aftercare service can leave room for better assessment of and subsequent alignment between the patients’ actual care needs in the community and the services offered. Another explanation can be that when the hospital staff communicate the care needs of the patient to the community services, they do so based on what they have seen during the hospital stay (observer bias) [30]. This can differ from the patients’ behaviour in a CRA setting where there are no in-house organised activities, and where, consequently, the staff can observe how the patient manages in a more home like setting. In addition, a stay in the CRA allows for more time in assessing and setting up the required level of services to support independent living. This is in line with the finding in an observational cohort study among six community residential alternatives compared to six standard acute wards [18], which found that patients having used the community alternative had more contact with community mental health teams, early intervention services and crisis teams.

Furthermore, the patient’s own role can be important, especially what the patients can learn and do differently after a stay at a “boring hotel” [26]. This study cannot answer whether the CRA might increase the patients’ contribution or abilities such as agency, responsibility, self-management, coping and empowerment. One way of looking at independence is by examining motivation and behaviour, as the CRA attempt to motivate the patients to adopt a more independent behaviour. The self-determination theory (SDT) can shed some light on this, as it claims to provide a universal framework for understanding the individual and environmental factors that shape motivation and subsequent behaviour [31]. According to SDT, motivation depends on the (lack of) support for three basic psychological needs: autonomy, competence, and relatedness. It does not seem to be fare fetched to suggest that these areas were strengthened; leading to the patients’ feeling more equipped to do self-care activities such as preparing their own meals, structuring their daily routines and introducing activities in their neighbourhood.

The chosen primary outcome, use of hourly based community health and social services, was chosen based on an assumption that discharge to the CRA would help identify the best level of service for each patient, which was expected to be lower than usual care. This does not imply that less use of community health and social services was a desired outcome by itself. The aim must be to balance the level of services to the patient’s needs. However, with the aim to promote independency among service users, the level of services should not be so high as to jeopardise this. To be almost self-reliant and be in command of one’s own life are basic rights that most humans takes for granted. Given the direction of the results in this study, pointing towards both less use of services and fewer re−/admissions for those randomised to the CRA, there are indications that having a strong community orientation in the discharge process can result in a service level promoting independency.

Even if both step-up [15‐19] and step down [20‐23] community residential services exist, none of the studies investigating the effects and costs are directly comparable to this study, as they offer in-house activities or treatment. However, according to these studies, there seems to be a clear indication that community residential services can reduce costs [17, 18, 20], similar to the point estimates found in this study of around 1/3 reduction: Byford et al. [17] found 22% lower total 12-month costs (£14,952 vs. £19,288), a UK based study by Slade et al. [18] reported 61% lower 12-month inpatient costs (£3832 vs. £9850) and Thomas et al. in Australia [20] found that the cost per day per client in the step-up step-down program was 32% lower ($517 vs. $758). The explanation for reduced costs in these studies and in our study, is chiefly due to reduced inpatient stays and use of specialist services.

We did not measure change in patients’ level of symptoms and functioning, but two other studies on community residential aftercare have done this [21, 23]. An observational study from Australia [21] found improvement in patients’ symptoms and functioning three months after discharge from the residential inpatient step-down unit. An RCT among justice involved persons [23] found a significant reduction in psychiatric symptom severity after two years in those who had been admitted to self-run community residential aftercare (Oxford House).

In this study, it was not possible to draw a definite conclusion about the effect, due to the small sample and imprecision of the estimates. The direction of the results and size of the point estimate, including findings in other studies, indicates that transferring patients ready for discharge from mental hospital to community residential aftercare without organized in-house activities has the potential to reduce total consumption of health services and costs without increased hospital admissions.