Readmission of Schizophrenic Patients: A Critical Issue in Mental Healthcare

Schizophrenia is one of the most common mental health conditions that is associated with various psychological symptoms. One symptom, hallucinations, is when an individual perceives things that do not exist in reality. Schizophrenic patients frequently exhibit a range of delusions accompanied by drastic changes in their behavior. Despite the psychiatric deinstitutionalization policies being solidified in mental health care (to keep psychiatric patients, like schizophrenic patients away from the hospital) the phenomenon of psychiatric readmission poses challenges to the deinstitutionalization policy (Machado, 2012).

The high readmission rate of psychiatric patients in general and schizophrenic patients, in particular, is a huge challenge that the mental health professionals experience. According to Baindera et al. (2003) & Lay et al. (2006), this development is what some call a revolving door,' while others have termed these patients to be frequent users. In a study by the Agency of Healthcare Research and Quality, and Hospital readmissions involving psychiatric disorders as cited by Healthcare cost and utilization project (HCUP,2015) completed in the past 30 days, 15.7 percent of initial inpatient stays for schizophrenia were readmitted with a principal diagnosis of schizophrenia. 18.6 percent were readmitted with any diagnosis of schizophrenia, and 22.4 percent were readmitted for any cause.

To portray the extent of this issue of repeated hospitalization, there has been the belief that this issue of readmission characterizes a new form of institutionalization. One cannot ignore that this issue can pose serious clinical consequences for the patients, who may suffer from a condition of institutionalism. Muramoto (as cited by Machado, 2012), revealed that patients who are frequently readmitted might suffer from a series of functional, social, and psychological losses. In addition, this situation, which may be a recurring pattern for patients, results in lack of mental health services and networks.

Burning Clinical Issue

As a psychiatric nurse for almost five years and two years of experience at a city hospital in North Central US, I have seen that many schizophrenic patients are admitted to the hospital. Currently, there is a high rate of readmission of these patients. However, it has been noted that there is no plan to address why the rate of admission is high. Even so, there is the need to question why there is documentation of the readmission rate, but there is no intervention to manage the rate of readmission. Bringing the issues to attention is particularly important considering the frequent readmission patterns of these patients can lead to psychological trauma, deterioration of their condition, and lack of mental health services and networks.

It is paramount that we address the issue as to why providers are not in line with the American Psychiatric Association (APA) guidelines for the treatment of schizophrenia. Kross (2016), revealed that clinician adherence to clinical practice guidelines in schizophrenia remains suboptimal, and uncertainty exists regarding how best to implement guidelines for maximum benefits. According to the APA guideline for schizophrenia, long-acting injectable medications (LAIs) are thought to be especially helpful in the stabilization and stable phase of schizophrenia. The use of long-acting injectable helps to improve adherence, which is a critical issue during the stable and stabilization phase. The APA recommends that patients with recurrent relapses, related to nonadherence, are candidates for a long-acting injectable antipsychotic medication, as are patients who prefer this mode of administration.

The subject is relevant in the current practice as it is vital that the practice promotes positive patient outcomes and is evidence-based. In addition, the practices must be in line with the recommended practice guideline and regulations. Recently, hospital readmission rate has been used to measure the quality of care provided by hospitals. Medicare reports spending 17.8 billion dollars on readmission of patients whose readmission could have been prevented (Center of Medicare and Medicare, 2012). As a result, Medicare established an admission readmission program that was effective on October 1st, 2012. If it is possible to prevent readmission of schizophrenic patients, it is necessary that the practice should be established.

Already, researchers have identified that if schizophrenic patients adhere to LAI medication, the rate of relapse and readmission will decrease. According to Kane et al. (2013), many chronic diseases, such as psychotic disorders like schizophrenia, affect patients who suffer from enormous problems in medication adherence. Such effects lead to countless avoidable emergency room visits and days in the hospital, as well as suboptimal overall outcomes. In addition, Kane et al. (2013) further mentioned that approximately 50% of patients suffering from chronic illnesses are not taking medication as prescribed after six months and about 70% of patients who have schizophrenia will relapse within the year of their medication. In addition, long-acting injectable antipsychotics are theoretically very powerful tools for assuring adherence and signals non-adherence (Kane et al., 2013). Hence the formation of this PICOT educates providers on the management of schizophrenia.

Provider PICOT

For psychiatric providers in a output clinic or in the hospital within North Central US, who provide care for patients with schizophrenia at the age of 18 and older, (p) will present a comprehensive, evidence-based practice as an educational program to address the use of long acting injectable antipsychotics (I), increase the number of patients offered long acting injectable medications compared to the use of oral antipsychotics (c), decrease the rate of hospital readmission as noted in a chart review (o) over a six-month period (T).

It is necessary that as we seek a change in providers behavior to improve patient outcomes. However, we also should look at what patient behaviors could be changed to achieve an improved outcome. An appropriate outcome for patients would include being compliant with the medications/ treatment ordered by the provider, which plays an important role to decrease rates of readmission.

Patient PICOT

Will schizophrenic patients age 18 years or older, who are admitted in a city hospital in the North Central US (P), who received an evidenced-based, educational program from providers and staff on the need for medications and the improved health outcomes for patients who use LAIs to adhere in present practice with Long acting Injectable antipsychotics (I), compared to treatment with oral antipsychotics (c), will accept the use of LAIs and will have decrease in readmission rates noted in their charts (O) over a period of six months (T)?

LITERATURE REVIEW

Research databases, such as University of Michigan-Flint Summons, CINAHL, PubMed, National Center for Biotechnology Information (NCBI), Biomed Central, and ProQuest were utilized to obtain information about the PICOT questions. The advanced search was utilized to ensure that the search results yielded recent articles with high relevance to the research question (if LAI will help reduce readmission rate). The keywords searched were Long-acting antipsychotics, oral antipsychotic, schizophrenia medications, readmission rates, and quantitative research.

The results yielded in CINAHL, PubMed, Biomed Central did not relate to the PICOT question. However, the other databases yielded both primary relevant sources and relevant non-primary sources. At this point, I had to focus on the University of Michigan-Flint Summons, and then I categorized my search by changing the search options to eliminate results that were older than five years and to show results that are full text online. Sixteen articles came up, and I chose five articles that I believe to have more information that will help answer the PICOT question stated above. I will be discussing the two articles in detail. I also chose a few other articles to support my paper. The Melnyk & Fineout-Overholt (2011) level of evidence was utilized to assign the level of evidence to the two chosen articles.

The article reviewed for this paper was written by Barrio et al. (2013), titled Effectiveness of long-acting injectable risperidone versus oral antipsychotics in the treatment of recent-onset schizophrenia. The article is a case-control study, according to Melnyk & Fineout-Overholts (2011) level of evidence. It discusses the efficacy of LAI, adherence to medication regimens as a major issue a for schizophrenic patients, and the importance of long-acting improved injectable Risperidone in helping to promote adherence that in turn promotes schizophrenic patients outcomes and prevents readmission. Nine authors were involved in the research. The authors are clinical experts in psychiatry and neuroscience.

Schizophrenia, Non-adherence, and Remission

According to Zimmermann et al. (2011), schizophrenia is a severe and chronic psychiatric disorder with a variable course that requires long-term treatment to achieve and maintain remission. One of the major challenges identified by the authors in the treatment of schizophrenia is the issue of medication non-adherence.

Valenstein et al. (2013), stressed that medication adherence had been studied as an issue since the first steps in the pharmacological treatment of the disease were taken. In addition, the authors pointed out that previous studies have shown that 50% of patients with schizophrenia take less than 70% of their prescribed doses, making nonadherence rates in schizophrenia one of the highest compared with other chronic psychiatric conditions (Kardas, 2011). This causes major concern as extensive evidence suggests that nonadherence is the greatest predictor of relapse in first-episode psychosis (Perkins, 2002). The authors revealed that in line with the above subject, a recent meta-analysis found that nonadherence among first-episode psychosis increased the risk of relapse four-fold leading to readmission (Barrio et al., 2013).

Efficacy of LAI in Decreasing Readmission Rates

Zimmermann et al. (2011) carried out a research study on all schizophrenic patients on their psychiatric unit from 2004 to 2008 who were on long-acting injectable Risperidone and were followed for two years. The control group was made up of 26 patients with schizophrenia that were selected from their unit. The control group was matched with the same qualities in terms of gender, marital status, age, etc. as the intervention group. The Positive and Negative Syndrome Scale (PANSS), Personal and Social Performance Scale (PSP), Remission in Schizophrenia Working Group (RSWG) were variables to be measured. After 2 years the variables related to efficacy of the antipsychotic treatment were collected which includes The Positive and Negative Syndrome Scale (PANSS), Personal and Social Performance Scale (PSP), hospital readmission and illness remission according to the symptom-based criteria proposed by the Remission in Schizophrenia Working Group (RSWG) from 2004 to 2008.

The data were analyzed using SPSS (Version 19.9 for Windows; SPSS, Inc., Chicago, Illinois, USA) and results demonstrated that there was a statistical significance (p< 0.05) between the two groups in terms of PANSS score and PSP score. There was no statistically significant difference between the two groups looking at the variable of hospital readmission and illness remission according to the symptom-based criteria, but two times fewer readmissions were seen in the intervention group as the control group.

The other article reviewed by Kane et al. (2013), titled No...