Patients with mental disorders are among the highest users of emergency department (ED) services, with visits characterized by long lengths of stay, intensive treatment, and elevated rates of hospitalizations. After discharge, fewer than half of these patients successfully transition to outpatient care, with high rates of readmission to the ED. Programs that allow patients with mental disorders to successfully engage with outpatient care hold the potential not only to improve quality and outcomes of care for people with mental disorders, but also to free capacity within EDs to provide care for other urgent needs. Care management programs can facilitate care engagement in people with mental illness after ED discharge. However, it has been difficult to disseminate these models more broadly. One reason for this challenge has been a shortage of mental health professionals who can serve in these roles. There is now an opportunity to improve care and fill these gaps with a new provider group, certified peer specialists—persons with a history of mental illness offering services to other individuals with mental illness. This study examines the potential benefits and trade-offs between certified peer specialists and professionals (nurses, social workers, and counselors) in managing care transitions for patients with mental disorders after ED discharge. We also aimed to study other patient and community factors that predict successful treatment engagement.
The original study aims were to (1) compare rates of treatment engagement achieved by certified peer care managers vs those achieved by professional care managers; (2) compare clinical outcomes between the 2 groups; and (3) examine treatment heterogeneity between the 2 groups, with a focus on whether patients presenting with different types of barriers to engagement demonstrate differential benefits across provider types. Due to accrual challenges and low follow-up rates, a decision was made to end the study early, to rely on administrative data for exploratory study outcomes, to modify the qualitative aim, and to reduce the target enrollment for the study from 1000 to 290. The study aims were modified as follows: Aim 1, use quantitative data from the randomized study sample to assess factors including care manager group (peer vs professional) predicting patient engagement after a mental health ED visit; and aim 2, use qualitative interviews with patients and providers to understand stakeholder perspectives on patient engagement after a mental health ED visit.
AIM 1: Eligible participants across 8 sites in South Carolina who were scheduled to be discharged from an ED visit to a participating community mental health center (CMHC) were randomly assigned at the individual level to either a professional care manager (nurse, social worker, or counselor) or a peer care manager. All care managers delivered an adapted version of a 1-year, manualized, evidence-based care management program for patients with mental illnesses. The program has been demonstrated to improve the quality and outcomes of care. This intervention supports patient engagement and care coordination. To assess factors that predicted patient engagement after the ED visit, including care manager group (peer vs professional), we used bivariate and multivariate hierarchical linear models to examine patient, provider, and community predictors of engagement in care. The primary study outcome was at least 1 outpatient clinic visit for a mental health problem in the 30 days after ED discharge. Secondary outcomes were the proportions of outpatient visits attended, ED readmissions, and all-cause inpatient admissions in the 6 months after ED discharge. AIM 2: For the qualitative aim, purposive sampling was used for patients and care managers. Randomized trial participants who had completed a 6- or 12-month follow-up survey were invited to take part in an in-depth interview. All active care managers were invited to participate in an interview. A total of 45 semistructured interviews with patients (n = 30 interviews) and care managers (n = 15 interviews) assessed barriers and facilitators to engagement with outpatient services at the patient, provider, and health care services levels as well as the use of strategies to promote engagement in treatment. Thematic analysis was used to identify themes at each of the 3 levels.
A total of 326 participants were randomly assigned to either peer specialists or professionals; 316 participants had data available for analysis. There was a significant difference in the rates of 30-day follow-up between the 2 intervention groups, with participants assigned to professionals being significantly more likely to have successful transitions to outpatient care than those assigned to peers (55% vs 43%; = .03). Peers had greater rates of turnover and wider variability in rates of outpatient follow-up than did professional care managers. In multivariable models, a range of demographic (age, gender), clinical (mental health diagnosis and comorbid substance use), and geographic (rurality, distance from the participating CMHC) factors were associated with different measures of treatment engagement. The qualitative aim found several determinants of successful transitions from the ED to outpatient care, including transportation challenges, patients' openness to receiving care, financial insecurity, and severity of mental health symptoms.
By identifying patient-, provider-, and system-level barriers, this study highlights the importance of providing services to support the transition to outpatient mental health care after discharge from the ED. On average, professional care managers had higher rates of 3-day outpatient follow-up than did peer care managers; in addition, peer care managers had higher rates of job turnover and variable performance across individual peer care managers. Additional research is needed to help identify barriers and develop strategies for optimizing care transition interventions across provider disciplines.
The early study termination precluded the opportunity to collect and analyze data for patient-reported outcomes and to qualitatively examine the components of the intervention. Other factors, including turnover of peer care managers and variability in the local clinic scope-of-practice rules, also limited our ability to draw definitive conclusions about the differential effectiveness of peers vs professionals in facilitating treatment engagement.
