Pilot Aims to Help Seriously Mentally Ill People Make Successful Hospital-to-Home Transition

Written by Teddi Fine

For many people with a broad range of chronic illnesses, transitional care practices ease the move from hospital to home. But those practices don’t often benefit the many people living with serious mental illnesses—until now. Thanks to a team of Johns Hopkins University School of Nursing researchers, a new model is addressing how the special hospital-to-home challenges for people with severe mental illnesses, and for their families, can be better met.

According to the SON’s Linda Rose, PhD, RN, and her faculty colleagues Linda Gerson, PhD, RN, and Cynthia Carbo, MSN, BSN, reporting in the December 2007 Archives of Psychiatric Nursing, three elements are central to successful community transitions for seriously mentally ill patients:

• Staying on track with medications
• Finding meaningful work and social activities; and
• Maintaining good individual and caregiver physical health.

Their nurse-based, transitional care model focused directly on those core elements. Preliminary, primarily descriptive findings from the pilot study suggest that the model can help people with serious mental illness and their families improve successful hospital- to-home transitions.

In their conclusions, the researchers cautioned that the small sample size, coupled with the setting’s demographics and the potential idiosyncrasy of the nursing logs underscored the need for more extensive study on larger, more diverse populations. At the same time, however, Rose, Gerson and Carbo posit that, to succeed, a transitional care model needs to be flexible, able to create community service partnerships, and able to meet individualized needs of patients and their families. “We hope,” said Rose, “that further study will allow us to identify an effective intervention to address the needs and improve the quality of life for this often underserved and most vulnerable population.”