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Multidisciplinary Team Investigates a TCM for Persons with Serious Mental Illness

Transitional Care Model (TCM) applied to  population with serious mental illness for the first time

The period following discharge from the hospital is a vulnerable time for patients. When hospital-to-home transitions are poorly handled, they result in hospital readmissions with an estimated annual cost of more than $40 billion, according to the Agency for Healthcare Research and Quality

​​People with multiple and persistent mental and physical health problems have high rates of hospital transition failures. New research points to needed modifications in the transition care model that could effectively accommodate the intense psychosocial needs of those with serious mental illness.

“Coordination of care during transition from hospital to home for a person with an acute psychiatric illness is a complex phenomenon, particularly for patients with comorbid medical conditions. Our research indicates that a transitional team approach that includes a psychiatric nurse practitioner, a social worker, and a peer support would provide the support needed for successful hospital to home transitions for these patients,” explains Nancy Hanrahan, PhD, RN, CS, FAAN, Associate Professor of Nursing.

Dr. Hanrahan’s research, “A Pilot Randomized Control Trial: Testing a Transitional Care Model for Acute Psychiatric Conditions,” has been published in the Journal of the American Psychiatric Nurses Association and is the first to study the transitional care model in the population with serious mental illness. The research team included Phyllis Solomon, PhD from the University of Pennsylvania  Social Policy and Practice School, and Matthew Hurford, MD, Philadelphia Department of Behavioral Health and Intellectual Disability Services and the University of Pennsylvania School of Medicine

Dr. Hanrahan is a national leader in psychiatric mental health nursing and known for her work documenting the psychiatric nurse workforce and her expertise in system-level mental health services research. She is a faculty member in the Center for Health Outcomes and Policy Research at Penn Nursing, as well as a Senior Fellow of the Leonard Davis Institute of Health Economics at the University of Pennsylvania. Dr. Hanrahan is involved with state and national policy initiatives such as parity, quality indicators, creating a web-based advanced practice psychiatric nurse employment guide, and reviewing Rural-Urban Continuum Codes for reimbursement.

 
UPfront Magazine Fall 2014  

UPfront Magazine
Fall 2014