Programs for Care System Transitions in Mental Health: A Systematic Review

Background

Care transitions are a common feature of health care, but most occur within a single health care system. However, patients can also face transitions between systems when they experience life events such as a new job, a change in insurance providers, or a move between locations. These transitions can be especially complicated when patients leave an integrated health care system such as the Military Health System (MHS) and are required to manage their own care until they enter a new system. Navigating these transitions can be especially important for patients who need regular care, such as those with mental health conditions.

The objective of this systematic review and meta-analysis is to summarize the evidence on interventions that are intended to improve health care system transitions for patients with mental health conditions.

This review examined the following key question (KQ) and subquestions:

• KQ1. What are the effects of mental health care transition programs?
  • KQ1a. What are the effects of mental health care transition programs for transitions from military to veteran health care systems?
  • KQ1b. Do the effects vary by population?
  • KQ1c. Do the effects vary by intervention type?
  • KQ1d. Do the effects vary by country?

Methods

We searched research databases (PubMed, PsycINFO, and the Web of Science), databases and registries of systematic reviews (Cochrane Database of Systematic Reviews [CDSR], Campbell Collaboration, International Prospective Register of Systematic Reviews [PROSPERO], Open Science Framework), and the Defense Technical Information Center (DTIC) database from inception to April 2020 for English-language evaluations of interventions to improve health care transitions for patients with mental health conditions. Existing systematic reviews were reference-mined for additional studies. The review was registered in PROSPERO (CRD42020187360).

Citations from these searches were independently screened by two reviewers using predetermined eligibility criteria. Both reviewers independently abstracted categorical data from studies that met inclusion eligibility criteria. One reviewer abstracted data and assessed risk of bias using the Cochrane Risk of Bias 2 (RoB 2) tool for included studies. These responses were independently checked by the topic lead. Outcomes included measures of health, health care, patient experience, and unintended consequences.

Results across studies were summarized using Hartung-Knapp corrected random effect meta-analyses when data allowed. All results were described in a narrative review. Meta-regressions were performed by preplanned subgroup analyses, which examined differential intervention effects by population, intervention subtype, and study country. Quality of evidence for each outcome in meta-analyses was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach.

Results

We identified interventions targeting health care transitions for active duty service members entering civilian life, children entering adulthood, and recently released prisoners. Quality of evidence was low or very low for most main and subgroup analyses.

Key Question 1. What Are the Effects of Mental Health Care Transition Programs?

Across studies, care transition intervention increased outpatient mental health service use (relative risk [RR] 1.27, confidence interval [CI] 1.02, 1.57; six studies). In single studies that could not be combined with others, we also found that interventions increased outpatient mental health service use (standardized mean difference [SMD] 0.80; 95 percent CI 0.72, 0.89; one study) and increased hospitalization/inpatient treatment (SMD 0.14; CI 0.06, 0.22; one study).

Key Question 1a. What Are the Effects of Mental Health Care Transition Programs for Transitions from Military to Veteran Health Care Systems?

In the only study examining service members entering civilian life, a care transition intervention reduced mental health symptoms (RR 0.73; CI 0.62, 0.86; one study).

Key Question 1b. Do the Effects Vary by Population?

Meta-regressions across studies indicated that interventions for children entering adulthood increased mental health service use more than interventions for recently released prisoners. Among children entering adulthood, interventions increased outpatient mental health service use (SMD 0.80; CI 0.72, 0.89; one study) and hospitalization/inpatient treatment (SMD 0.14; CI 0.06, 0.22; one study). Among recently released prisoners, an intervention reduced mental health symptoms (RR 0.24; CI 0.16, 0.36; one study). Interventions had no consistent effect on any other outcome.

Key Question 1c. Do the Effects Vary by Intervention Type?

We categorized interventions as health coaching, service navigation, care coordination, or any combination of the three; all analyses were based on a single study. Service navigation was associated with reduced mental health symptoms (RR 0.73; CI 0.62, 0.86; one study) and increased insurance coverage (RR 4.64; CI 2.17, 9.91; one study). A study of health coaching and service navigation showed that the combined intervention increased primary care use (RR 1.29; CI 1.11, 1.50; one study). A care coordination and service navigation intervention was associated with increased patient self-efficacy/self-activation (SMD 0.42; CI 0.14, 0.69; one study). Combined health coaching and care coordination interventions were associated with reduced mental health symptoms (RR 0.24; CI 0.16, 0.36; one study) and increased primary care use (RR 2.22; CI 1.37, 3.58; one study). An intervention composed of all three types was associated with increased outpatient mental health service use (SMD 0.80; CI 0.72, 0.89; one study) and hospitalization/inpatient treatment (SMD 0.14; CI 0.06, 0.22; one study). No other combinations were associated with changes in outcomes, and meta-regressions indicated that intervention type was not related to intervention effectiveness on outpatient mental health or primary care use. Data were not sufficient for additional meta-regressions with other outcomes.

Key Question 1d. Do the Effects Vary by Country?

Interventions were evaluated in the United States (n = 10), the United Kingdom (n = 3), Canada (n = 2), Australia (n =1), and New Zealand (n = 1). Interventions in the United States increased outpatient mental health use (SMD 0.80; CI 0.72, 0.89: one study), hospitalization/inpatient treatment (SMD 0.14; CI 0.06, 0.22; one study), and patient self-efficacy/self-activation (SMD 0.42; CI 0.14, 0.69; one study). Studies in the United Kingdom indicated that care transition interventions increased primary care use (RR 2.24; CI 1.80, 2.78; two studies). An intervention in Australia increased primary care use (RR 1.29; CI 1.11, 1.50; one study). Other interventions studied in the United States, the United Kingdom, and Australia and all interventions studied in the Canada and New Zealand were not associated with consistent effects. Meta-regressions indicated no difference in intervention effectiveness between countries for outpatient mental health and primary care use. Additional meta-regressions for other outcomes could not be run due to lack of data.

Conclusion

We found no consistent effects of care transition interventions across studies and outcomes but interventions may increase outpatient mental health service use. Indirect comparisons across populations were limited by the small number of studies in included patient subgroups. Additional research on interventions for care transitions among patients with mental health conditions is needed.