Improving the Inpatient-to-Outpatient Transition
Principal Investigator: 
Organization: 
Rocky Mountain MIRECC

For suicidal Veterans who are treated on an inpatient psychiatric unit, the weeks and months following their discharge pose a special risk. One study found, for instance, that among Veterans who died by suicide after hospitalization in a psychiatric facility, 43 percent of the deaths occurred within the first month, with the first week being particularly high-risk. Much of the risk seems to be rooted in the transition from inpatient care to outpatient care, which can leave Veterans feeling unsettled. With that in mind, Bridget Matarazzo and colleagues at the Rocky Mountain Mental Illness Research, Education, and Clinical Center (MIRECC) have developed and tested a new program, the Home-Based Mental Health Evaluation program, or HOME program , designed to lower that risk by creating a better transition between inpatient and outpatient care for Veterans who are at risk of suicide.

To improve this transition, the program addresses three separate issues, Matarazzo explains. First, leaving the structured environment of a psychiatric hospital and returning to a relatively unstructured home environment can be nerve-racking. Whereas the hospital is a safe and protective place—a “cocoon,” as some patients have described it—home can seem uncertain, stressful, and even threatening, particularly because it is often the place where the Veteran had suicidal thoughts or a suicide attempt.

Second, once Veterans have left the inpatient environment, many do not engage in outpatient treatment. For example, one large study that examined Veterans and non-Veterans who had been treated in an emergency department or inpatient unit in a hospital found that only about half of those psychiatric patients took part in follow-up outpatient care. Matarazzo says that research suggests that many patients simply do not remember their post-discharge plans once they have been released following a suicide attempt, even if they are given the plans both orally and in writing. This is important because not taking part in regular treatment makes it considerably more likely that a Veteran will die by suicide.

Third, among Service Members and Veterans there is a stigma associated with mental illness and suicide that makes many individuals hesitant to take advantage of mental health treatment. This may be a major reason why some Veterans do not take part in outpatient care following inpatient treatment for psychiatric issues.

Matarazzo’s program, the HOME program, is designed to address these three issues and help Veterans make a successful transition from inpatient psychiatric care to outpatient services. To do this, the program has four steps that together are designed to get Veterans seeing outpatient providers as soon as possible after leaving the hospital and ensure that the Veterans continue seeing the providers instead of stopping after one or two sessions.

The first step is to contact the Veteran while still in the hospital to explain the HOME program and establish a sense of connection. Next, the Veteran is contacted by phone within one business day of leaving the hospital and is encouraged to quickly engage in follow-up care. Third, there is a home visit within the first week after discharge. At this time the HOME provider speaks with the Veteran and anyone else in the home about such topics as making the home safer (putting locks on guns, keeping pills in a safe location, putting up crisis hotline stickers, and so forth). Fourth, the HOME provider calls the Veteran at least once a week until the Veteran is engaged in ongoing care. During all these contacts the HOME provider collects information relevant to ongoing suicide risk—details such as recent suicidal thoughts or behavior, substance use, and adherence to medication schedules—and regularly reviews and updates the Veteran’s safety plan, which is a list of coping strategies designed for a Veteran to use when the warning signs of a suicide crisis appear or when an actual crisis occurs. The provider also regularly discusses any obstacles the Veteran may be facing in continuing to get care—such as transportation issues—and offers suggestions for how to deal with such obstacles.

To perform an initial evaluation of the program, Matarazzo and colleagues enrolled 34 Veterans who had been admitted to a VA inpatient psychiatric unit and who had reported either thinking about suicide or engaging in suicidal behavior. These Veterans participated in the HOME program and their outcomes were compared with those of a matched control group of 34 Veterans who had been admitted to the same unit over the previous two years.

The Veterans in the HOME program entered ongoing psychiatric care much sooner after leaving the hospital than the control group—a mean of six days versus a mean of ten days—and they were much more likely to remain in that care. Every one of the 34 Veterans in the HOME program had engaged in care within three months of being discharged from the hospital, compared with only 79 percent of the control group. Furthermore, the Veterans in the HOME program reported that they were experiencing fewer suicide-related symptoms, such as suicidal thoughts, as a result of the program and also that they felt cared for and safe because of the program.

With the success of this initial demonstration program and funding from the Military Suicide Research Consortium, Matarazzo expanded the HOME program to four VA medical centers, with a total of more than 300 Veterans enrolled. She and her colleagues are still finishing the data analysis for that larger study, with completion expected by September 2017.

Meanwhile, the results of this demonstration program and another with both rural and non-rural Veterans at the Durham VAMC were so impressive that the program was one of a dozen programs from VA centers around the country chosen in a “shark tank” competition to be spread to other VA centers (see HOME Program Wins VA Shark Tank Competition, Named “Gold Status” Program). As a result, the HOME program will be implemented in the William Jennings Bryan Dorn VA Medical Center in Columbia, South Carolina. Furthermore, Matarazzo and colleagues have received funding from the VA’s Office of Rural Health to continue to expand the HOME program to Veterans in additional rural communities.

Assuming the program’s impressive results are repeated on this larger scale, the HOME program will offer those who treat Veterans at risk of suicide a major new tool in lowering that risk, specifically in the dangerous period between inpatient care and engagement in an outpatient program.

Bridget B. Matarazzo PsyD, Samantha A. Farro PhD, Melodi Billera LCSW, Jeri E. Forster PhD, Janet E. Kemp PhD, Lisa A. Brenner PhD, ABPP (Rp)
Suicide and Life-Threatening Behavior
2 February 2017