Implementation and Evaluation of a Transition to Discharge Program for the Reduction of Early Readmission in a Mental Health Inpatient Unit
Phase: NA
Conditions: Readmission, Mental Health Disorder, Hospitalizations Psychiatric
Sponsor: Fundación Pública Andaluza para la Investigación de Málaga en Biomedicina y Salud

 
 
 
 
Implementation and evaluation of a 
Transition to Discharge Program for the 
reduction of early readmission in a mental 
health inpatient unit. 
Vera Carbonell-Aranda*1,2,3, Yaiza García-Illanes1, María Traverso-Rodríguez1, Antonio 
Bordallo-Aragón1, Berta Moreno-Kustner2, 3, José Guzmán-Parra1, 2, # Jesús Herrera-
Imbroda1, 2, 3, # 
 
20/5/2023 
NTC number:  
 
 
 
 
 
 
 
 
 
 
1 Unidad de Gestión Clínica de Salud Mental, Hospital Regional Universitario de Málaga, Instituto de Investigación 
Biomédica de Málaga (IBIMA), 29010 Malaga, Spain 
2 Departamento de Personalidad, Evaluación y Tratamiento Psicológico, Facultad de Psicología, Universidad de 
Málaga, Andalucía Tech, Campus de Teatinos S/N, 29071 Malaga, Spain 
3 Grupo de Neuropsicofarmacología, Hospital Regional Universitario de Málaga, Instituto de Investigación Biomédica 
de Málaga (IBIMA), 29010 Malaga, Spain 
*Corresponding autor: Vera Carbonell-Aranda; vera.carbonell.sspa@juntadeandalucia.es 
#This authors contributed equaly to this work 
 

 
 
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ABSTRACT 
Background  
Early readmission to psychiatric units poses a significant challenge for both patients with mental 
health issues and healthcare institutions. It hampers patient progress and prognosis, and the 
professional approach taken during discharge can greatly influence the recovery process. This 
paper proposes a multicomponent discharge transition intervention to mitigate the risk of early 
readmission to a Mental Health Hospitalization Unit (MHHU). 
Methods 
The intervention entails developing a measurement scale to assess patients' risk of early 
readmission, allowing for stratification into high, medium, and low-risk categories. Tailored 
intervention strategies will focus on ensuring adherence and continuity of care post-discharge, 
with a more comprehensive approach for high-risk patients. Additionally, a post-discharge 
psychotherapeutic group will be incorporated for high-risk cases to support recovery. The 
efficacy of the program will be analyzed by comparing the overall early readmission risk at the 
Regional Hospital of Malaga's MHHU with the previous year, using admission episodes from two 
other hospitals in the province as a control group where the intervention program is not 
implemented. The success of the post-discharge group psychotherapeutic intervention will be 
evaluated through pre-post assessments of recovery measures, functionality, subjective well-
being, social support, and treatment satisfaction. 
Discussion 
This proposal aims to address the issue of early readmission to psychiatric units by enhancing 
predictability and understanding of intervention strategies to reduce readmission rates. 
Trial registration 
 
KEY WORDS 
Early readmission, discharge intervention, psychiatric unit, continuity of care, psychotherapy 
group, recovery. 
 
INTRODUCCIÓN 

 
 
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Discharge from hospital after admission to a Mental Health Inpatient Unit is a particularly 
sensitive time, which can place the individual in a situation of great vulnerability.  The transition 
from admission to the patient's usual environment and the return to care in his or her unit of 
reference, mostly the Community Mental Health Unit (CMHU), represents a major challenge for 
both the individual and the health institutions, often compromising continuity of care and 
leading to repeated hospital admissions, a phenomenon known as the "revolving door" (1).  
The rate of early readmissions in a short psychiatric hospitalization unit can be a negative 
indicator of quality of care, resulting in a deficient attention to the needs and peculiarities of 
users that has important repercussions for patients, their caregivers and the health system (2). 
A correct interpretation of the impact that early readmission can have on the quality of care 
must always be based on a community-centered care model (3), where psychiatric 
hospitalization is a measure of last resort and to some extent can be considered a therapeutic 
"failure" in a large number of patients. 
Readmission rates vary widely depending on the type of measure employed, with approximately 
1 in 7 patients discharged from an acute psychiatric care unit estimated to be readmitted within 
30 days and up to 40% readmitted within 1 year.  In this regard, numerous studies have been 
conducted around the world to discern the variables that influence hospital readmission rates 
and to determine which specific interventions are effective in reducing readmission rates (4,5). 
The factors influencing the risk of readmission have been studied for decades. There are 
variables that have frequently been associated with a higher recurrence of hospitalizations, 
some of them related to clinical and sociodemographic aspects of the patient, such as poor 
treatment adherence, substance abuse, psychiatric diagnosis of psychosis or affective disorder, 
suicidal ideation, gender, marital status, social isolation, etc., and others more associated with 
institutional factors, such as the involuntary nature of admission, length of stay, or the 
availability of an adequate care plan and community therapeutic resources after discharge (6). 
Regarding interventions, there is an enormous heterogeneity in the available evidence, due both 
to the diversity of post-discharge interventions that have been developed in this regard, and to 
the variability of measures and results that are taken as a reference to assess their efficacy (1). 
In some studies, the number of readmissions within different time frames (30 days, 6 months, 
one year) has been used as the dependent variable, while in others, the effectiveness of post-
hospitalization intervention is assessed using other parameters such as the duration of future 
hospitalizations or the reduction in suicidal ideation or attempts. Scientific knowledge on the 

 
 
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subject yields promising results. However, this heterogeneity makes it difficult to draw clear 
conclusions about this issue. 
In a systematic review carried out in 2019, a classification of these interventions has been made 
based on a clustering method and according to their key components (1), and they can be 
divided into: Critical Time Interventions (CTI), Transitional Discharge Model (TDM), peer support, 
contact-based interventions, role-based interventions, psychoeducational interventions, 
multicomponent interventions and others. From this and other studies, it is evident that 
interventions based on the Transition to Discharge Model have yielded significant results in 
reducing readmissions, achieving earlier discharges from hospital units, and improving 
therapeutic adherence.  
Interventions with a psychoeducational and skill-building profile have shown good results in 
reducing readmission rates, promoting self-management and behavioral regulation, and 
increasing levels of emotional well-being and symptom reduction. Post-discharge interventions 
focused on a single component in isolation (such as contact-based, peer support, role-based, 
pharmacological management, etc.) by themselves demonstrate inconsistent results regarding 
readmission reduction, varying across studies (1,7). 
In summary, all studies reporting significant effects include elements of intensive case 
management, Cognitive Behavioral Therapy, and psychoeducation, either in combination or 
linked to another element such as peer support. The success of psychoeducational interventions 
and those focusing on the therapeutic relationship underscores the importance of addressing 
personal issues and emotional elements during care transition when aiming to reduce 
psychiatric readmissions (7).  
On the other hand, clinical practice guidelines (CPG) for addressing severe mental illness 
emphasize the importance of psychosocial rehabilitation in the recovery process. This involves 
therapeutic actions aimed at training and developing personal and social skills, 
psychoeducational strategies with families and users, building social networks, and promoting 
personal autonomy, among others. The objective is to enhance the psychosocial functioning of 
individuals with severe mental illness and facilitate their adaptation and maintenance within the 
community (8,9). From all of this, it becomes clear the importance of conducting a 
multicomponent therapeutic approach that combines elements aimed at ensuring continuity of 
care and effective and intensive case management, with those aimed at providing a supportive 
bond and environment to address personal and emotional difficulties. This approach 
strengthens the patient's skills and support system, enhancing social support networks (7,9).  

 
 
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The aim of this study is, firstly, to create a tool for assessing the risk of early readmission that 
allows for stratification of admitted patients according to their risk level, based on the analysis 
of clinical and sociodemographic variables. The second objective is to implement an intervention 
program tailored to each risk level, involving coordination among all involved mental health 
units and a specific intensive program for patients at higher risk. 
 
METHODS 
 
• 
Aims 
General 
-To assess whether a Multicomponent Discharge Transition Intervention reduces the risk 
 
of early readmission compared to a control group following standard treatment. 
Secondary 
- To check whether the risk of early readmission is reduced with respect to the previous year 
in the experimental group and in the control group.  
-To check whether early readmission rates are reduced in the experimental group compared 
with the control group and with respect to readmission rates in the previous year.   
-Identify risk factors that are associated with early readmissions.  
-To test whether a scale for estimating the risk of early readmission has adequate 
psychometric characteristics for such estimation.    
-To test whether a Post-Discharge Recovery Support Psychotherapy Group improves 
outcome on measures of recovery, functioning, subjective well-being, social support, and 
satisfaction with mental health treatment in patients at high risk of early readmission.   
- To test whether the Transition to Discharge intervention also reduces the risk of frequent 
readmission (revolving door). 
 
• 
Design 

 
 
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The present study is a quasi-experimental cluster clinical trial aimed at assessing the efficacy 
of a multicomponent discharge transition program for the reduction of early readmissions 
in a MHHU. The development of this study consists of two distinct parts or elements:  
To carry out the main objective, a quasi-experimental design with a control group will be 
used, and within the intervention, an early readmission risk assessment scale will be created 
to categorize patients into different risk levels.  
In addition, a study will be conducted to assess the predictive value and validity of the early 
readmission risk rating scale and to study the risk factors for early readmission. 
 
• 
Setting 
The present study will be carried out in the MHHU of the Regional University Hospital (RUH) of 
Malaga, a public hospital of the Andalusian Health Service. In addition to the Mental Health 
Clinical Management Unit of the HRU of Málaga, this MHHU is a reference for two other regional 
hospitals in the province of Málaga: The Málaga East Axarquía Hospital and North Málaga Health 
Management Area. The Mental Health Clinical Management Unit of the RUH of Malaga, 
according to figures from the 2022 database of users, serves a reference population of 336,968 
people, while 150,823 people depend on the Mental Health Clinical Management La Axarquía 
and 109,958 depend on the Mental Health Clinical Management  North of Málaga, resulting in 
a reference population of 597,749 people for hospitalization resources.  
The MHHU has 40 beds in double rooms and is divided into two functional units. The access 
routes to hospitalization in this unit are admission from the Emergency Services, after evaluation 
by a psychiatrist, and programmed admission from another unit. The average occupancy rate is 
two thirds (28 beds) of the total capacity and the average stay in the year 2022 was 13.7 days, 
with a total number of admissions of 838. The data collected at the RUH of Malaga indicate an 
early readmission rate of 15.08% in the year 2022, using a time reference of 30 days until 
readmission.   
The Spanish public health system is functionally organized into levels, with Primary Care 
comprising the first level and Ambulatory Specialized Care and hospital Emergency Services 
comprising the second level of care. The third level of care consists of hospital units with a high 
degree of specialization. The proposed intervention will primarily take place in the 
hospitalization unit (third level), as well as in the community-based outpatient care facilities 

 
 
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affiliated with said hospital, including the North Guadalmedina and Central Malaga Community 
Mental Health Units (second level). 
 
• Intervention and control group 
Intervention group 
The intervention program is based on the Discharge Transition Model for the prevention of 
hospital readmission in Mental Health. For its development, a multidisciplinary readmission 
commission was established, comprised of professionals from various categories and from 
different Mental Health facilities. The aim was to address this issue in detail and actively 
participate in the review of available evidence and decision-making regarding the development 
and implementation of the current program.  
This is a multicomponent program that initially involves the development of a scale to assess the 
risk of readmission for each patient, followed by its systematic application. This allows for 
stratification of patients according to their risk of early readmission and adaptation of the 
intervention to the needs of each risk level. The intervention includes elements aimed at 
promoting continuity of care after discharge, transitioning back to the community setting, as 
well as elements aimed at enhancing personal and emotional resources through 
psychotherapeutic approaches. The following describes the different components of this 
intervention program. 
 
 
Construction of the Early Readmission Risk Scale  
For the preliminary analysis of risk factors associated with readmission, a retrospective 
observation will be conducted. This will involve analyzing all episodes from the previous calendar 
year stored in the database of the MHHU of the RUH of Malaga, provided that the records are 
complete. "Cases" will be selected from episodes that resulted in readmission within 30 days 
post-discharge, while an equivalent number of "controls" will be randomly selected through 
simple random sampling. Following this analysis, a measurement instrument will be developed 
to determine the risk of early readmission for all patients admitted to the MHHU.  
A literature search was conducted to identify variables that have been associated with 
readmission and early readmission in other populations. The following variables were selected 

 
 
8 
 
for analysis in the reference population: Sociodemographic factors (sex, age, marital status, legal 
incapacity, employment status, criminal history, and social functioning), psychiatric history 
(previous admissions, emergency service visits in the twelve months prior to admission, history 
of suicide attempts, attendance at community nursing follow-ups in the six months prior to 
admission, and somatic comorbidity), reasons for admission (presence of hetero- or auto-
aggression or deficits in self-care), clinical characteristics (primary diagnosis, substance use, non-
adherence to follow-up in the previous 12 months, and non-adherence to treatment up to one 
month before admission), admission characteristics (urgent or scheduled access route and 
length of stay), and discharge measures (coordination with referring physician in the CMHU and 
prescription of depot medication).  
During admission to the hospitalization unit, all users must have the aforementioned Early 
Readmission Risk Scale of the MHHU of the RUH of Malaga administered. This will allow for the 
classification of patients according to their risk level, establishing defined cutoff points, resulting 
in three categories: Patients at low risk, medium risk, and high risk. This scale will be completed 
by the referring physician during the initial assessment interview upon admission to implement 
the proposed measures for each risk level. Additionally, the referring physician will establish 
contact with the case management figure responsible for the program for the referral of cases 
with a score indicative of a high risk of early readmission or patients with early readmission 
within 30 days post-discharge. 
Intervention measures based on the risk of early readmission 
For patients classified in the low-risk group, general measures would be applied. For patients in 
the medium-risk group, reinforced measures would be implemented. Lastly, for patients 
considered to be in the high-risk group, intensive case management measures would be applied, 
and if they meet the inclusion criteria, they would be included in the Post-Discharge Group 
Psychotherapeutic Intervention.  
1. General measures 
The following measures would be applied to patients with a low risk of readmission: 
-Ensure coordination between physicians during admission and a follow-up appointment 
within 7 days. 
-If the patient presents substance abuse, ensure an appointment at the Provincial Drug 
Dependency Center (PDC) upon discharge and record the date in the discharge report. 

 
 
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-If the patient presents social impairment, refer them to a Social Worker at the MHHU during 
admission and initiate a social history. 
2. Reinforced measures 
The following measures would be applied to patients with a medium risk of readmission. In 
addition to the previous measures, the following would be incorporated: 
-Schedule at least three follow-up appointments: one (via telephone) with a psychiatrist 
from the MHHU within 24 hours post-discharge, and two at the Community Mental Health 
Unit: the first within 7 days and the second between days 21 and 30. 
-If the patient presents social impairment, schedule an appointment with a social worker 
from the Community Mental Health Unit within 14 days post-discharge. 
-If the patient has a Severe Mental Disorder, schedule a nursing visit during their stay at the 
MHHU. 
3. Intensive measures 
3.1 Intensive case management measures 
The following measures would be applied to patients with a high risk of readmission or who 
have experienced early readmission. In addition to the measures from the previous levels, 
the following would be incorporated: 
-Schedule at least three follow-up appointments: one, in this case, in-person, with a 
psychiatrist from the MHHU within 24 hours post-discharge, and two at the Community 
Mental Health Unit: the first within 7 days and the second between days 21 and 30. 
-If the patient has a Severe Mental Disorder, schedule two nursing visits: one during the 
hospitalization and one in the first week post-discharge. The latter will preferably be 
conducted at the patient's home. 
-If the patient has documented medication non-adherence, consider depot medication 
based on clinical characteristics. 
-All readmissions and patients at high risk of readmission will be assigned a case 
management figure who will develop a follow-up program for each patient and manage all 
their appointments during the first month post-discharge. This includes reminding patients 
of appointments 24 hours in advance, reengaging patients in case of non-attendance, and 
coordinating with reference facilities.  

 
 
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3.2 Post-Discharge Psychotherapeutic Recovery Support Program 
For application to patients at high risk of early readmission who meet the inclusion criteria. 
The proposed psychotherapeutic intervention is considered as an adjunct to the standard 
treatment received by patients, as well as to the intensive case management measures 
proposed. It consists of a multicomponent group psychotherapeutic intervention from a 
rehabilitative and recovery-oriented perspective (10) This intervention will be structured 
into 20 sessions, each lasting 90 minutes, held weekly in an open format. It will be directed 
by two cotherapy professionals. The group will consist of a maximum of 12 participants, who 
may join at different times.  
The intervention program includes different areas of work that are developed in a 
transversal way throughout the 20 sessions, following an open and flexible semi-structured 
format. Each area of work was included based on the available evidence regarding the 
effectiveness of psychosocial and psychotherapeutic interventions collected in scientific 
literature, Clinical Practice Guidelines, and the Integrated Care Process in Severe Mental 
Disorder of the Andalusian Health Service (8–12). The contents addressed by the Post-
discharge Recovery Support Psychotherapeutic Program can be grouped around the 
following areas:  
• 
Initial Phase: Introduction. Explanation of the framework and group rules. Addressing 
group objectives. Exploring personal expectations and identifying needs. Initiating 
therapeutic rapport and fostering group cohesion. These aspects will be addressed 
throughout the intervention and will be more evident during the welcoming of new group 
participants. 
• Interpersonal Management: With the aim of promoting interpersonal functioning and 
independence, as well as adaptation to the community, dysfunctional relationship patterns 
will be addressed, which will be manifested in the group's own functioning. Both social 
perception skills or reception, social cognition or processing skills, and behavioral response 
or expression skills will be addressed.  
• 
Problem Solving: This area of work aims to establish a link between symptoms and 
practical difficulties in their immediate context. Identifying and breaking down the problem, 
setting achievable goals, generating solutions, implementing them, and evaluating the 
results will be some of the skills to work on. 

 
 
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• 
Symptom Management and Coping Resources: This involves promoting recognition of 
the clinical condition, facilitating awareness about the origin of distress, its course, and 
typical ways of expression, fostering self-awareness and self-management. The relationship 
with the symptom, its acceptance, and pharmacological management will be addressed, 
along with recognition of prodromes, self-care habits, and crisis management.  
• 
Family intervention: Four multi-family sessions will be carried out on a monthly basis in 
an integrated manner. They will be mainly based on the optimization of communication 
strategies in the family environment and management of crisis situations.  
• 
Values orientation and commitment to meaningful activities: The therapeutic approach 
is focused on achieving greater subjective well-being and attaining a more satisfying and 
meaningful life, always from a recovery-oriented and person-centered model. 
• 
Relapse prevention: Anticipation of possible scenarios, detection of potential risks and 
implementation of effective coping strategies. Strategies aimed at enhancing self-control, 
self-efficacy and self-determination, through the joint development of safety plans and the 
enhancement of personal strengths. 
Other aspects that will be addressed throughout the therapeutic process include emphasis 
on the therapeutic bond, group cohesion, strengthening social and family ties, peer support, 
and learning in the here and now of the group reality. 
 
Control group 
 
To assess the effectiveness of the Multicomponent Discharge Transition Program, users 
from Málaga East Axarquía Hospital and North Málaga Health Management Area will be 
employed as the control group. Participants in the control group will continue with their 
usual treatment. 
Additionally, users from the Mental Health Management Unit of Regional Hospital of Málaga 
who were admitted the previous year and thus did not participate in the intervention 
program will also be used as a control group. 
 
• 
Participants and recruitment 

 
 
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For the development of the present study, data from all hospital admission episodes at 
MHHU during the 12 months following the implementation of the Discharge Transition 
Intervention Program will be considered. Similarly, data from all users who have 
experienced any hospital admission episodes at UHSM in the year prior to the intervention 
will also be utilized. 
The experimental group, to which the Discharge Transition Intervention Program will be 
applied, will consist of users whose Community Mental Health Units (CMHU) are affiliated 
with the Regional Hospital of Málaga. Users belonging to other hospitals in the province will 
be excluded from the intervention program and will form part of the control group.  
Participants included in the Post-Discharge Group Psychotherapy Support Recovery 
Program will be those at high risk or with an early rehospitalization already occurred, who 
also meet the inclusion criteria. The relevance of their inclusion will be assessed through a 
clinical interview by the Specialist in Clinical Psychology in charge of the program, following 
these criteria. 
Inclusion criteria: 
▪ 
Be of legal age. 
▪ 
Speak spanish fluently. 
▪ 
Have had recent admission to the MHHU of the Regional Hospital of Málaga and a score 
considered as "High Risk" on the Early Rehospitalization Risk Scale or have experienced 
an early rehospitalization. 
▪ 
Belong to the Clinical Management Unit of Mental Health of the RUH of Málaga. 
▪ 
Have sufficient cognitive capacity to understand the rules and contents of the group 
intervention. 
 
Exclusion criteria:  
 
▪ 
Individuals whose primary diagnosis is a Mental and Behavioral Disorder due to 
psychoactive substance use. 
▪ 
Moderate or severe intellectual disability. 
▪ 
Clinical Management Unit belonging to a hospital other than the RUH of Málaga. 
▪ 
Lack of commitment to attending sessions or complying with group rules. 
 
 

 
 
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• 
Study variables 
Main outcome variables 
The main outcome variable will be the risk of early reentry of the experimental group 
compared to the control group, which did not follow the intervention.  
Secondary outcome variables 
The risk of early rehospitalization of the admission episodes from the experimental group 
will be compared to the risk of early rehospitalization of admission episodes from the 
previous year. 
Frequent rehospitalization will be assessed as having undergone at least two readmissions 
within a 6-month follow-up period. The risk of frequent rehospitalization will be considered 
as a secondary variable.  
In order to assess the effectiveness of the Recovery Support Psychotherapeutic Program, 
pre- and post-intervention scales will be administered to all participants to take into account 
other psychological and clinical variables. This evaluation will be conducted by blinded 
evaluators before the program begins and upon its completion, after the last session. The 
instruments to be used are as follows:  
-Core Om (13,14): It is a self-report questionnaire composed of 34 items that allows for a 
brief assessment of the patient's status, widely used for evaluating therapeutic change 
based on four dimensions: Subjective well-being, Problems/Symptoms, General functioning, 
and Risk scale. The questionnaire items are scored on a Likert scale from 0-4. It is a valid and 
reliable instrument in its Spanish version.  
- The Duke Social Support Questionnaire (Duke-unk-11) (15,16), assesses the perceived 
degree of social support. It is a self-administered questionnaire consisting of 11 items and a 
Likert-type response scale (1-5). 
- The Personal and Social Performance Scale (PSP) (17,18), It is a hetero-applied and very 
brief instrument that allows quantifying changes in the functional recovery of patients in the 
following areas: a) self-care; b) usual social activities, including work and study; c) personal 
and social relationships; and d) disturbing and aggressive behaviors. The result on the scale 
is established by assigning to each of the areas a severity level. The total score ranges from 
0 to 100. 

 
 
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- Recovery Process Questionnaire (QPR-15-SP) (19) is a self-reported questionnaire used to 
assess progress in measures of recovery linked to overall psychological well-being, personal 
achievements, quality of life, and empowerment. It consists of 15 items on a Likert scale 
from 0 to 4, with a high score indicating recovery. It has adequate reliability and validity 
indices and has been psychometrically adapted and validated in the Spanish population (20).  
- Client’s Assessment of Treatment (CAT). This scale evaluates patient satisfaction with 
hospital treatment, and in this study, it will be adapted to extend this measure to the overall 
mental health treatment received. Users rate each item on a scale from 0 to 10 (21,22). 
 
• 
Data analysis 
In the analysis for the creation of the early rehospitalization risk scale, a univariate logistic 
regression analysis will be used. For the final selection of factors, a forward stepwise 
multivariate analysis will be performed, introducing variables with greater statistical 
significance. Finally, a scale will be developed to measure the risk of early rehospitalization 
in each admission episode, whose sensitivity and specificity will be tested beforehand using 
a receiver operating characteristic (ROC) curve. The construction of the scale will follow the 
procedure outlined in detail in Sullivan et al. (23). 
 
To evaluate the differences between the intervention group and the control groups, a 
univariate and multivariate mixed logistic regression analysis will be conducted, introducing 
potential confounding variables (unit occupancy, age, sex, and the variables used in the scale 
for estimating the risk of early rehospitalization). To assess potential differences in Core Om, 
Duke-unk-11, PSP, and QPR among patients participating in the Post-Discharge Recovery 
Support Psychotherapy Program, the paired Student's t-test for repeated measures or the 
non-parametric Wilcoxon signed-rank test for a single sample will be used. 
 
 
DISCUSSION 
 
The present research study aims to analyze the risk factors for early rehospitalization of patients 
discharged from a short-term psychiatric hospitalization unit. Based on this information, the goal 
is to stratify the risk and direct more intensive therapeutic measures to those individuals with a 
higher likelihood of rehospitalization to reduce early rehospitalization rates.  

 
 
15 
 
 
Thus, determining the risk of psychiatric rehospitalization for individual patients is a critical step 
in efforts to address the potentially avoidable high rate of this negative outcome, as highlighted 
in the READMIT study (4). This study conducted in Canada succeeded in providing a framework 
to identify patients at high risk of rehospitalization through the development of a prognostic 
index with moderate discriminative capacity. 
 
One of the main strengths of our study is that it will be conducted in a real-world context, and 
the instrument to be used for patient stratification will be developed in the same population 
where it will subsequently be applied, reducing the possibility of cultural factors or context-
specific factors biasing the validity of the risk scale. Additionally, the individuals involved in the 
care of hospitalized patients will work directly on this instrument and subsequently on the 
intervention to be developed, which will consist of multiple components. 
 
Among the challenges of the study are being able to fulfill all the measures outlined in the 
intervention program, as external factors may condition it: shortage of hospital beds, premature 
discharges or voluntary discharges, staffing deficits, lack of community resources, etc. 
Additionally, many factors associated with early rehospitalization may be difficult to address 
within the program itself: substance abuse, homelessness, difficulties associated with group 
work, cognitive deficits, heterogeneity of participating subjects, etc. 
 
One of the major limitations of the study is that it will only be conducted in one inpatient unit, 
so generalization of the results to other settings will be problematic. As reflected in previous 
studies, such as the one cited above, its findings have not been able to effectively discriminate 
potentially readmitting patients in subsequent studies conducted with different populations 
(24). This tells us about the complexity of the phenomenon of early readmission, an event that 
is difficult to predict, multicausal and involves factors that require a complex approach (25). 
 
Finally, an important aspect is that the treatment allocation is not randomized, which may 
introduce biases that will be addressed by using two control groups. However, there may 
potentially be confounding variables that will be considered in the analysis. Given these 
limitations, if this study yields satisfactory results, a likely future direction could be to develop a 
randomized, multicenter clinical trial at the regional or state level. 
 
LIST OF ABBREVIATIONS 

 
 
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CAT: Client’s Assessment of Treatment 
CMHU: Community Mental Health Unit 
CPG: Clinical Practice Guidelines 
CTI: Critical Time Interventions 
MHHU: Mental Health Hospitalization Unit  
PDC: Provincial Drug Dependency Center 
PSP: Personal and Social Performance Scale 
QPR: Recovery Process Questionnaire  
RUH: Regional University Hospital 
TDM: Transitional Discharge Model  
 
DECLARATIONS 
 
Ethics approval and consent to participate 
 
The protocol of the current study has been submitted and approved by the Provincial Research 
Ethics Committee of Málaga, with approval number: 
For the study of risk factors and the development of the early rehospitalization risk assessment 
scale, as well as for comparing the rehospitalization risk between study groups, retrospective 
clinical data recorded in the unit's electronic records will be used, and obtaining informed 
consent has not been deemed necessary. Prior to participating in group psychotherapeutic 
intervention, participants will sign informed consent before commencement. 
 
The study will be conducted according to national and international standards outlined in the 
Declaration of Helsinki and Kyoto. Confidentiality of the subjects included in the study will be 
ensured in accordance with the provisions of Organic Law 3/2018, of December 5, on the 
Protection of Personal Data and guarantee of digital rights, as well as European Regulation 
2016/679 regarding the protection of individuals with regard to the processing of personal data 
and the free movement of such data. 
 
Consent for publication 
Not applicable. 
 
Availability of data and materials 

 
 
17 
 
The datasets used and analysed during the current study are available from the corresponding 
author on reasonable request. 
 
Competing interests 
The authors declare that they have no competing interests. 
 
Funding 
V. C.-A. and J. H.-I. have received a “Río Hortega” contract grant from the Ministry of Science 
and Innovation of Spain (Carlos III Health Institute). Instituto de Salud Carlos III, Río Hortega 
Grant CM22/00232, Vera Carbonell-Aranda; Río Hortega Grant CM21/00255, Jesús Herrera-
Imbroda. 
 
Authors' contributions 
V. C.-A.: Participated in study design, acquisition of data and was major contributor in writing 
this manuscript; Y.G-I: participated in the conceptualization and revision of the manuscript; M.T-
R: contributed in the conceptualization and revision of the manuscript; A. B-A: Participated in 
study design, provided access to the data and reviewed the manuscript. B. M.-K.: Participated in 
conceptualization and revision of the manuscript; J. G.-P.: Contributed to study and data analysis 
design and in the writing and revision of the manuscript. J. H.-I.: Participated in 
conceptualization, study design, writing and revision of the manuscript. All authors read and 
approved the final version. 
 
Acknowledgements 
We thank all the professionals who have been part of the early reentry committee for their work, 
which has made the design of this program possible. We would also like to thank all the 
professionals of the hospitalization unit of the Regional Hospital of Malaga for their 
collaboration and their work to make this proposal go ahead. 
 
 
Bibliography 
 
1. 
Tyler N, Wright N, Waring J. Interventions to improve discharge from acute adult mental 
health inpatient care to the community: Systematic review and narrative synthesis. BMC 
Health Serv Res. 2019;19(1).  

 
 
18 
 
2. 
Donisi V, Tedeschi F, Salazzari D, Amaddeo F. Pre- and post-discharge factors influencing 
early readmission to acute psychiatric wards: implications for quality-of-care indicators 
in psychiatry. Gen Hosp Psychiatry. 2016 Mar 1;39:53–8.  
3. 
Wobrock T, Weinmann S, Falkai P, Gaebel W. Quality assurance in psychiatry: quality 
indicators and guideline implementation. Eur Arch Psychiatry Clin Neurosci [Internet]. 
2009 
Nov 
[cited 
2022 
Dec 
2];259(Suppl 
2):219. 
Available 
from: 
/pmc/articles/PMC3085766/ 
4. 
Vigod SN, Kurdyak PA, Seitz D, Herrmann N, Fung K, Lin E, et al. READMIT: A clinical risk 
index to predict 30-day readmission after discharge from acute psychiatric units. J 
Psychiatr Res. 2015 Feb 1;61:205–13.  
5. 
Vigod SN, Kurdyak PA, Dennis CL, Leszcz T, Taylor VH, Blumberger DM, et al. Transitional 
interventions to reduce early psychiatric readmissions in adults: systematic review. The 
British Journal of Psychiatry [Internet]. 2013 Mar [cited 2022 May 18];202(3):187–94. 
Available 
from: 
https://www.cambridge.org/core/journals/the-british-journal-of-
psychiatry/article/transitional-interventions-to-reduce-early-psychiatric-readmissions-
in-adults-systematic-review/82F44E78A2213CA118CEE2B51A7A747C 
6. 
Owusu E, Oluwasina F, Nkire N, Lawal MA, Agyapong VIO. Readmission of Patients to 
Acute Psychiatric Hospitals: Influential Factors and Interventions to Reduce Psychiatric 
Readmission Rates. Healthcare [Internet]. 2022 Sep 1 [cited 2022 Dec 2];10(9). Available 
from: /pmc/articles/PMC9498532/ 
7. 
Hegedüs A, Kozel B, Richter D, Behrens J. Effectiveness of Transitional Interventions in 
Improving Patient Outcomes and Service Use After Discharge From Psychiatric Inpatient 
Care: A Systematic Review and Meta-Analysis. Front Psychiatry [Internet]. 2020 Jan 21 
[cited 2024 Jan 29];10. Available from: https://pubmed.ncbi.nlm.nih.gov/32038320/ 
8. 
García-Herrera Pérez-Bryan JM, Hurtado Lara MM, Quemada González C, Nogueras 
Morillas EV, Bordallo Aragón A, Martí García C, et al. Guía de Práctica Clínica para el 
Tratamiento de la Psicosis y la Esquizofrenia. Manejo en Atención Primaria y en Salud 
Mental. [Internet]. Plan Integral de Salud Mental. Servicio Andaluz de Salud, editor. 2019 
[cited 
2024 
Jan 
29]. 
Available 
from: 
https://www.sspa.juntadeandalucia.es/servicioandaluzdesalud/sites/default/files/sincfi
les/wsas-media-pdf_publicacion/2020/1gpc_psicosis_completa.pdf 
9. 
Ministerio de Ciencia e Innovación. Guía de Práctica Clínica de intervenciones 
psicosociales en el trastorno mental grave [Internet]. 2009 [cited 2024 Jan 29]. Available 
from: 
https://portal.guiasalud.es/wp-
content/uploads/2018/12/GPC_453_TMG_ICS_compl.pdf 

 
 
19 
 
10. 
Lam M, Li L, Anderson KK, Shariff SZ, Forchuk C. Evaluation of the transitional discharge 
model on use of psychiatric health services: An interrupted time series analysis. J 
Psychiatr Ment Health Nurs [Internet]. 2020 Apr 1 [cited 2024 Jan 29];27(2):172–84. 
Available from: https://pubmed.ncbi.nlm.nih.gov/31529589/ 
11. 
Tyler N, Wright N, Waring J. Interventions to improve discharge from acute adult mental 
health inpatient care to the community: systematic review and narrative synthesis. BMC 
Health Serv Res [Internet]. 2019 Nov 25 [cited 2024 Jan 29];19(1). Available from: 
https://pubmed.ncbi.nlm.nih.gov/31760955/ 
12. 
Del Río Noriega F, Castellano Ramírez J, Fernández Burgos F, Fernández Gutiérrez B, 
Guerra Arévalo J, Huizing E, et al. Trastorno mental grave. Proceso asistencial integrado. 
[Internet]. 2a ed. Junta de Andalucía. Consejería de Salud y Familias., editor. 2020 [cited 
2024 Jan 29]. Available from: https://www.juntadeandalucia.es/sites/default/files/2022-
10/PAI_Trastorno_Mental_Grave_2020.pdf 
13. 
Chris  Evans JMCFMMBKAJCGM. CORE: Clinical Outcomes in Routine Evaluation. 
http://dx.doi.org/101080/jmh93247255. 2009 Jan;9(3):247–55.  
14. 
Feixas i Viaplana G, Evans C, Trujillo A, Saúl Gutiérrez LÁ, Botella L, Corbella S, et al. La 
versión española del CORE-OM: Clinical Outcomes in Routine Evaluation - Outcome 
Measure. Revista de Psicoterapia. 2012;23(89):109–35.  
15. 
Bellón Saameño JA, Delgado Sánchez A, Luna del Castillo JD, Lardelli Claret P. Validity and 
reliability of the Duke-UNC-11 questionnaire of functional social support. Aten Primaria. 
1996 Sep 15;18(4):153–6, 158–63.  
16. 
Broadhead WE, Gehlbach SH, de Gruy F V., Kaplan BH. The Duke-UNC Functional Social 
Support Questionnaire. Measurement of social support in family medicine patients. Med 
Care. 1988;26(7):707–21.  
17. 
Morosini PL, Magliano L, Brambilla L, Ugolini S, Pioli R. Development, reliability and 
acceptability of a new version of the DSM-IV Social and Occupational Functioning 
Assessment Scale (SOFAS) to assess routine social funtioning. Acta Psychiatr Scand. 2000 
Apr 1;101(4):323–9.  
18. 
Garcia-Portilla MP, Saiz PA, Bousoño M, Bascaran MT, Guzmán-Quilo C, Bobes J. 
Validation of the Spanish Personal and Social Performance scale (PSP) in outpatients with 
stable and unstable schizophrenia. Rev Psiquiatr Salud Ment. 2011 Jan;4(1):9–18.  
19. 
Law H, Neil ST, Dunn G, Morrison AP. The Questionnaire about the Process of Recovery 
(QPR).  
20. 
Goodman-Casanova JM, Cuesta-Lozano D, Alupoaei C, Grasa Bello EM, Herrera-Imbroda 
J, Mayoral-Cleries F, et al. Psychometric validation of the 15-item Questionnaire about 

 
 
20 
 
the Process of Recovery in Spain (QPR-15-SP). Front Psychol [Internet]. 2023 [cited 2024 
Jan 29];14. Available from: https://pubmed.ncbi.nlm.nih.gov/37484089/ 
21. 
Richardson M, Katsakou C, Torres-González F, Onchev G, Kallert T, Priebe S. Factorial 
validity and measurement equivalence of the Client Assessment of Treatment Scale for 
psychiatric inpatient care - a study in three European countries. Psychiatry Res [Internet]. 
2011 
Jun 
30 
[cited 
2023 
Apr 
14];188(1):156–60. 
Available 
from: 
https://pubmed.ncbi.nlm.nih.gov/21342706/ 
22. 
Priebe S, Gruyters T, Heinze M, Hoffmann C, Jäkel A. [Subjective evaluation criteria in 
psychiatric care--methods of assessment for research and general practice]. Psychiatr 
Prax. 1995;22(4).  
23. 
Glenn D, Golinelli D, Rose RD, Roy-Byrne P, Stein MB, Sullivan G, et al. Who gets the most 
out of cognitive behavioral therapy for anxiety disorders? The role of treatment dose and 
patient engagement. J Consult Clin Psychol [Internet]. 2013 Aug;81(4):639–49. Available 
from: https://linkinghub.elsevier.com/retrieve/pii/S0022202X15370834 
24. 
Spinner EN, Stapleton M, Oppenlander JE, Murray E, Shaikh R, Ramkirpaul E. Utility of the 
READMIT Index to Identify Community Hospital 30-Day Psychiatric Readmissions. Issues 
Ment Health Nurs [Internet]. 2021 [cited 2024 Jan 16];42(4):391–400. Available from: 
https://pubmed.ncbi.nlm.nih.gov/33027602/ 
25. 
Herrera-Imbroda J. Reingreso psiquiátrico y calidad asistencial. Boletín Psicoevidencias. 
2023;65.