Nakanishi et al. Int J Ment Health Syst (2015) 9:23
DOI 10.1186/s13033-015-0015-9

Open Access

RESEARCH

Association between length of hospital
stay and implementation of discharge planningin acute psychiatric inpatients in Japan
Miharu Nakanishi1*†, Junko Niimura1†, Michika Tanoue2†, Motoe Yamamura3†, Toyoaki Hirata4†
and Nozomu Asukai5†

Abstract
Background: Japan has introduced an acute psychiatric care unit to the public healthcare insurance program, but
its requirement of a shorter length of stay could lead to discharges without proper discharge planning. The aim of thisstudy was to examine the association between the implementation of discharge planning and the length of stay ofacute psychiatric inpatients in Japan.
Methods: This retrospective cross-sectional study included 449 patients discharged from the ‘psychiatric emergency
ward’ of 66 hospitals during a two-week period from March 7 to 20, 2011. The assigned nurse or nursing assistant foreach patient provided information on the implementation of discharge planning in the hospital stay.
Results: Approximately one quarter of the 449 patients (n = 122) received no support for coordination with post-discharge community care resources. The 122 patients who had received no support for community care coordination
had a significantly lower mean age at admission, a shorter length of stay, and a higher rate of either no follow-up or
unidentified post-discharge outpatient service than the other 327 patients. Multilevel linear regression analysis demonstrated a significantly greater length of stay among patients who were older, those who had a primary diagnosis
of schizophrenia, those who were admitted compulsorily, those who received hospital outpatient services, and those
who received community care coordination support from the assigned nurse or nursing assistant. The implementation of support for community care coordination did not indicate a significant association with these factors, whichhave been related to an increased risk of psychiatric readmission.
Conclusion: Patients to whom the assigned nurse or nursing assistant provided support on community care coordination experienced a significantly greater length of hospital stay. The implementation of support for community carecoordination did not indicate a significant association with these factors, which have been related to an increased riskof psychiatric readmission. The mental health policy should increase focus on discharge planning in the acute psychiatric setting to enhance a link between psychiatric inpatient care and post-discharge community care resources.
Background
Historically, Japan has a larger number of psychiatrichospitals than other Organisation for Economic Cooperation and Development (OECD) countries. Moreover,*Correspondence: mnakanishi‑tky@umin.ac.jp†
Miharu Nakanishi, Junko Niimura, Michika Tanoue, Motoe Yamamura,Toyoaki Hirata and Nozomu Asuka are equally contributed to this work1
Mental Health and Nursing Research Team, Tokyo Metropolitan Instituteof Medical Science, Setagaya‑ku, Tokyo, Japan
Full list of author information is available at the end of the article

the length of stay in psychiatric beds in Japan appears
strikingly longer than other OECD countries [1]. In
2004, the Ministry of Health, Labour, and Welfare
announced a policy for the transition from psychiatric inpatient care to community-based mental healthservices [2]. Nevertheless, the mental health care system in Japan has predominantly remained dependent
on hospital-based services, with only a slight decline in
the length of stay in psychiatric hospitals during the last
decade. The National Patient Survey reported an average© 2015 Nakanishi et al. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License(http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium,provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license,
and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/
publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Nakanishi et al. Int J Ment Health Syst (2015) 9:23

of length of stay of 385.7 days in 2002 [3] and 341.6 daysin 2011 [4].
Several patient characteristics have been identified
as factors related to a longer length of stay in psychiatric inpatient care; such factors include male sex [5–8],
schizophrenic and delusional disorders [6, 7, 9], physicalcomorbidity [8], younger age of onset of mental disorder [8], and less adherence to medication [10]. However,length of stay depends on the service system rather than
individual patient characteristics [11, 12].
The national government has initiated several policies to promote the transition from psychiatric inpatientcare to community-based mental health services. Under
the public healthcare insurance program, the Ministryof Health, Labour, and Welfare introduced an acute psychiatric care unit as well as an additional benefit schedule to pay for discharge planning in psychiatric inpatientcare [13]. Acute psychiatric care units under the publichealthcare insurance program are designed to discharge
inpatients within 3 months. Psychiatric acute care hospitals had an average of length of stay of 54.4–79.7 daysin 2012 [14]. Discharge planning provides the critical link
between inpatient treatment and community-based postdischarge care [15, 16]. The additional benefit schedule
for discharge planning is aimed at improving dischargeof long-stay inpatients, paying only for psychiatric longterm care units. However, discharge planning is required
not only for long stays but also in acute care settings toprevent long stays and readmission in new inpatients. A
shorter length of stay without proper discharge planning
would increase risk for readmission [17, 18]. Follow-up
outpatient services prevent readmissions of psychiatricpatients after discharge [19]. Provider communication
between inpatient treatment and outpatient care plays a
key role in preventing early readmission [20]. However,
the requirement of a shorter length of stay could lead todischarges from acute psychiatric inpatient care without
proper discharge planning. Thus, the aim of the present
study was to examine the association between the implementation of discharge planning and length of hospital stay of acute psychiatric inpatient care in Japan. We
hypothesised that enhanced implementation of dischargeplanning would require a relatively greater length of stayfor acute psychiatric inpatients.

Methods
DesignThis study was conducted using a retrospective crosssectional design.
Setting

Eligible institutions consisted of 80 psychiatric hospitals
with a ‘psychiatric emergency ward’ in the list compiled

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by the Japanese Association for Emergency Psychiatry at
the end of August 2010. The psychiatric emergency ward
is certified as an acute psychiatric care unit under the feeschedule for the public healthcare insurance program;the ward has a high staffing requirement, including one
or more full-time designated psychiatrists, two or more
full-time psychiatric social workers, and one or more
nurses per ten patients.
Each hospital was asked to rate patients who were discharged from the hospital’s psychiatric emergency ward
during a two-week period from March 7th to 20th, 2011.
Each hospital was also asked to exclude patients who
were discharged to another unit in the same hospital,
another hospital, or a medical care facility under the public long-term care insurance program.
Participants

A total of 561 patient-level questionnaires were collected from 66 hospitals, an 82.5% response rate.
Among the 561 questionnaires, 112 questionnaires
were excluded because of incomplete information.
The final sample for analysis consisted of the remaining 449 questionnaires from 66 hospitals. In contrast
to the 112 excluded patients, the 449 included patients
had a higher rate of discharge to their own homewhere they lived alone [χ2 (5) = 12.55, p = 0.028]. The
66 hospitals included in this study had an average of
63.4 beds in emergency care units. One-third of the 66
hospitals (n = 20) were located in the Kanto region.
There was no significant difference from the 14 hospitals that did not respond to the survey either in number of beds in emergency care wards [t (17.46) = 0.05,
p = 0.958] or in distribution of regions [χ2 (6) = 3.94,
p = 0.685].
Procedures

The questionnaires were administered over a two-month
period from March to April 2011. A set of paper questionnaires was mailed to each participating hospital. The
completed questionnaires were also collected by mail.
An assigned nurse or nursing assistant was asked toread the instructions and to answer the questions independently. The set of questionnaires had an introductory
section, including a description of the purpose of thestudy, an explanation of the voluntary nature of participation, and an assurance of anonymity for the patientsand responding hospitals. The participating hospitals
were not required to sign consent forms; returning thequestionnaire implied consent. Informed consent was
not sought from the patients because our observation
was based on retrospective reports from nurses about
the patients who had already been discharged from thehospital.

Nakanishi et al. Int J Ment Health Syst (2015) 9:23

Measures

The questionnaire collected information on patient characteristics, implementation of discharge planning, social
functioning at discharge, and length of stay.
Discharge planning consisted of seven domains and 34
items (Table 1). These domains and items were reviewed

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by a working group that included researchers and practitioners from a psychiatric hospital. The domains weredeveloped based on categories of the psychiatric nursing intervention classification system in Japan [21]. The
items were intended to cover a variety of discharge planning [22], the concept of the therapeutic nurse-client

Table 1 Discharge planning in the early-mid phase of the hospital stay and preparation for discharge
Activityn (%)
Early-mid

Preparation

Explore the patient’s view on medication

295 (65.7)308 (68.6)

Share with the patient why medication will be continued, and how to take medication post-discharge

176 (39.2)

289 (64.4)

Education about self-administration of medication

36 (8.0)104 (23.2)

Explain strategies to address post-discharge side effects of medication

103 (22.9)

205 (45.7)

Consult with an assigned physician on expected difficulties in post-discharge medication management

105 (23.4)

164 (36.5)

Explain mechanism of the disease and symptoms

119 (26.5)

169 (37.6)

Discuss identification of each symptom in accordance with the patient’s perceived experience of disease237 (52.8)

271 (60.4)

Discuss the cause of hospitalisation

285 (63.5)

295 (65.7)

Explore the patient’s feelings and wishes in his/her life with the disease

193 (43.0)

281 (62.6)

Explain why hospital staff (in outpatient service) and the patient will meet regularly post-discharge

169 (37.6)

331 (73.7)

Verify the date of outpatient service and means of transportation

95 (21.2)

300 (66.8)

Discuss identifying triggers that increase symptoms

191 (42.5)

280 (62.4)

Discuss identifying signs of deterioration

140 (31.2)

244 (54.3)

Develop and share post-discharge strategies to address deterioration post-discharge

106 (23.6)

261 (58.1)

Ensure means of post-discharge access to healthcare agency when the symptoms worsen

82 (18.3)

237 (52.8)

Advice about coping with symptoms

172 (38.3)

264 (58.8)

Psychotropic medication management

Disease management

Symptoms management

Support for personal relationships
Facilitate self-exposure based on assertion training

46 (10.2)

74 (16.5)

Advice and intervention for relationship building

129 (28.7)

173 (38.5)

Contact with family members to provide emotional support

161 (35.9)183 (40.8)

Complement the information that physician provided to family members

170 (37.9)200 (44.5)

Advice about communication with the patient

129 (28.7)

170 (37.9)

Debrief responses and feelings when visiting the patient or the patient visits them

199 (44.3)

266 (59.2)

Respond to their concerns about the patient’s symptoms and challenging behaviours

182 (40.5)

210 (46.8)

Inform current condition and prognosis of the patient

173 (38.5)

198 (44.1)

Share regarding the disease and medication

135 (30.1)

183 (40.8)

Refer to peer support group available in the community or hospital46 (10.2)

59 (13.1)

Explain why medication and outpatient service will be continued, and how to address deterioration and crisis

93 (20.7)

195 (43.4)

Family support

Family involvement

Coordination with post-discharge community care resources
Consult on social rehabilitation and participation to facilitate the patient’s wishes

88 (19.6)

211 (47.0)

Contact with family members to explore the patient’s post-discharge place in daily life

96 (21.4)

203 (45.2)

Trial participation in day-care, workshop, or Alcoholics Anonymous

48 (10.7)

86 (19.2)

Visit planned post-discharge residence

38 (8.5)

59 (13.1)

Help the patient collect necessities for post-discharge daily life

73 (16.3)

148 (33.0)

Multidisciplinary meeting to share information on social rehabilitation, participation, and place in daily life

97 (21.6)

153 (34.1)

Meeting with in-hospital workers and community service providers

55 (12.3)

94 (20.9)

Nakanishi et al. Int J Ment Health Syst (2015) 9:23

relationship [23], and family involvement [24]. The
assigned nurse or nursing assistant retrospectively rated
implementation of the activity during the early-mid
phase of the hospital stay and in preparation for discharge(1 = implemented, 0 = not implemented). The early-mid
phase was defined as the duration from admission to
reduction in acute symptoms (e.g., the patient is moved
from a seclusion room to a shared bedroom). Because
the present study focused on the link between inpatient
treatment and community-based post-discharge care,patients were divided into the following two groups: 122
patients who had received no support for seven activities in coordination with post-discharge community careresources both during the early-mid phase and in preparation for discharge, and the remaining 327 patients who
had received any community care coordination support.
Length of stay was defined as the number of days
between admission and discharge.
Social functioning at discharge was retrospectively
evaluated by the Japanese version of Global Assessmentof Functioning (GAF) scale [25]. The GAF provides asummary score reflecting the level of psychological,
social, and occupational functioning on a scale from 1 to
10. Satisfactory validity was reported [26].
Patient characteristics included age, sex, educationlevel, working status before admission, primary diagnosis, juridical basis of admission, total number of psychiatric hospitalisations, presence of physical comorbidity,
current place of residence, and follow-up outpatient service after discharge. Current place of residence wasdivided into living alone at own home, cohabitation withfamily, residential care facility, readmitted to hospitalfrom home, dead shortly after discharge, or unidentified place of residence. ‘Residential care facility’ included
daily life adjustment training facilities (engoryou), welfare homes (fukusi-home), group homes, and other residential facilities (nyuusyo-shisetsu). Follow-up outpatient
services after discharge assessed whether the discharged
patient received follow-up services. The questionnairealso included age at first presentation to mental healthservices. However, as many respondents did not indicate
the patient’s age at first presentation (64 of 449, 14.3%),
this was excluded from the analysis.
Ethical considerations

To preserve respondent anonymity, identification numbers
were assigned to hospitals. The study was approved by the
Ethics Committee of the Tokyo Institute of Psychiatry.
Statistical analysis

Differences between the 122 patients who had received
no support for community care coordination and thePage 4 of 8

remaining 327 patients were analysed based on patientcharacteristics and length of stay. Because some categories of primary diagnosis had a small number of patients(<10%), diagnoses were divided into schizophrenia, affective disorders, or other. Work status was divided into thefollowing three categories: engaged in work, not engaged
in work, and unidentified working status. The length ofstay was transformed using a natural logarithm due tothe highly skewed distribution.
Multilevel linear regression analysis was used using
the natural logarithm of length of stay as the dependent
variable and implementation of discharge planning as theindependent variable. The model also included patientcharacteristics as independent variables.
Because data were taken from multiple patients fromeach hospital, multilevel modelling was used for multivariate analyses. The models included random effects foreach hospital to account for within-hospital correlations.
All statistical analyses were conducted using Stata SE
for Windows, version 13.0 (StataCorp, College Station,
Texas, USA). The two-tailed significance level was set at
0.05.

Results
Patient characteristics

The mean age at admission was 44.9 years. Half of
respondent patients were men, not engaged in work,and had a primary diagnosis of schizophrenic disorders.
The majority of patients were discharged to cohabitation with family. The average length of stay was 49.0 days
(SD = 50.9) (Table 2).
Implementation of discharge planning

In the early-mid phase of the hospital stay, more thanhalf of assigned nurses or nursing assistants of the 449
patients discussed with patients their view on medication (65.7%), the cause of hospitalisation (63.5%), andidentification of each symptom in a manner consistent with the patient’s perceived experience of disease(52.8%). Less than one-tenth of nurses provided education about self-administration of medication to thepatient (8.0%) or visited the planned post-discharge residence (8.5%; Table 1). The 449 patients had an averageof 9.9 activities (standard deviation 8.0) in the early-mid
phase of the hospital stay and 16.2 (9.6) at preparation
for discharge. All seven domains showed a significant
increase in the total number of implemented activities from the early-mid phase of the hospital stay topreparation for discharge [t (448), 4.19–15.19; p < 0.05].
Approximately one quarter of the 449 patients (n = 122)
had received no support for coordination with post-discharge community care resources.

Nakanishi et al. Int J Ment Health Syst (2015) 9:23

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Table 2 Characteristics of 449 patients discharged fromemergency psychiatric care units in Japan
Patient characteristic

Mean (SD) or n (%)

Age at admission, year (median = 43.0)

44.9(17.3)

206(45.9)

Sex, male

Education level
Junior high school

119(26.5)High school

175(39.0)

rate of either no follow-up or unidentified post-discharge
outpatient service than the other 327 patients (Table 3).
Factors related to the length of stay

The multilevel linear regression analysis demonstrated asignificantly greater length of stay among older patientsand those with a primary diagnosis of schizophrenia,
compulsory admission, hospital outpatient follow-up services, and who had received support for community carecoordination. The random effect of hospital accounted
for <1% of total variance (Table 4).

Vocational school, college49(10.9)

University

69(15.4)

Unidentified

37

(8.2)

Full-time56(12.5)

Main findings of the study

Part-time47(10.5)

Sheltered employment

12

(2.7)

Employment, unspecified

28

(6.2)

Family business54(12.0)

Not engaged in work234

(52.1)

Unidentified

18

(4.0)

203

(45.2)As expected, the implementation of discharge planningdemonstrated a negative association with length of stay.
A significantly longer length of stay was observed among
patients who had received support on coordination with
post-discharge community care resources. Furthermore,
a greater length of stay was observed among patients who
received post-discharge follow-up by the hospital outpatient service. Patients who did not receive community
care coordination support were discharged after a shorter
length of stay from the hospital with either unidentified
outpatient services or no follow-up. These results suggestthat because of the requirement of a shorter length ofstay, some patients may have been discharged from acute
psychiatric hospitals without proper discharge planning.
The public healthcare insurance program requires that atleast 40% of annual admissions to psychiatric emergency
units are new patients, although the readmission rate ofdischarged inpatients is not taken into account under thefee schedule. The mental health policy should increase
focus on discharge planning in the acute psychiatric setting to enhance a link between psychiatric inpatient careand post-discharge community care resources.
Among the 34 discharge planning activities, only threewere implemented to half of the 449 patients during theearly-mid phase of the hospital stay, although dischargeplanning should begin at the time the inpatient is admitted to the psychiatric unit. The implementation of discharge planning significantly increased in preparation
for discharge. However, coordination with post-dischargecommunity care resources was never administered toa quarter of the 449 patients. The nurses would havedetermined the implementation of discharge planningaccording to individual patient needs. Meanwhile, theimplementation of support for community care coordination did not indicate a significant association withcompulsory admission or schizophrenic disorder, whichhave been related to an increased risk of psychiatric readmission [27]. As the psychiatric emergency ward has
to discharge inpatients within 3 months, it may be that

Discussion

Working status before the admission

Primary diagnosis, ICD-10
Schizophrenia, schizotypal, and delusional
disorders (F20–F29)
Mood (affective) disorders (F30–F39)

115(25.6)

Psychoactive substance use (F10–F19)

26

(5.8)

Organic (F00–F09)

25

(5.6)

Neurotic, stress-related and somatic (F40–49)

24

(5.4)

Other categories

56(12.5)(77.3)

Juridical basis of admission, compulsory

347

Total number of psychiatric admissions

3.1

(4.3)

Physical comorbidity

103(22.9)

Length of stay, day

49.0(50.9)

Social functioning at discharge (1–10)

6.6

(1.7)

Current place of residence
Lives alone at own home69

(15.4)

Cohabitation with family

306(68.2)

Residential care facility

26

(5.8)

Readmitted to hospital from home

20

(4.5)

Dead shortly after discharge

2

(0.5)

Place of residence unidentified

26

(5.8)

Follow-up outpatient service after discharge
Followed by outpatient service of the hospital309(68.8)

Followed by outpatient service of other hospital

123(27.4)

No follow-up with post-discharge outpatient
service7(1.6)

Unidentified

10

(2.2)

Patient characteristics and support on community carecoordination

The 122 patients who had received no support for community care coordination had a significantly lower mean
age at admission, a shorter length of stay, and a higher

Nakanishi et al. Int J Ment Health Syst (2015) 9:23

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Table 3 Comparison between 122 patients who did not and 327 patients who did receive community care coordination
supportPatient characteristic, mean (SD) or n (%)

Community care coordination support
No (n = 122)

Yes (n = 327)

Test statistic

Age at admission, year

41.5 (17.1)

46.2 (17.3)

Sex, male52 (42.6)

154 (47.1)

t (218.82) = 2.55*

Education level
Junior high school

27 (22.1)

92 (28.1)

High school

123 (37.6)

52 (42.6)

Vocational school, college

11 (9.0)38 (11.6)

University

20 (16.4)

49 (15.0)

Unidentified

25 (7.7)

12 (9.8)

Working status before the admission
Engaged in work

46 (37.7)

151 (46.2)

Not engaged in work

68 (55.7)

166 (50.8)

Unidentified

8 (6.6)

10 (3.1)

Schizophrenic

56 (45.9)

147 (45.0)

Affective

32 (26.2)

83 (25.4)

Other

34 (27.9)

97 (29.7)

Compulsory admission

97 (79.5)

250 (76.5)

Total number of psychiatric admissions

3.0 (4.2)

3.1 (4.3)

Physical comorbidity

25 (20.5)

78 (23.9)

Length of stay, day

33.2 (46.2)

54.9 (51.4)

Social functioning at discharge (1–10)

6.4 (1.8)

6.7 (1.6)

Primary diagnosis

Current place of residence
Lives alone at own home

14 (11.5)55 (16.8)

Cohabitation with family

84 (68.9)222 (67.9)

Residential care facility

6 (4.9)20 (6.1)

Readmitted to hospital from home

6 (4.9)14 (4.3)

Dead shortly after discharge

2 (1.6)0 (0.0)

Place of residence unidentified

10 (8.2)

16 (4.9)

Follow-up outpatient service after discharge
Followed by outpatient service of the hospital

75 (61.5)

234 (71.6)

Followed by outpatient service of other hospital

35 (28.7)

88 (26.9)

No follow-up/unidentified

12 (9.8)

5 (1.5)p value0.011

χ2 (1) = 0.72

0.398

χ2 (4) = 2.96

0.564

χ2 (2) = 4.58

0.101

χ2 (2) = 0.14

0.932

χ2 (1) = 0.47

0.492

t (218.90) = 0.20

χ2 (1) = 0.57

0.841
0.451

t (239.65) = 4.30*<0.001χ2 (5) = 9.00

0.109

χ2 (2) = 17.61*<0.001t (200.86) = 1.79

0.075

* Significant at p < 0.05.

inpatient treatment had a greater focus on the management of acute psychosis. In addition, the majority of
our sample patients were admitted involuntarily. In thepsychiatric emergency ward, at least 60% of all admissions should be involuntary admissions. Thus, a longer
stay would have required establishment of a therapeuticpatient-nurse relationship.
The length of stay in acute psychiatric care was significantly associated with a primary diagnosis of schizophrenic disorder and compulsory admission. This
is in agreement with previous research in Western
psychiatric inpatient care settings [5–7, 9]. However,there was no significant association with male sex andphysical comorbidity. These findings are in contrast
with a previous study regarding patient characteristics
and longer length of stay [5–8]. Furthermore, in contrast from previous findings [6, 7], it is notable that thelength of stay in the psychiatric emergency ward did
not differ between the hospitals. The universal benefit schedule strict defines the care setting in the psychiatric emergency ward under the public healthcare
insurance program. Therefore, care settings would not
differ between units. Factors relating to length of stayshould be explored among inpatients in other psychiatric care settings as well as psychiatric emergency wards
in Japan.

Nakanishi et al. Int J Ment Health Syst (2015) 9:23

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Table 4 Linear regression analysis of the natural logarithmof length of stay
Coefficient 95% CI

p value

2.41

1.89–2.93<0.001

Age at admission, year

0.01*

0.01–0.02<0.001

Sex, male

0.11−0.05–0.28

0.183Intercept
Fixed effectEducation level (junior high school = 0)
High school

Vocational school, college

−0.02
0.14

University

0.04

Unidentified

−0.16

0.848

−0.23–0.19

0.361−0.16–0.44

0.771−0.23–0.31

0.337−0.49–0.17

Working status before admission (not engaged in work = 0)
Engaged in work

Unidentified

−0.15

0.083

−0.33–0.02−0.23−0.66–0.19

0.285

Schizophrenic

0.40*

0.20–0.59<0.001Affective disorder

0.18

Compulsory admission

0.47*−0.05–0.41

0.27–0.67<0.001

Total number of psychiatricadmissions−0.01−0.03–0.01

0.267

Physical comorbidity

0.04−0.17–0.24

0.714−0.42–0.05

0.130

Primary diagnosis (other = 0)

0.129

Current place of residence (cohabitation with family = 0)
Lives alone at own home

Residential care facility

−0.18
0.01

Readmitted to hospital from
home

−0.18

Dead shortly after discharge−0.49

Place of residence unidentified −0.21

Social functioning at discharge

0.921−0.35–0.37

0.372−0.59–0.22

0.435−1.72–0.74

0.258−0.56–0.15−0.08–0.02

0.255

Follow-up outpatient service of −0.35*
other hospital−0.54 to −0.17<0.001

No follow-up/unidentified−1.17*−1.63 to −0.72<0.001

Residual

0.73

0.63–0.84

Intercept: hospital

0.003

10−11 × 0.28 − 23,291.62−0.03

Follow-up outpatient service after discharge (follow-up outpatient
service by the hospital = 0)

Received support on community 0.61*
care coordination

0.43–0.80<0.001

Random effectIntra-class correlation coefficient <0.001(ICC)

a greater rate of discharge to their own residence thanthose excluded from the analyses. Third, the implementation of nursing care was evaluated by one assigned nurse
or nursing assistant of each patient. Discharge planningis based on a multidisciplinary approach; hence, information on discharge planning should be collected withmulti-professional views. Fourth, the assessment did
not collect information on patient medication compliance and social functioning at admission, both of whichhave previously been associated with length of stay [5].
Finally, our observation was based on a retrospective
and cross-sectional evaluation that provided information
only about those who were discharged. Length of stay inpsychiatry is suggested to follow a hazard-based distribution [28]. Future research should examine the effectof discharge planning on readmission rate of psychiatricinpatients as well as length of stay in a prospective study
design.
Despite these limitations, the present study is the firstto present an association between the implementation ofdischarge planning and length of stay for acute psychiatric care using national representative data.

Conclusions
The present study examined the association between theimplementation of discharge planning and the length ofstay of acute psychiatric inpatients in Japan. Patients towhom the assigned nurse or nursing assistant provided
support on community care coordination showed a significantly greater length of hospital stay. The length ofstay in acute psychiatric care was also significantly associated with a primary diagnosis of schizophrenic disorderand compulsory admission. The implementation of support for community care coordination did not indicate
a significant association with these factors, which havebeen related to an increased risk of psychiatric readmission. The mental health policy should increase focus ondischarge planning in the acute psychiatric setting toenhance a link between psychiatric inpatient care andpost-discharge community care resources.

1,182.97

Authors’ contributions
JN and MT designed the study with input from MY, TH, and NA. All authors
were involved in the conduct of the study, interpretation of results, andrevision and correction of the report, which was drafted by MN and JN. The
analyses were led by MN. All authors read and approved the final manuscript.

Limitations
The present study has the following limitations. First,
while the response rate was large, there may have beena responder bias. Second, the patients in our sample had

Author details
1
Mental Health and Nursing Research Team, Tokyo Metropolitan Instituteof Medical Science, Setagaya‑ku, Tokyo, Japan. 2 Mental Health and PsychiatricNursing, Graduate School of Health Care Sciences, Tokyo Medical and Dental
University, Bunkyo‑ku, Tokyo, Japan. 3 Division of Nursing Sciences, Graduate
School of Human Health Sciences, Tokyo Metropolitan University, Arakawa‑ku,
Tokyo, Japan. 4 Chiba Psychiatric Medical Centre, Chiba‑shi, Chiba, Japan.
5
Research Project for Mental Health Promotion, Tokyo Metropolitan Instituteof Medical Science, Setagaya‑ku, Tokyo, Japan.

Fitness of modelχ2 (23)178.61

Log likelihood−566.48

Akaike’s information criterion(AIC)<0.001* Significant at p < 0.05.

Nakanishi et al. Int J Ment Health Syst (2015) 9:23

Acknowledgements
The authors gratefully acknowledge the following individuals for their support
in developing the questionnaire: Tamio Sueyasu and Sakae Nakano, Japanese
Psychiatric Nurses Association; Masumi Otake, Ichiyokai Hospital; and Tomoko
Noda, Tokyo Medical and Dental University.
Compliance with ethical guidelines
Competing interests
The present study was funded by the Ministry of Education, Culture, Sports,
Science, and Technology, and the Tokyo Institute of Psychiatry. The funders
had no role in the design and conduct of the study; collection, management,
analysis, and interpretation of data; or preparation, review, and approval of themanuscript. The authors declare that they have no conflict of interest.
Received: 9 December 2014 Accepted: 20 May 2015

References
1. Organisation for Economic Cooperation and Development. OECD healthstatistics. 2014.
2. Ministry of Health, Labor, and Welfare. Reform vision of mental healthservices. http://www.mhlw.go.jp/topics/2004/09/dl/tp0902-1a.pdf.
3. Ministry of Health, Labor, and Welfare. The national patient survey. 2002.
4. Ministry of Health, Labor, and Welfare. The national patient survey 2011.
5. Compton MT, Craw J, Rudisch BE. Determinants of inpatient psychiatric length of stay in an urban country hospital. Psychiatr Q.
2006;77(2):173–88.
6. Pertile R, Donisi V, Grigoletti L, Angelozzi A, Zamengo G, Zulian G, et al.
DRGs and other patient-, service- and area-level factors influencing
length of stay in acute psychiatric wards: the Veneto Region experience.
Soc Psychiatr Psychiatr Epidemiol. 2011;46(7):651–60.
7. Liu CM, Li CS, Liu CC, Tu CC. Determinants of psychogeriatric inpatient length of stay and direct medical costs: a 6-year longitudinal
study using a national database in Taiwan. Psychiatry Clin Neurosci.
2012;66(5):423–31.
8. Douzenis A, Seretis D, Nika S, Nikolaidou P, Papadopoulou A, Rizos EN,
et al. Factors affecting hospital stay in psychiatric patients: the role ofactive comorbidity. BMC Health Serv Res. 2012;12:166.
9. Masters GA, Baldessarini RJ, Öngür D, Centorrino F. Factors associated with length of psychiatric hospitalization. Compr Psychiatry.
2014;55(3):681–7.
10. Xafenias A, Diakogiannis I, Iacovides A, Fokas K, Kaprinis G. Factors
affecting hospital length of stay: is substance use disorder one ofthem? A study in a Greek public psychiatric hospital. Am J Addict.
2008;17(5):447–51.
11. Oshima I, Mino Y, Inomata Y. How many long-stay schizophrenia patientscan be discharged in Japan? Psychiatry Clin Neurosci. 2007;61(1):71–7.

Page 8 of 8

12. Badriah F, Abe T, Nabeshima Y, Ikeda K, Kuroda K, Hagihara A. Predicting
the length of hospital stay of psychiatry patients using signal detection
analysis. Psychiatr Res. 2013;210(3):1211–8.
13. Ministry of Health, Labor, and Welfare. Annual Health, Labour and Welfare
Report 2008-2009. Part 2 Key Administrative Measures of the Ministryof Health, Labour and Welfare. Chapter 6 Promotion of Self-Sufficiency
Support for People with Disabilities. http://www.mhlw.go.jp/english/wp/
wp-hw3/dl/Part02-06.pdf.
14. Japan Psychiatric Hospitals Association. WHO Lecture in 2013. http://
www.nisseikyo.or.jp/admin/ippan/02info/05topic/201310_WHO.pdf.
15. Shepperd S, Lannin NA, Clemson LM, McCluskey A, Cameron ID, Barras SL.
Discharge planning from hospital to home. Cochrane Database Syst Rev.
2013;!:CD000313.
16. Nurjannah I, Mills J, Usher K, Park T. Discharge planning in mental health care: an integrative review of the literature. J Clin Nurs.
2013;23(9–10):1175–85.
17. Johnstone P, Zolese G. Systematic review of the effectiveness of planned
short hospital stays for mental health care. BMJ. 1999;318(7195):1387–90.
18. Figueroa R, Harman J, Engberg J. Use of claims data to examine theimpact of length of inpatient psychiatric stay on readmission rate. Psychiatr Serv. 2004;55(5):560–5.
19. Nelson EA, Maruish ME, Axler JL. Effects of discharge planning and compliance with outpatient appointments on readmission rates. Psychiatr
Serv. 2000;51(7):885–9.
20. Vigod SN, Kurdyak PA, Dennis CL, Leszcz T, Taylor VH, Blumberger DM,
et al. Transitional interventions to reduce early psychiatric readmissions inadults: systematic review. Br J Psychiatry. 2014;202(3):187–94.
21. Sawada A, Porter SE, Kayama M, Setoya N, Miyamoto Y. Nursing care delivery in Japanese psychiatric units. Br J Nurs. 2006;15(17):920–5.
22. Nakanishi M, Sawamura K, Sato S, Setoya Y, Anzai N. Development of aclinical pathway for long-term inpatients with schizophrenia. Psychiatry
Clin Neurosci. 2010;64(1):99–103.
23. Reynolds W, Lauder W, Sharkey S, Maciver S, Veitch T, Cameron D. The
effects of a transitional discharge model for psychiatric patients. J Psychiatr Ment Health Nurs. 2004;11(1):82–8.
24. Ewertzon M, Lützén K, Svensson E, Andershed B. Developing the conceptof family involvement and the alienation questionnaire in the context of
psychiatric care. Int J Ment Health Nurs. 2008;17(6):439–49.
25. Takahashi S, Ohno Y, Someya T. Quick reference to the diagnostic criteria
from DSM-IV. Tokyo: Igaku-Shoin; 1995 (in Japanese).
26. Yamauchi K, Ono Y, Baba K, Ikegami N. The actual process of rating the global assessment of functioning scale. Compr Psychiatry.
2001;42(5):403–9.
27. Graca J, Klut C, Trancas B, Borja-Santos N, Cardoso G. Characteristics offrequent users of an acute psychiatric inpatient unit: a five-year study inPortugal. Psychiatr Serv. 2013;64(2):192–5.
28. Stevens A, Hammer K, Buchkremer G. A statistical model for length ofpsychiatric in-patient treatment and an analysis of contributing factors.
Acta Psychiatr Scand. 2001;103(3):203–11.

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