A Transition to Discharge Program for the Reduction of Early Readmission in a Mental Health Inpatient Unit: Study Protocol

Abstract

Early readmission to psychiatric units poses a significant challenge for both patients 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). The present proposal consists of two distinct phases with two clearly differentiated main objectives. On the one hand, following an observational design, the development of a measurement instrument to assess patients’ risk of early readmission, allowing for stratification into the high-, medium-, and low-risk categories. On the other hand, according to a quasi-experimental design, the implementation and evaluation of the intervention program, with a focus on tailored interventions to ensure adherence and continuity of care post-discharge, with a more intensive approach for high-risk patients. A post-discharge psychotherapeutic group will also be introduced for high-risk cases to support recovery. The program’s effectiveness will be evaluated by comparing the early readmission rates at the Regional Hospital of Malaga’s MHHU to those of the previous year. Two other hospitals in the province, where the intervention is not applied, will serve as control groups. Success will also be measured through pre- and post-assessments of the recovery, functionality, subjective well-being, social support, and treatment satisfaction of those participating in the psychotherapeutic group. This proposal aims to address the issue of early readmission by enhancing predictability and understanding intervention strategies to reduce readmission rates.

1. Introduction

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 a community mental health unit (CMHU), represents a major challenge for both the individual and the health institutions, often compromising the 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 the quality of care, resulting in deficient attention being paid to the needs and peculiarities of users, which 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 one in seven 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 availability of an adequate care plan and community therapeutic resources after discharge [6]. In a recent study, a one-year follow-up was conducted with young adults after experiencing a first psychotic episode, finding a readmission rate of around 45%. The study examined variables related to an increased risk of readmission and relapse, identifying potential predictive factors in the use of psychoactive substances and the use of long-acting injectable antipsychotics to promote treatment compliance. Another important and recent study emphasized the significance of antipsychotic treatment and its impact on improving the quality of life and reducing the risk of relapse [7]. These findings highlight the importance of considering these aspects in the therapeutic approach to ensure treatment adherence and long-term recovery [8].

Regarding interventions, there is enormous heterogeneity in the available evidence, due both to the diversity of the post-discharge interventions that have been developed in this regard and to the variability of the 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 a 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 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 the following: critical time interventions (CTIs), 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. Most post-discharge interventions focus on a single component in isolation (such as contact-based, peer support, role-based, pharmacological management, etc.) and by themselves demonstrate inconsistent results regarding the readmission reduction, varying across studies [1,9].

In summary, all the 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 the care transition when aiming to reduce psychiatric readmissions [9].

On the other hand, clinical practice guidelines (CPGs) 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 [10,11].

Psychiatric readmission is a very complex issue, and its approach must take into account all the involved variables. Existing interventions focus only on one or a few of the implicated aspects. All of this makes clear the importance of conducting a multicomponent therapeutic approach based on a discharge transition model [1,6,12]. This model focuses on reducing hospital readmission and combines elements aimed at ensuring continuity of care, treatment adherence 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 their social support networks [9,10]. Our proposal is integrative and aims to build upon elements described above that have proven their relevance in reducing readmissions in recent studies. Additionally, this study is groundbreaking as it presents an intervention approach tailored to each patient’s risk level.

The aim of this study is, firstly, to create a tool for assessing the risk of early readmission that allows for the stratification of admitted patients according to their risk level, based on an analysis of clinical and sociodemographic variables. The second objective is to implement and evaluate if a multicomponent discharge transition intervention program reduces the risk of early readmission compared to a control group. Lastly, we aim to test whether a post-discharge recovery support psychotherapy group, applied to high-risk of readmission patients, improves the outcomes in terms of measures of recovery, functioning, subjective well-being, social support, and satisfaction with mental health treatment.

2. Methods

2.1. Design

To fulfill the first part of this study, following an observational design, an early readmission risk index 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 index and to study the risk factors for early readmission.

For the evaluation of the efficacy of the multicomponent discharge transition program for the reduction of early readmissions to an MHHU a quasi-experimental cluster clinical trial aimed at assessing the efficacy will be conducted.

To evaluate the post-discharge psychotherapeutic recovery support program a quasi-experimental pre–post assessment will be conducted. This evaluation will be conducted by blinded evaluators before the program begins and upon its completion, after the last session.

2.2. Setting

The present study will be carried out in the MHHU of the University Regional Hospital of Malaga (URHM), a public hospital run by the Andalusian Health Service. In addition to the mental health clinical management unit of the URHM of Málaga, this MHHU is a reference for two other regional hospitals in the province of Málaga: Málaga East Axarquía Hospital and Málaga North Antequera Hospital. According to figures from the 2022 data of the Andalusian Mental Health Program, the Mental Health Clinical Management Unit of the URHM of Malaga has a catchment area of 336,968 individuals, while the mental health clinical management units of La Axarquía and Málaga North Antequera Hospital cover 150,823 and 109,958 individuals, respectively, with a total catchment area of 597,749 individuals.

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. The data collected at the URHM 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 affiliated with said hospital, including the North and Central Malaga Community Mental Health Units (second level).

2.3. Procedure

2.3.1. Construction of the Early Readmission Risk Index

A measurement instrument will be developed to determine the risk of early readmission for all patients admitted to the MHHU. During admission to the hospitalization unit, all users must have the aforementioned early readmission risk index of the MHHU of the URHM 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 index 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.

To construct the risk index and test its internal validity, we have used the procedure described by Sullivan et al. [13]. In summary, this procedure will comprise the following steps:

• Calculate the estimators of the regression coefficients of the multivariate logistic regression model.
• Organize the risk factors into categories to determine a reference value for each risk factor.
• Determine the distance of each category to the reference category.
• Calculate a point value for each category.
• Calculate the model’s ability to discriminate between those who were and those who were not readmitted at 30 days after discharge, by calculating the C statistic (area under the curve).

2.3.2. Description of the Transition to Discharge Program for the Reduction of Early Readmission

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 the available evidence and decision-making regarding the development and implementation of the current program.

This is a multicomponent program that includes elements aimed at promoting continuity of care after discharge and 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.

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.

A.

General measures

The following measures would be applied to patients with a low risk of readmission:

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Ensure coordination between physicians during admission and a follow-up appointment within 7 days.

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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 with social impairment, refer them to a social worker at the MHHU during admission and initiate a social history.

B.

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:

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Schedule at least three follow-up appointments: one (via telephone) with a psychiatrist from the MHHU within 24 h post-discharge, and two at the community mental health unit: the first within 7 days and the second between days 21 and 30.

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If the patient presents with social impairment, schedule an appointment with a social worker from the community mental health unit within 14 days post-discharge.

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If the patient has a severe mental disorder, schedule a nursing visit during their stay at the MHHU.

C.

Intensive measures

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:

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Schedule at least three follow-up appointments: one, in this case, in-person, with a psychiatrist from the MHHU within 24 h post-discharge, and two at the community mental health unit: the first within 7 days and the second between days 21 and 30.

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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.

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If the patient has documented medication non-adherence, consider depot medication based on clinical characteristics.

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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 h in advance, re-engaging patients in case of non-attendance, and coordinating with reference facilities.

2.

Post-Discharge Psychotherapeutic Recovery Support Program

This program is intended for patients at high risk of early readmission who meet the inclusion criteria. Participants in the post-discharge group psychotherapy support recovery program will be those at high risk of early readmission (assessed with the risk index) or those who have already been readmitted early after discharge, as long as they meet the inclusion criteria. Their eligibility for inclusion will be assessed through a clinical interview conducted by the clinical psychologist in charge of the program.

The proposed psychotherapeutic intervention is considered 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 [14]. This intervention will be structured into 20 sessions, each lasting 90 min, held weekly in an open format. It will be directed by two co-therapy professionals. The group will consist of a maximum of 12 participants, who may join at different times.

The support program will include 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 will be included based on the available evidence regarding the effectiveness of psychosocial and psychotherapeutic interventions collected in the scientific literature, clinical practice guidelines, and the Integrated Care Process in Severe Mental Disorder of the Andalusian Health Service [1,10,11,14,15]. The contents addressed by the post-discharge recovery support psychotherapeutic program can be grouped into 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.
• 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, and 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 an 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.

2.4. Inclusion and Exclusion Criteria for the Psychotherapeutic Recovery Support Program

Inclusion criteria:

• ▪ Must be over 18 years old.
• ▪ Speak Spanish fluently.
• ▪ Have had recent admission to the MHHU of the Regional Hospital of Málaga and a score considered to be “High Risk” on the early rehospitalization risk index or have experienced an early rehospitalization.
• ▪ Belong to the clinical management unit of mental health of the URHM 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 URHM of Málaga.
• ▪ Lack of commitment to attending sessions or complying with group rules.

2.5. Control Group to Compare the Transition to Discharge Program for the Reduction of Early Readmission

To assess the effectiveness of the multicomponent discharge transition program, users from Málaga East Axarquía Hospital and Málaga North Antequera Hospital will be employed as the control group. Participants in the control group will continue with their usual treatment.

Additionally, users from the URHM catchment area who were admitted the previous year and thus did not participate in the intervention program will also be used as a control group.

2.6. Participants and Sample Size

For the analysis of the risk factors and the development of a risk index for early readmission, a retrospective observational study will be conducted. This will involve analyzing all the episodes from the previous calendar year in the clinical records of the URHM. “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. The sample will be 236 participants (118 with early readmission).

Data from the clinical records of all the hospital admission episodes at the 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 and are within the catchment area of the URHM in the year prior to the intervention will also be utilized. The average number of admissions to the MHHU was 786 per year (range: 688–895, based on data from the last 10 years) and the average number of admissions in the control group from Málaga East Axarquía Hospital and Málaga North Antequera Hospital is estimated to be 210 per year. For a logistic regression with a sample of 786 participants (118 with early readmission and 210 in the control group), an alpha of 0.05, and a power of 80%, the sensitivity analysis indicates that this study will be able to estimate a moderate to large effect size (OR = 1.822).

For the evaluation of the psychotherapeutic recovery support program, data will be collected from participants in the groups conducted during the study period who agree to participate in the research and sign the informed consent form. It is estimated that two groups per year can be formed. Assuming that 20% of potential participants will decline to participate in this study and another 20% will not complete the program, the final sample size is expected to be approximately 14 participants. For a repeated-measures t-test, with an alpha of 0.05 and a power of 80%, the sensitivity analysis estimates that this study will be able to detect large effect sizes (effect size dz = 0.702).

The sensitivity analyses were conducted using G*Power 3.1.9.2.

2.7. Study Variables

2.7.1. Variables for the Construction of the Risk Index

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 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).

2.7.2. Variables for the Assessment of the Transition to Discharge Program for the Reduction of Early Readmission

Main Outcome

The main outcome variable will be the risk of early readmission in the experimental group compared to the control group (individuals from the other two hospitals who will not follow the intervention).

Secondary Outcome

The risk of early readmission of those who followed the program will be compared to the risk of early readmission from the previous year at the URHM.

The risk of frequent readmission will be considered a secondary variable and compared with the risk at the hospitals that did not follow the intervention and with the data of the previous year at the URHM prior to the implementation of the intervention.

2.7.3. Variables for the Psychotherapeutic Recovery Support Program

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. The instruments to be used are as follows:

Main Outcome

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Core Om [16,17]: 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 to 4. It is a valid and reliable instrument in its Spanish version.

Secondary Outcomes

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The Duke Social Support Questionnaire (Duke-unk-11) [18,19]: It 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).

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The Personal and Social Performance Scale (PSP) [20,21]: It is a hetero-applied and very brief instrument that allows for 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) [22,23]: It 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.

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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 [24,25].

2.8. Data Analysis

Descriptive analyses will be conducted for the continuous and categorical variables. For the continuous measures, the summary statistics will include the mean (SD) and standard deviation. If the normality criteria are not met, the median and the first and third quartiles will be reported. The categorical variables will be summarized as the counts and percentages.

In the analysis for the creation of the early rehospitalization risk index, 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 risk index 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.

To evaluate the differences between the intervention group that follows the transition to discharge program for the reduction of early readmission and the control groups, a univariate and multivariate mixed logistic regression analysis will be conducted, introducing potential confounding variables (unit occupancy, age, sex, socioeconomic status, diagnosis and the variables used in the risk index for estimating the risk of early rehospitalization). To assess the robustness of the results and the impact of potential confounders, a sensitivity analysis will be conducted. Alternative statistical models will be used to adjust for different sets of confounding variables. The results of these analyses will be compared with the main model to evaluate the stability of the estimates and the potential influence of confounders on the studied relationship.

To assess the potential differences in the 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.

Missing data will be assessed for patterns (e.g., missing completely at random, missing at random, or missing not at random). Depending on the nature and extent of the missingness, appropriate statistical methods such as multiple imputation or sensitivity analyses will be applied. Additionally, if necessary, we will perform a complete-case analysis and report any potential biases arising from missing data.

3. Expected Results and Discussion

The present research study aims to analyze the risk factors for the 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.

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 index. Additionally, 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 this 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.

Furthermore, this study has significant limitations due to the sample size, which may impact the generalizability of the findings. The relatively small number of participants may not fully represent the broader psychiatric patient population, as the selected individuals could differ in various ways, such as in their social background, clinical conditions, or severity of illness. These differences in social factors and clinical characteristics may not align with those of the general psychiatric population. As a result, the findings of this study may not be applicable to all psychiatric patients, potentially limiting the external validity of the results. Moreover, the sample size limits the number of potential confounding variables to be considered.

One of the major limitations of this 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 [26]. 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 [27]. To gain a more comprehensive understanding of the overall effectiveness of the intervention, further research in different contexts would be essential. When implementing this intervention in other psychiatric units, adaptations could be made to align with the specific characteristics and structures of those units, with careful consideration of the follow-up care after hospitalization. Additionally, more intensive interventions could be scheduled depending on the available resources in each unit. Given the current lack of staff training in program implementation, it is also crucial to develop a training program that equips professionals with the necessary skills to carry out follow-up care after discharge.

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.

To overcome these limitations, a multicenter randomized clinical trial would improve the generalizability of the results, evaluating the effectiveness of the intervention in different populations and contexts. In future research, as mentioned in Vignapiano’s meta-analysis, new digital technologies could be incorporated to prevent readmissions. Incorporating digital health solutions marks a major step forward in mental health care, providing the opportunity for better patient outcomes and increased involvement. The follow-up of patients after discharge through the use of smartphone applications would allow for the detection of warning signs [28].