Transitional care for seriously mentally ill persons: a pilot study.

This article reports the results of a pilot study of a nurse-based in-home transitional care intervention for seriously mentally ill persons. The goals of the intervention were to address the lack of continuity of care in existing programs and to meet the immediate postdischarge needs of severely mentally ill persons. This article focuses primarily on the applicability and feasibility of the intervention for this population, given the challenges of engaging seriously mentally ill patients in a community-based protocol and the complexity of their illnesses. Factors that are important to community adjustment postdischarge were identified: caregiver concerns and health status impeding illness management, lack of structure/involvement in daily activities, structural and functional factors affecting adherence, and presence of symptoms after discharge. Use of an advanced practice nurse to provide transitional care can offer an alternative to patients who might otherwise be left poorly treated or untreated in the community setting.