Topic-

Influential factors in reducing re-admission risk and promoting

recovery: perspectives of forensic out-patients with dual

diagnosis.
Abstract

Hospital readmission produces undesirable outcomes for the healthcare system, practitioners,

patients, and their families. The cost implication of hospital readmission among forensic

patients with dual diagnosis is a major concern due to the high hospitalisation cost. Further,

frequent hospital readmission strains families, reducing social support and increasing’s cases

of social stigma and demotivating workers. The study aimed to understand the factors that

propagate hospital readmissions among forensic patients with dual diagnosis. The knowledge

of the factors and the barriers that promote patient recovery will help develop evidence-based

practices and guidelines in managing hospital readmission. The study adopted a systematic

review to understand the factors that promote hospital readmission. The study found that

readmission rates are higher among patients with a history of substance abuse, facing mental

health issues, and medical and psychiatric comorbidities. The research recommends

strengthening patient follow-up and adequate discharge planning, providing peer support

services, and enhancing in-service training for care workers.

CHAPTER 1: INTRODUCTION

1.0 Overview

The de-institutionalization of mental psychiatric care has significantly resulted in a faster

transition and significant move to community treatment from inpatient care. Although the

approach has received positive outcomes, there are cases of patients experiencing severe

challenges when discharged from hospitals (Becker et al., 2017). These challenges resulted in

increased chances of hospital admissions, particularly in the acute wards. The instances of

readmission are an issue of concern to healthcare facilities and medical practitioners since it

increases pressure on the limited resources in healthcare facilities (Cakir et al., 2017).

Besides, the increased cases of hospital readmissions cause a rise in the years of life lost in

care and harm the quality of life. Hospital readmission is an issue of concern among

healthcare practitioners as it increases treatment costs, patient experience, and outcomes.

Reducing readmission is integral in enhancing the quality of care and cost-reduction

approaches. The readmission rates for forensic patients with dual diagnosis are high,

increasing the risk of longer hospital stays, hospital-related complications, and complexity of

care. The readmission among forensic patients with dual diagnosis is high even when the

reason for hospitalisation is unrelated to addiction treatment (Tully et al., 2019). According to

Tully et al. (2019), readmission rates are higher among women, as female patients in the UK

occupy 15% of beds. Preventing readmission is critical for forensic patients; hence, the need

to understand the factors promoting readmission of forensic patients with dual diagnosis.

According to Clarke et al. (2013), the high rate of hospital readmission was associated with

patients with schizophrenia, with women readmitted at the rate of 27% against men at 21%

per year in the U.K. Understanding the factors that propagate the increased hospital

readmission for forensic patients is integral in developing appropriate interventions.

Conversely, hospital readmission is expensive for healthcare facilities and associated with

health outcomes; hence, an effective intervention is needed to manage the issue. Fazel et al.

(2s016) say, "Costs per patient are substantially more in such hospitals, with some estimates

of £152 000 per year per patient in the UK at low secure institutions and £273 000 in high

secure hospitals and an estimated overall budget of over £1 billion.” The study noted that

hospital readmission costs represent a high component of the mental health budget in the UK.

Reif et al. (2017) add that “alcohol and drug use disorders were among the top ten conditions

with the most all-cause 30-day readmissions where mental disorder, a comorbid substance

use diagnosis is a major predictor of readmissions.” Understanding the risk factors and

causes of readmission is imperative in developing effective interventions. The incidences of

hospital readmission among dual-diagnosed patients have significantly risen in the recent past

(Del Favero et al., 2020). Studies have shown a prevalence of co-morbid psychiatric disorders

and substance abuse. The incidence of readmission among dual-diagnosed patients is high

among the younger generation, with those having little education, males, offence history, and

affected by anti-social personality disorder risk population. Ogloff et al. (2004) say, “Dual

diagnosis has also been associated with high violence and criminal behaviour rates." The risk

of violence and readmission to hospital by psychiatric patients increases when they

experience dependence disorder. Readmission on psychiatric units is a serious concern

among mentally dual-diagnosed patients (Tully et al., 2019). Readmissions are disruptive and

costly to patients and their families, creating a sense of failure among healthcare providers.

Moreover, low patient outcomes can demoralise the healthcare providers and the patients

resulting in low job satisfaction among care providers and adherence to medication by

patients. Understanding the causes of the increased risk of readmission is critical in

promoting initiatives that result in positive and successful treatment of patients (Owusu et al.,

2022). Despite the increasing knowledge of the unique needs of patients with dependence
disorder and substance abuse, there is a dearth of studies exploring the strategies to reduce re-

admission risk and recovery promotion. There is a knowledge deficit on the impact of dual

diagnosis or dependence disorder for forensic psychiatric patients (Becker et al., 2017).

Patients with psychiatric disorders and co-occurring substance abuse have challenges

receiving treatment as re-admission cases are often high. Reif et al. (2017) say that forensic

patients with dual diagnosis experience poor outcomes, hospital readmission, incarceration,

high levels of homelessness, and non-compliance with treatment. The patients have lower

psychosocial functioning, increasing the risk of hospital readmission, reoffending, and

recidivism (Tully et al., 2019). Expanding the knowledge of the factors that increase the risk

of hospital re-admission among dual-diagnosed patients is critical in enabling the

management of healthcare facilities to develop effective interventions. Reducing re-

admission is integral for healthcare facilities in enhancing patient outcomes, cost reduction,

and improving job satisfaction among practitioners.

1.1 Aim of the Review

The review aims to identify and discuss factors influencing the risk of hospital re-admission

for forensic outpatients with dual diagnosis and to improve understanding of promoting

recovery. The study underscores the challenges hospital readmission brings for forensic

patients with dual diagnoses. Studies have shown that though the needs of forensic mental

health patients can be like general mental health, there are critical distinctions such as

violence, recidivism, substance use, offending, and legislative additions. While forensic

patients can be unique concerning the abovementioned factors, this review aims to determine

whether readmission and recovery are influenced by common elements such as income and

comorbidity. Even though considerable progress has been made toward implementing routine

mental outcomes, studies reviewed in this paper depict that the developed tools lack
assurance that they can help forensic mental health patients. Therefore, a holistic forensic

mental health assessment risk tool is needed to cover placement pathways, recovery, patient

reoffending, and re-hospitalization risk. This review attempts to thematically reconcile

general and forensic mental health perspectives and ideas to bring out a holistic methodology

for reducing re-hospitalization, reoffending, and promoting recovery. Forensic services are

associated with high-cost and low-volume services that balance caring for vulnerable

populations and public protection. The challenge faced by forensic service providers is the

lack of effective guidelines and practices to manage the factors that propagate hospital

readmission. The study underscores that the specific interventions and healthcare needs are

varied for patients with different diagnoses; hence, a literature review is needed to establish

the influential factors for hospital readmission for forensic patients with dual diagnoses.

1.2 Problem Statement

Forensic patients with dual diagnosis have complex treatment issues that require intensive

treatment to reduce cases of re-hospitalization. These patients require effective treatment

strategies to help them recover and realise optimal psychosocial function. Ogloff et al. (2004)

say the group’s challenge: “Traditionally, substance use and psychiatric problems were

addressed sequentially by separate mental health and drug and alcohol services," leaving

patients excluded from services before stabilising. Providing comorbid patients with

integrated treatment is critical in reducing hospital readmission. Nonetheless, there is a

paucity of data on the impact of integrated treatment on forensic patients faced with a double

diagnosis. Patients with substance abuse problems are more likely to be re-hospitalized.

Psychiatric issues associated with substance use disorders predispose patients to poor

treatment outcomes, recidivism, and readmission. After discharge, most forensic patients with

such significant predisposing factors exhibit a high re-hospitalization risk. While data from
different studies depict a high re-hospitalization rate, underlying psychiatric problems such as

schizophrenia predispose the patients to re-hospitalisation (Askola et al., 2022). A more

holistic assessment of comorbid conditions could help forensic services design patient

recovery plans considering how age, social background, external stressors, and other aspects,

such as post-discharge care, affect patient recovery. Several other factors determine the

patients’ mental health conditions, including but not limited to income, substance use, and

living standards. Even though re-hospitalization is often a primary response to treating

recidivists, it makes treatment more expensive, putting a strain on clinical facilities,

caregivers, and social structures. As such, patients from low-income families are more likely

to miss treatment, risking readmission and recidivism, putting them in a continuous loop of

re-hospitalisation. This bars many forensic patients from recovery, access to employment,

and better living standards.

Clinical treatment remains the primary recovery strategy for forensic outpatients. However,

forensic psychiatry services need to consider the personal experience and individual

perception of psychiatric procedures as determinants of patient recovery. Cooperation

between the patients and psychiatrists increases the chances of recovery, thus reducing the

chances of re-hospitalisation, according to Mezey et al. (2010). While the inclusion of patient

view on recovery in treatment, it is critical to note that forensic psychiatry is mired in

constant change and dynamic trends leading to persistent gaps in service provision. Askola,

Louheranta, and Seppänen (2022) delve into subjective narratives as they highlight prevalent

themes that could help reconcile patients' personal views of recovery and evidence-based

medical treatment methodologies. For instance, they say that overcoming institutional

challenges that affect mental well-being helps to reduce the direness of pre-treatment

challenges, enhance patient adaptation and recovery, and solve other treatment-related

concerns.
1.3 Study Objectives

 To examine the factors contributing to re-hospitalization risk among forensic

outpatients with dual diagnosis.

 To distinguish the factors that promote recovery among forensic outpatients with dual

diagnosis.

 To identify the barriers to recovery and re-hospitalization risk reduction in forensic

outpatients with dual diagnosis.

1.4 Research Questions

 Do psychiatric problems associated with substance use disorders predispose patients to

poor treatment outcomes, recidivism, and re-hospitalization of forensic patients?

 Does competence-based care significantly increase the chances of recovery amongst

forensic outpatients with dual diagnosis?

 Does the simultaneous application of clinical treatment, personal experience, and

individual perception of psychiatric procedures determine patient readmission?

1.5 Rationale of the Study

The study is instrumental in increasing knowledge of the factors that promote hospital

readmission among forensic patients with dual diagnosis, which is critical in developing

appropriate interventions. Shaffer et al. (2015) contend that understanding the causes of the

rise in hospital readmission and ED revisits requires an investigation of the predictive risk

factors. Forensic patient readmission and recovery depend on treatment and underlying

diagnoses such as substance use and violence. Little effort has been put into studying
demographic factors such as income, access to social services, and living standards as critical

determinants of patient recidivism. By looking into the Canadian Forensic Mental Health

Systems, Wilson et al. (2016) proved that forensic mental health patients, while on discharge,

are more likely to re-hospitalise due to a litany of legal conditions attached to their

conditional discharge (p.279). Legal aspects of forensic mental health often bind outpatients

to specific rules and regulations that determine rearrests and re-arrest under conditional

discharge. From the works of Crocker et al. (2015), these patients can be criminally

responsible for mental health disorder accounts (p.107). The difference in the application of

the law often affects forensic mental health populations adversely, thus reducing their

chances of recovery and consequentially increasing re-hospitalization. Psychiatric history and

engagement in violence with the likelihood of detention after a conditional discharge

adversely affects historical offenders and increase their readmission rates. This study attempts

to find a holistic solution to reduce recidivism, enhance recovery, and reduce re-admission.

Using a qualitative systematic review, survey sources are aggregated, and data is analysed to

gain insight into re-hospitalization risks and factors that promote recovery among forensic

outpatients. Both Aggregated review of data and interpretative aimed to develop a theory for

understanding and predicting behaviour.

Fewer studies explore the risk factors in reducing re-admission risk and in recovery

promotion, focusing on forensic patients with dual diagnosis. For instance, Reif et al. (2017)

say that ineffective patient care, psychiatric illness, and community resources such as

residential and employment status determine the readmission rates. The priority among care

providers is to reduce hospital stays to lower the cost of operation and increase patient

outcomes and satisfaction. While the impact of hospital readmission is known, a paucity of

studies explores the risk factors for increased readmission rates among forensic patients with
dual diagnosis. Knowledge of factors that promote increased re-admission risk and recovery

promotion are integral in developing effective interventions.

1.6 Structure of the Dissertation

This research introduces the idea that while the needs of forensic mental health patients can

be like general mental health, critical distinctions include violence, recidivism, substance use,

offending, and legislative additions. The methodology section explores the use of a

systematic review of existing studies to identify the themes and patterns in the findings. The

literature review section further assesses psychiatric problems associated with substance

abuse, treatment outcomes, and recovery. The literature depicts how competence-based care

may enhance recovery among forensic patients. Typically, Simultaneous application of

clinical treatment and personal views on treatment helps increase the chances of patient

recovery. The findings section aggregates and interprets findings from Canadian, UK, and

Australian forensic mental health data. The conclusion summarises the study and highlights

its limitations and gaps that may inspire further research.

Chapter 2: Methodology

2.0 Introduction

The study explored the influential factors in reducing re-admission risk and in recovery

promotion focusing on forensic outpatients with dual diagnosis. The selected studies for the

review were seven high-quality articles that provided relevant data to answer the research

question. Two papers from the included studies were from the US, two from the UK, and one

from Canada, Hong Kong, and Finland. The studies adopted diverse methodological designs,

with one paper embracing scoping review, two papers using retrospective cohort review, one

prospective design, two adopting quantitative design, and one embracing longitudinal study

design. Most papers adopted a diverse sample population with factors such as age, race,

health, and social-economic indicators given prominence.

2.1 Research Design

A qualitative research approach was adopted in the study to understand the influential factors

in reducing re-admission risk and in recovery promotion focusing on forensic outpatients

with dual diagnosis. The systematic review was embraced since it effectively collected data

from secondary sources and existing literature. The method was adopted because it gave the

researcher an interpretative feature that helps explore people's perspectives and attitudes. The

study emphasised creating knowledge that will result in evidence-based practice that aids in

understanding influential factors in reducing re-admission risk and in recovery promotion

focusing on forensic outpatients with dual diagnosis. A qualitative study was an appropriate

method for the analysis since it promotes the evaluation and synthesis of studies that offer
unique conclusions and perspectives, resulting in the development of effective evidence-

based interventions (Zhou et al., 2019). The approach fits the study because it enabled the

researcher to access data to draw findings representative of the whole population.

The study adopted a standardised method for integrating the mixed-method research literature

review. A range of studies was included in the systematic review, which focused on stating

the research questions, aims, and objectives, study selection, quality assessment, screening,

appraisal, extraction, and synthesis of data to create a narrative format. Heyvaert et al. (2017)

note that reviewing questions is the first step in selecting an appropriate study for research. In

this case, the review of research questions resulted in three questions that included: (1) do

psychiatric problems associated with substance use disorders predispose patients to poor

treatment outcomes, recidivism, and re-hospitalization of forensic patients?; (2) does

competence-based care significantly increase the chances of recovery amongst forensic

outpatients with dual diagnosis?; and (3) does the simultaneous application of clinical

treatment and personal experience, and individual perception of psychiatric procedures

determine patient readmission? The second process was article selection, identified through a

rigorous search, screening, mapping, quality appraisal, and assessment. The third phase was

article synthesis which involved identifying patterns, matches, gaps, and mismatches in

outcomes.

The use of the Preferred Reporting Items for Systematic Reviews (PRISM) tool was adopted

in the identification of literature. According to Elo et al. (2014), the PRISM approach

involves creating search terms, a literature review, a quality assessment, a review of the

research, and data extraction. Conversely, the use of systematic review and meta-analysis

tools was embraced because it is useful in exploring the patterns and themes in existing

studies. The findings from the systematic review will be critical in understanding influential
factors in reducing re-admission risk and in recovery promotion focusing on forensic

outpatients with dual diagnosis.

2.2 Search Strategy and Data Sources

The overarching research was designed to understand the influential factors in reducing re-

admission risk and in recovery promotion focusing on forensic outpatients with dual

diagnosis. The 45rliterature search was based on the research objectives, questions, and aims.

The search strategy began with reviewing the research questions and goals to ensure that it

meets the purpose of the study. The study developed and tested a search strategy for

methodological, content, and face validities to search source articles electronically from

reputable databases. The study searched peer-reviewed and reputable databases that include

Scopus, Science Direct, JBI Connect, PubMed Clinical Queries site, BMC, Medline,

EMBASE, Psych INFO, EBSCOhost-CINAHL, Google Scholar, Campbell Collaboration and

ProQuest, Web of Science, the Cochrane Reviews and Trails. The study selected these

databases because they guarantee high-quality and peer-reviewed studies. Also, they are well-

established and multi-disciplinary research platforms that contain data from wide-range

studies, address multiple issues, and are regularly updated and peer-reviewed. The survey

embraced the peer-reviewed articles since they provided studies with a better representation

of methods and themes, contained verifiable information, and offered highly impactful

studies.

Apart from the studies from reputable databases, the researcher searched for grey literature

that involved identifying information from sources beyond the published literature. In the
research, the citations for grey literature included Academic Search Complete, which offers

information from different academic areas, including education, humanities, business, and

general educational. The sources contained indexed sources covering news sources, selected

newspapers, and scholarly journals. Also, the study explored the ClinicalTrials.gov website

as it offers current information on clinical trials addressing varied conditions and diseases.

The website contained many clinical studies that private industry, federal agencies, and the

National Institute of Health sponsor. The other grey source included NIH RePORTER, drawn

from various extant databases, including Medline and PubMed Central. The website was

embraced by reputable and relevant professional organisations such as the National Alliance

on Mental Illness, the American Psychiatric Association, and the National Institute of Mental

Health. Besides the grey literature, the study searched data from the reference lists of

published research. The approach was designed to gather sufficient data to conclude

influential factors in reducing re-admission risk and in recovery promotion focusing on

forensic outpatients with dual diagnosis.

Keywords and phrases were used in searching for relevant studies for the research. The

keywords and phrases included re-admission risk, predictive factors, forensic outpatients,

dual diagnosis, recovery promotion, and barriers to recovery. The search for data from grey

literature was complemented by using keywords with the relevant articles subjected to

inclusion criteria. Many wide-ranging databases were designed to reduce errors and bias in

reviewing the data. The approach was critical since it helped to guarantee that the review was

transparent and explicit, which promotes accountability, replication, debate, and updated

review.

2.3 Selection of Articles

The researcher independently reviewed the articles by accessing the titles, abstracts, and full-

text review. The relevant studies based on the inclusion and exclusion criteria were selected

in the research.

2.3.1 Inclusion Criteria

The selected studies for inclusion in the research focused on influential factors in reducing re-

admission risk and promoting recovery among forensic outpatients with dual diagnosis.

The studies selected were those with research context as psychiatric hospitals, which is the

setting where forensic patients with the dual diagnosis were readmitted. Also, the study set

research articles as opposed to commentary or letters. Studies that reported risk factors and

readmission within 30-90 days were selected. According to Zhou et al. (2019), the approach

was appropriate because it was premised on the knowledge that the findings are consistent

with systematic studies that collect data on readmission predictors. In addition, studies were

published in English because translating studies from other languages is time-consuming and

expensive. Nonetheless, it should be noted that studies published in languages other than

English are of high quality, and their exclusion has nothing to do with their quality. The study

included studies published in the last decade to collect historical and current data on

influential factors in reducing re-admission risk and promoting recovery among forensic

outpatients with dual diagnosis. Despite the methodological flaws, studies that contained

relevant, reasonable, and high-quality content were included.

2.3.2 Exclusion Criteria

The articles excluded from the study failed to meet the inclusion criteria and addressed the

readmission date of 30-90 days. For instance, studies published in languages other than

English, those that failed to provide full-text access, and those that contained duplicates and

stemmed from commentaries, opinions, conference proceedings, and editor letters were
excluded. The reviewer read through the articles, journals, and reports for their abstracts,

introduction, and topic to establish that those selected contained relevant and reasonable

content (Braun & Clark, 2016, p.77). Also, the approach ensured that the chosen content

aligned with the research objectives and answered the research questions. At the inclusion

criteria stage, the reviewer read through the articles to ensure that they offer clarity with those

duplicates, and those without access to full texts were excluded, as emphasised by Creswell

and Poth (2018). The researcher conducted a comparative analysis to assess the differences

and similarities between the published and unpublished results. As highlighted, the study

focused on studies published in English and addressed the readmission of forensic patients

with no restrictions on the design, location, or sex of the participants.

2.4 Quality Assessment and Risk of Bias

The reviewer conducted a quality assessment to ensure the findings aligned with the study

objectives and questions. The reviewer assessed the independent assessment for each article,

focusing on the data sources, sampling strategy, population and its characteristics, and the

data collection method. The approach was instrumental in reducing the risk of bias in the

study and guaranteeing that the findings were relevant. For instance, Gray (2014) notes that

articles with invalid and flawed methodology should be excluded from research to ensure

high-quality results. The assessment required the researcher to conduct a full search and

abstract reviews to ensure that the captured data fits the research objectives and is relevant

(Elo et al., 2014). As aforementioned, the research used a range of databases to identify

relevant studies and reduce the risk of bias. Independent reviews of the articles were critical

in reducing errors and bias.

2.5 Data Extraction and Analysis

The data extraction was done using the Joanna Briggs form. The tool effectively extracts data

since it contains checklists that a reviewer uses to access high-quality data. According to

Aromataris and Munn (2020) and a study by Creswell and Poth (2018), the checklist contains

ten items that include the study setting, design, location, population, data extraction, article

availability, exposure, and outcome, as well as the data about the reviewer. The study

extracted data from the article, including information about the conceptual framing,

biographical information, publication date, study design, sample size, population, location,

and context, as well as the main findings (Braun & Clarke, 2016). Nonetheless, the data

extraction was challenging because pooling the extracted risk factors involved studies that

explored varied diagnoses, follow-up periods, and variables exploring the risk factors for

patient readmission. Braun and Clark (2016) state that data extraction is an integral step in

research. It involves data search and familiarisation of data, theme and pattern reviews and

definition, and report writing. The process helps analyse relevant content that answers the

research question.

The data analysis and synthesis was an integral process that involved coding the extracted

risk factors depending on the classification and categorisation of meanings. Data

interpretation and meta-analysis were useful for synthesising the findings (Gray, 2014). A

thematic analysis was embraced since it helps analyse data from the articles to create trends,

themes, and patterns. The thematic analysis involved reading and assessing the articles

independently to guarantee that the data reflect medical practitioners' perspectives,

perceptions, attitudes, and views supporting forensic patients with dual diagnosis. The study

embraced thematic analysis to guarantee that the themes derived from the data answer the

research questions and reflects the objectives.

2.6 Ethical Consideration

The approval and consent for the research was sought from the supervisor before the research

was started. The researcher provided the supervisor with the research topic, aims, objectives,

and methodology before being allowed to proceed with the research. The approval of the

ethical review board was not sought though critical for research, because there was no

collection of personal information. The study relied on secondary sources of data; hence, no

involvement of human participants since it was not primary research. Nevertheless, the

researcher concealed any personal and identifiable information of respondents or the location

of healthcare Patients facilities to protect the anonymity of the participants.

2.7 Chapter Summary

The study systematically reviewed research to expose the selected objectives and themes. A

systematic review entails reading through various study materials and research. The first

strategy identifies the sample size, study objectives, methodology, results, conclusions,

summary, and research limitations. After a thorough review of the studies, the second stage is

initialisation. This is comparing, classifying, and labelling themes identified from each

research. The next part of the study entails constructing themes starting from labelling the

identified data, translating, and further assessing them to support or counter the identified

positions. Defining and describing the themes avail an immersive analysis of the topic while

allowing a non-biased view of the identified themes and topics. The rectification phase entails

relating the research objectives with the established broad themes to stabilise the identified

research by supporting ideas with systematically analysed findings from different research.
CHAPTER 3: LITERATURE REVIEW

3.0 Introduction

The study underscores the challenges faced by healthcare providers and patients occasioned

by increased cases of hospital readmission by forensic outpatients with dual diagnosis. The

issue raises concerns regarding cost implications, increasing treatment costs, and lowering

workers' morale and patient outcomes. Knowledge of the risk factors that reduce readmission

and promote the recovery process is imperative to healthcare providers. To reduce the

chances of re-hospitalization while promoting recovery amongst forensic outpatients with

dual diagnosis, adequate treatment of exhibited psychiatric conditions is the primary solution.

Forensic patients with a dual diagnosis require an intricate treatment that requires effective

and intensive therapy to realise reduced reoffending, better psychosocial functioning, and

reduced psychiatric illness. The literature review seeks to establish factors contributing to

hospital readmission risk and barriers to recovery and explore theoretical understanding of

the issues studied.

The study review addressed factors contributing to the risk of hospital readmission among

forensic patients with dual diagnosis. The study noted that type of disease, substance abuse,

mental health issues, medical and psychiatric comorbidities, unsuccessful follow-up, and

social factors such as homelessness are risk factors. The second theme identified in the

literature review is the factors that promote recovery. These factors include competence-

based care, diverse treatment approaches, and sufficient inpatient care, critical factors that

promote faster recovery and reduce readmission among forensic patients with dual diagnosis.

The review’s second theme is the barriers to realising reduced hospital readmission. The

review showed that forensic patients experience barriers relating to social problems, housing,

and financial difficulties. The study showed that constant change and dynamic trends leading

to persistent gaps in service provision create a barrier to developing effective interventions to

reduce hospital readmission. Also, the review revealed that the meaning of recovery, personal

experience, and individual perception of psychiatric procedures are hindrances to the efforts

to reduce hospital readmission among forensic patients with dual diagnosis. These themes are

further discussed in detail below.

3.1 Factors Contributing to Re-Hospitalization Risk

The main reason for increased hospital readmission is the type of disease. Studies have

shown that specific illnesses or diagnosis influences readmission rates. A survey by Heslin

and Weiss (2015) cited schizophrenia, bipolar, mood disorder, and psychotic disorders

diagnoses as critical factors that increase readmission rates. The study noted that patients with

the diseases have a high chance of suicide ideation. According to Owusu et al. (2022),

“Suicidal ideation or thoughts of self-harm, history of psychological problems in childhood,

and the first episode of the psychiatric disorder under 18 years have been revealed as related

factors for readmission.” The study further identified the period of hospitalisation and
substance abuse as key hazards that undermine the rate of patient recovery for forensic

outpatients. Psychiatric patients without hospital beds are forced to go home, resulting in

readmissions. The issue of readmission impacts the quality of care, patient outcomes, and

treatment costs. Patient’s history and ages influence the readmission rates since they are

associated with chronic ailments. Similarly, the disease's severity and course significantly

relate to the readmission rates. Studies show that comorbidity, symptom severity, primary

diagnosis, suicidality, and self-injuries are significant risk factors (Owusu et al., 2022). The

characteristics of hospitalisation are influential in determining the length of stay, aftercare

services provided, and access to inpatient care services. Also, the discharge medication and

the disposition to partial hospitalisation and residential treatments are critical factors.

Understanding the factors that cause readmission is essential for healthcare providers since it

helps develop management interventions that reduce the treatment costs and burden of

treating patients.

Besides, the increased readmission rates are attributable to the diagnosis of schizophrenia,

poor functioning, suicidal thoughts, and economic variables such as public insurance and

homelessness. Shaffer et al. (2015) study identified varied reasons for readmissions

depending on location, ethnicity, and research subjects. On the other hand, Shaffer et al.

(2015) added that disabilities, personality disorders, and developmental delay adversely affect

forensic outpatients’ chances of recovery if not taken into consideration during treatment,

Bodén et al. (2011) also argue that medication adherence underlying psychological disorders

such as PTSD, and suicidal ideation vastly affects chances of re-hospitalization of patients

(p.37). Length of stay predicts their ability to recover for forensic patients in their first

treatment visit. According to Zeff et al. (1990), a longer stay significantly reduces the

chances of readmission for psychiatric patients (p.91). Other factors affecting the patient’s

treatment process include discharge plans and transitional efforts. Pow et al. (2015) posit that
focused and well-coordinated transitional efforts are key in reducing the readmission rate for

patients with acute psychiatric problems (p. 176). Whilst patients with previous chronic

psychiatric disorders have been found to need more inpatient treatment and more coordinated

psychological care. Madi, Zhao, and Li (2007) state that patient management after discharge

largely reduces readmission risk for psychiatric outpatients (p.30). Typically, forensic

outpatients with chronic psychiatric issues have an increased risk of re-hospitalization. The

findings of Gunnell et al. (2008) show that patients with high readmission rates exhibited

suicidal attempts and self-injury behaviours (p.337). Clinical implications of the findings

above help clinicians to focus not only on ascertaining whether suicidal ideation or other

psychological behaviours depict a subtle call for help. With an in-depth study of factors

influencing the chances of readmission, it is possible to design culturally unique care.

When substance abuse is a primary diagnosis, there is a high risk of patient re-hospitalization.

Associated substance use disorders typically increase the risk for adverse outcomes, re-

offending, and readmission. Drug abuse and violent offending are some of the most

significant risk factors leading up to the re-hospitalization of forensic outpatients. After

discharge, patients with such predisposing factors have a high re-hospitalization risk. While

other data from several studies reveal a high re-hospitalization rate for forensic patients

within the first few years of discharge, a study by Askola, Louheranta, and Seppänen (2022)

further depicts that schizophrenia and other related disorders as primary re-hospitalization

hazards for most psychiatric patients. Other re-hospitalization predisposing factors include

depression and personality disorders. A study by Hoffmann (1994) agrees with prior studies

that the highest determinant of future re-hospitalization is the prevalence of re-

hospitalizations in the history of the patient's treatment (p.206). The study further expounds

on age as a predictive value influencing chances of hospitalisation and other factors such as

drug compliance, self-harm, and antisocial behaviours. Other physiological factors, such as
age, affect the chances of hospitalisation for forensic outpatients and are associated with re-

hospitalization predisposing factors such as bipolar disorder. However, It is unknown

whether these factors are relevant to all forensic outpatients (Dayson et al., 1992, p.994).

Individualised treatment that considers unique primary and comorbid diagnoses should

therefore be devised.

Demographic and clinical features such as low income and lack of underlying psychiatric

conditions are common among patients with high re-hospitalisation rates. Readmissions make

treatment more expensive, thus putting strain on not only caregivers but also clinical

facilities. Patients from low-income households are more likely to miss treatment, risking

readmission or recidivism. By studying psychiatric patients in Qatar, Elhassan et al. (2020)

found that 10.5% of psychiatric patients were readmitted within the first 30 days of discharge

(p.4). Most of the re-hospitalized patients were unemployed, single, and male. By studying

941 youth, Phillips et al. (2020.) also found that 13.8% were re-hospitalized once, while 6.9%

of the study population had been readmitted twice or more after initial treatment.

The study also proves that prior hospitalisation, medical and psychiatric comorbidities are

significant determinants of re-hospitalizations. Most forensic patients with single and

multiple readmissions will likely live with underlying medical and psychiatric conditions.

Even though the factors mentioned above by the studies could predict chances of re-

hospitalization, a higher readmission rate is also considered an indicator of poor psychiatric

services during prior treatment at inpatient levels. While considering other studies, Byrne et

al. (2010) posit that patients readmitted to psychiatric care, including but not limited to those

with hospitalisation history, self-reported improvements, and better treatment outcomes had

higher chances of re-admission if they showed severe symptoms at discharge (p.109). Other

predisposing factors highlighted by the study include age and the number of readmissions
over 30 days of release. Even though studies associate higher re-hospitalization rates with

demographic and clinical characteristics, it is critical to consider how external stressors and

other aspects, such as post-discharge care, affect patient readmission.

Even though the factors above significantly determine patient re-hospitalization, disposition

of authorities, laws, and recidivism after discharge are other leading causes of readmission

for psychiatric patients. Wilson et al. (2016), by studying the Canadian Forensic Mental

Health Systems, proved that forensic outpatients are criminally responsible under the codes

of the review board while on conditional discharge (p.279). This means there is a greater

likelihood of detention of previously admitted individuals than new mentally ill offenders.

Crocker et al. (2015) proved that the Forensic board determines whether outpatients on

conditional discharge can be criminally responsible for mental disorder accounts (p.107).

Differences in the application of the law affect recidivists with serious mental illnesses, their

verdicts, and their trajectories when traversing mental health and criminal justice institutions.

Typically, psychiatric history and engagement in violence with the likelihood of detention

after a conditional discharge adversely affect historical offenders' readmission likelihood. In

line with the study, Crocker et al. (2015) support a need for a systematic risk assessment

technique that would avail a verdict system with less likelihood of detention of past forensic

outpatients (p.108). When investigating empirical factors predicting recovery success for

conditional release forensic patients, Manguno‐Mire et al. (2014) found that 70% of

individuals released on incompetence to stand trial exhibited lower recidivism rates than

those discharged from hospitals. Whereas inpatients who had gone through the correctional

department showed lower readmission rates, those from the hospital are more likely to be

readmitted because of violence and substance use. The value of risk assessment procedure

and protective factors underlie a more balanced and accurate risk assessment exemplifying
the potential for guiding treatment and reducing chances of re-hospitalizations for forensic

inpatients.

Besides, unsuccessful follow-up and inadequate planning as the causes of high-readmission

rates. Patients suffering from substance abuse disorders are expected to seek treatment

follow-up, which they often ignore promptly—the services such as inpatient detoxification

stays and hospital discharge experience low readmission rates. Zhou et al. (2022) add that

outpatient and residential addiction treatment is integral to reducing readmission and

substance abuse. Reif et al. (2017) explain, “Medicaid beneficiaries with comorbid mental

and substance use disorders had a reduced likelihood of readmission in hospitals where a

higher proportion of patients received outpatient mental health treatment within seven days

after discharge.” Substance abuse and mental health disorders increase the risk of hospital

readmissions. These patients require additional addiction treatment, which increases

detoxification readmission.

Overall, the review showed that the risk factors associated with the risk of readmission

include the following:

 Type of Disease

 History of substance abuse

 Mental health issues

 Medical and psychiatric comorbidities

 Unsuccessful follow-up and inadequate planning

 Social factors such as homelessness

 Disposition of authorities, laws, and Recidivism

3.2 Factors That Promote Recovery

Cross-sector endeavours for competence-based care should include communities, public

health, patients, and mental health teams. These parties comprise co-production initiatives

that make up mental health services designed for the unique cultural needs of each forensic

outpatient. Lwembe et al. (2017) evaluated the effectiveness of cross-sector initiatives that

include the parties above (p.16). With 25 patients enrolled in the study, results depicted a

75% retention rate for ethnic minorities. A survey by Palmer and Ward (2007) interviewed 21

asylum seekers. Results from the research showed a high prevalence of exclusion of

minorities in the UK (p.199). Both studies encourage consideration of many social, practical,

cultural, and legal issues influencing the population's mental health. While the initial research

suggests a shift from the orthodox biomedical models for treating forensic outpatients, the

latter proposes a patient-centred approach to treatment. Both studies suggest reorganisation of

the entire treatment right from welfare to immigration policies. Changing from mainstream

forensic psychiatric mental health services to co-production needs a long-running debate

about revamping healthcare systems with definitive approaches to forensic mental health. At

the core of co-production, aspects such as patient recovery and community care would take

years of research, development, and policy formulation during implementation (McFadden et

al., 2022, p.258). Even without institutional confirmations, the studies prove that using

effective co-production models promotes recovery by applying culturally competent

treatment methods.

Access to competence-based care significantly increases the chances of recovery amongst

forensic outpatients. Working with key stakeholders such as communities, public health,

patients, and mental health teams provides a holistic mental healthcare plan focused on

reducing recidivism, readmission, and recovery. This is possible through co-production

initiatives making health services unique to the needs of each forensic outpatient. Through a

study, Lwembe et al. (2017) prove that minorities are excluded from mental health services.
Tools designed for forensic patients should consider how the interaction between social,

practical, cultural, and legal issues determines recovery rates and readmission risks among

the patients. This approach calls for unique treatment for diverse populations to promote

forensic outpatient recovery. For forensic outpatients, clinical characteristics could be used to

ensure effective psychiatric care that is acceptable to the patients. By depicting the depth of

linguistic diversity, McFadden et al. (2022) Call for cultural and linguistic diversity in

forensic psychiatric service. Cultural competence with coproduction approaches to treatment

cannot be more important.

Diverse treatment approaches for a diverse population effectively promote forensic outpatient

recovery. Forensic patients exhibit an array of clinical characteristics, and to ensure effective

treatment, psychiatric care must be effective and acceptable to the patients. By referring to

Australian forensic mental health settings, McFadden et al. (2022) explain the depth of

cultural and linguistic diversity of forensic mental health patients (p.258). A study by Durey

et al. (2014) proves that the Aboriginals comprise 17-30% of Australia's forensic patient

population (p. 196). This highlights the importance not only of cultural competence but also

co-production of treatment approaches. Through a systematic review of 109 potential papers,

Bhui et al. (2007) evaluated a set of models to assess methodologies of improving cultural

competence and service delivery with nine pieces of research done in North America

recommended that to improve care, there a need for cultural competence (p.2). This entails

modifying clinical and organisational practices to achieve holistic care. Performance

measures for cultural competence must first evaluate the suitability of evidence-based

approaches to the cultural groups it serves. If suitable, these practices can be adapted during

individual and group treatments. Most forensic mental health treatment algorithms have been

adopted as Evidence-based practices, yet their applicability to specific racial and ethnic

groups has not been tested. Explicit measures, such as medication adaptation and culture-
targeted outcomes, could help achieve general forensic mental health well-being for

outpatients.

Reducing the readmission of forensic patients with a dual diagnosis can be addressed by

providing sufficient inpatient care. The approach is instrumental in managing the presenting

problem and stabilising the patient's health status. Healthcare practitioners are expected to

develop elaborate discharge plans and guarantee patients of effective support when they

transition from healthcare facilities to psychiatric care at their homes; moving from an

inpatient to an outpatient setting can be difficult for many patients, reducing adherence to

treatment and medication regimen. Short-term case management, follow-up calls, discharge

services, psycho-education, and bridge visits are instrumental in reducing hospital

readmission. The family members are responsible for ensuring that the patient can access

adequate outpatient services in society. The approach will help reduce readmissions since

alternative psychiatric hospitalisation is available. If the subsequent psychiatric crisis starts,

the family can take the patient to the nearest healthcare facility offering assertive community

treatment services. Improving discharge planning is an integral strategy in reducing hospital

readmission as it promotes 3e8the transition to a community setting from an inpatient

environment. The goal is to ensure that patient outcomes improve and readmissions decline.

According to Forchuk et al. (2007), there needs to be more well-documented initiatives that

help in reducing hospital readmission for forensic patients with double diagnosis. The

existing measures, including the Transitional Discharge Model adopted in countries such as

Scotland and Canada, emphasise extending relationships and peer support with inpatient

service providers.

In summary, the review noted that the following factors enhance faster recovery of forensic

patients with dual diagnosis:

  Providing competency-based care

 Developing diverse treatment approaches that address the health needs of every

individual in society.

 Providing sufficient inpatient care

3.3 Barriers to Recovery and Re-hospitalization Risk

Even though clinical treatment is the primary recovery strategy for forensic outpatients, the

meaning of recovery, personal experience, and individual perception of psychiatric

procedures are also significant determinants of patient readmission. To identify factors

promoting recovery amongst psychiatric patients, Mezey et al. (2010) sampled ten patients

detained in medium secure units for an average of 4 years (p. 685). Respondents hold varied

perceptions of recovery. While reduction of symptoms was necessary, it does not mean full

patient recovery. To some patients, acceptance by the community, education, finding a home,

and avoidance of re-offending promoted their recovery. In agreement with the study,

Anthony (1993) posits that recovery is a personal and unique process of changing individual

values, attitudes, skills, goals, and roles as mechanisms for coping with the limitation of the

illness (p.11). Roberts and Wolfson (2004) set out to study steps taken in developing a

recovery-based practice by defining the international recovery movement and a critical

appraisal of its background. The research sets mental health systems' objectives concerning

their capacity to abate impairment, disadvantage, and dysfunction. While the studies

mentioned above may give an insight into the role of the patient in their recovery, the

postulations veer from the original assertions that reduction of violent offending and

treatment adherence promote a full recovery of forensic outpatients. Even though personal

experience and perception could help forensic outpatients recover, adhering to evidence-

based treatment methodologies is critical.

Forensic psychiatry is mired in constant change and dynamic trends leading to persistent gaps

in service provision. To get an in-depth assessment of subjective narratives of Finnish

forensic service stakeholders, such as patients, and service providers, Askola, Louheranta,

and Seppänen (2022) interviewed eight forensic psychiatric patients, six parents of the

patients, and nine forensic nurses. The study highlighted three prevalent themes of pre-

treatment challenges, adaptation, and recovery and treatment-related concerns. The research

mirrors institutional challenges affecting entire populations’ mental well-being. By analysing

WHO strategies, the study proposes actions for promoting; universal and targeted measures

for meeting people’s physical and social needs, with the target being reducing mental health

problems starting at the individual and institutional levels. Chow and Priebe (2016) found

that mental health institutionalisation in the early 1990s led to other treatment institutions,

such as prisons, housing, and forensic units in Western Europe (p.1). Gordon and Lindqvist

(2007) shed light on why even with the rise of institutions, it is difficult for some European

forensic outpatients to recover (p. 421). The study subtly indicates that challenges leading to

psychiatric problems among patients have not been solved yet. Tomlin et al. (2021) explain

that there is still a large disparity in successful psychiatric treatment methods, lengths of stay,

and legal frameworks (p.110). Key demographic differences in European countries also

determine whether forensic outpatients recover. While gaps in service provision might

significantly affect patient recovery, social difficulties and disparity in demographics lead to

marginalisation, a rise in re-offending behaviour, and social isolation.

Apart from mental disorders, delinquent behaviours, and addictions, forensic outpatients with

dual diagnoses often face social problems, housing, and financial difficulties. While working

with a forensic coach, Swinkels et al. (2020) developed a social network intervention for

baseline assessment of outpatients in 3, 6, 9, 12, and 18 months (p.3). The study’s primary

objective was to assess whether mental wellbeing, personalised and multimodal treatment
reduced the risk of criminal recidivism and multiple health problems. Respondents who

underwent the therapy above method exhibited a reduced risk of violent behaviours and

showed personal satisfaction with the treatment. Although social intervention has proven

effective in hastening recovery for many forensic outpatients, such efforts can be thwarted by

individual negative attitudes towards treatment (Chow and Priebe, 6, 2016). Personal

perspectives and responses to outreach efforts typically greatly hinder positive mental health

outcomes.

The review showed that reducing hospital readmission among forensic patients with dual

diagnosis is impacted by the following factors:

 Social problems, housing, and financial difficulties faced by patients.

 Constant change and dynamic trends in forensic service led to persistent gaps in

service provision.

 The different meanings of recovery, personal experience, and individual perception of

psychiatric procedures

3.4 Gaps in Literature

There needs to be more data on the risk factors related to psychiatric readmission among

forensic patients with dual diagnosis, including the heterogeneity of varied research from

different populations and regions. The diverse locations like rural vs urban or multi-state vs

metropolitan and research subjects such as mixed ages and adults vs children play an integral

role in increasing the discrepancy of hospital readmission rates. Consequently, growing

knowledge gaps and inconclusive predictors create interest in understanding the risk factors

for increased readmission rates by forensic patients with dual diagnosis.

CHAPTER 4: FINDINGS

4.0 Overview of Selected Studies

The search for the study resulted in 688 articles from the initial search from 13 databases,

including Scopus, Science Direct, JBI Connect, PubMed Clinical Queries site, BMC,
Medline, EMBASE, Psych INFO, EBSCOhost-CINAHL, Google Scholar, Campbell

Collaboration and ProQuest, Web of Science, Cochrane Control Register of Trials, and the

Cochrane Reviews and Trails. The reviewer conducted the first screening resulted in the

exclusion of 644 articles because they were duplicates. Additional 20 articles were excluded

because they lacked full-text view after the reviewer read the abstract and titles. The reviewer

excluded four articles that failed to provide qualitative results on the influential factors in

reducing re-admission risk and in recovery promotion focusing on forensic outpatients with

dual diagnosis. From the initial 688 articles, ten articles were screened for eligibility, where

three were excluded. The remaining seven articles were included in the study and used in the

thematic analysis. The included studies were embraced since they had elements such as

confirmatory and representativeness of the participant.

The study on influential factors in reducing re-admission risk and in recovery promotion

focusing on forensic outpatients with dual diagnosis was analysed through a thematic

analysis. From the thematic analysis, themes and patterns were identified. According to

Braun and Clarke (2006), thematic analysis is an effective tool for reporting, analysing, and

recognising repeated themes and trends as it entails code selection and theme construction.

The research was guided by a research question that sought to establish. Readmission

designed to secure care for patients increases the costs of treatment to healthcare facilities and

patients, as well as accompanying emotional and social costs. The service providers,

caregivers, patients, and their families experience loss when repeated readmission occurs. For

instance, readmissions cause low morale among healthcare workers since it is equated to

treatment failure. Forensic patients with dual diagnosis often experience increased stress, lack

of family support, and unstable housing, making it difficult to recover fully. Besides, the

increased cases of hospital readmission of forensic patients with dual diagnosis erode public

confidence, resulting in low adherence to medication and care-seeking behaviours. Therefore,

 the knowledge of risk factors for hospital readmission is imperative to develop appropriate

interventions.

Previous studies have shown that psychiatric patients have a higher risk of readmission to

hospitals, which measures the quality of services offered in an organisation (Becker et al.,

2017; Cakir et al., 2017; Del Favero et al., 2020; Donisi et al., 2016). Reducing patient

readmission cases shows an organisation's focus on reducing costs and improving patient

outcomes. Owusu et al. (2022) agree that "Studying the influential factors relating to

readmission may help improve management interventions. Identifying predictors of

readmission at this level can inform health policies and quality improvement interventions to

mitigate the cost and the burden to systems and families." Studies need to establish the re-

hospitalisation risk factors since it helps develop appropriate interventions that reduce

readmission. During readmission, some patients often exhibit treatment-seeking behaviours

that are instrumental in guiding healthcare providers in planning care provision. The

readmission rates differ from one country, age group, and region to the other. Understanding

the factors that increase the risk of re-hospitalization of patients in varied age groups or

countries is essential in developing effective interventions.

All of the below should be in the methods chapter not in the findings chapter.
Identificatio
n
 688 recorded articles identified in the
database search
Screening

644 articles were excluded for

duplication and relevance
20 articles were excluded because
they lacked full access
Eligibility

20 articles without full access

were screened out
4 articles were screened and
excluded for the non-reporting
impact of grief and other relevant
variables
Included

7 articles were included in this

3 articles screened-out
study review
 4.2 The Summary of Included Articles Is Presented in the Table Below (It would be helpful to add the country where the study

was conducted. This is important for the discussion because findings from e.g., the USA may not be entirely relevant to the UK because

of different health /social care systems.?)

It would also be useful to add the number and kind of patients in the samples for the empirical studies .?)

AUTHOR(S) STUDY OBJECTIVES METHODOLOGY FINDINGS

Owusu, E., Oluwasina, F., Nkire, N., Lawal, The study aimed at establishing Scoping Review The study found that substance abuse,

M.A., and Agyapong, V.I.O. 2022. the interventions and predictors developmental delays, and learning disabilities

Readmission of Patients to Acute of hospital readmissions among are hospital readmission risks. The study

Psychiatric Hospitals: Influential psychiatric patients. recommends better crisis prevention and

Factors and Interventions to Reduce residential treatment to reduce readmission.

Psychiatric Readmission

Rates. Healthcare, 10(4), 1808.

https://doi.org/10.3390/healthcare100

91808
 Reif, S., Acevedo, A., Garnick, D. W., & The study aimed at establishing Longitudinal studies The study revealed that residential treatment is

Fullerton, C. A. (2017). Reducing whether follow-up services at integral in reducing readmission as it prevents

Behavioral Health Inpatient residential detoxification or behavioural health admissions.

Readmissions for People With inpatient hospital stays reduce (Meaning unclear. What is meant by

Substance Use Disorders: Do Follow- readmission. ‘behavioural health’)

Up Services Matter? Psychiatric

Services (Washington, D.C.), 68(8),

810–818.

https://doi.org/10.1176/appi.ps.20160

0339

Heslin, K.C. & Weiss, A.J. (2015). Hospital To assess data readmissions for Quantitative study Periods of hospitalisation and substance abuse

readmissions involving psychiatric mood disorders and as key hazards undermine forensic outpatients’

disorders, 2012: Statistical Brief# schizophrenia. recovery rate.

189. Rockville, MD: Agency for

Healthcare Research and Quality,

pp.1–17.
 Phillips, M.S., Steelesmith, D.L., Campo, The study explored the patient, Retrospective cohort The study found that hospital and patient-level

J.V., Pradhan, T. & Fontanella, C.A. community, and hospital factors study factors are the main risk markers for

(2020). Factors associated with contributing to hospital psychiatric readmission.

multiple psychiatric readmissions for readmission among psychiatric

youth with mood disorders. Journal patients.

of the American Academy of Child &

Adolescent Psychiatry, 59(5), 619–

631.

Penney, S. R., Marshall, L., & Simpson, A. I. The study sought to establish Prospective design The research found that substance abuse is a

F. (2017). A prospective study of the reasons for patient predictor of high hospital readmission.

pathways to hospital readmission in readmission

Canadian forensic psychiatric

patients. The Journal of Forensic

Psychiatry & Psychology, 29(3),

368–386. doi:10.1080/14789949.201

7.1395061
Hariman, K., Cheng, K. M., Lam, J., Leung, The research sought to establish Quantitative study The study revealed that hospital readmission

S. K. & Lui, S. S. Y. (2020). Clinical the clinical risk factors that increased because of comorbid substance

risk model to predict 28-day increased hospital readmission misuse, previous admission, and history of

unplanned readmission via the among acute psychiatric violence,

accident and emergency department patients.

after discharge from acute psychiatric

units for patients with psychotic

spectrum disorders. BJPsych

Open, 6(1), e13

Weinstein, Z. M., Cheng, D. M., D’Amico, The study evaluated whether Retrospective cohort The study found that acute care utilisation is

M. J., Forman, L. S., Regan, D., addiction consultation is study prevalent among addiction patients.

Yurkovic, A., Walley, A. Y. associated with acute care

(2020). Inpatient addiction utilisation.

consultation and post-discharge 30-

day acute care utilisation. Drug and

Alcohol Dependence, p. 213,

108081. doi:10.1016/j.drugalcdep.20

20.108
Findings

(This is where the findings begin. You could have a short introduction saying e.g. There

were seven relevant papers identified. Then provide a short picture of the papers e.g. As

table x shoes, x papers were from USA and only x from the UK; most of the studies were

surveys etc….)

4.3 Overarching Themes

The review affirmed the challenges brought by increased readmission of forensic patients

with dual diagnosis on families, healthcare facilities, and healthcare practitioners. The main

concern is the rising costs of treatment occasioned by a rise in readmissions. Also, the

readmissions have impacted the attitude of healthcare practitioners since increased revisits to

the hospital are associated with low-quality care and incompetence. These challenges drove

the study to understand the risk factors for influential factors in reducing re-admission risk

and in recovery promotion focusing on forensic outpatients with dual diagnosis. The review

revealed the following themes:

1. Follow-Up Arrangement

The review showed that lack of follow-up arrangement and adequate discharge plan are the

risk factors for hospital readmission among forensic patients with dual diagnosis. The

absence of discharge plans and follow-up by psychologists/psychiatrists is blamed for the

increased readmissions. According to Zhou et al. (2022), (This paper is not in your

table?) follow-up compliance predicts increased hospital readmission as adherence to

medication among patients is low. Patients often fail to observe treatment due to a lack of

follow-up that predisposes them to an increased risk of readmission. Reif et al. (2017) agree

that reducing behavioural admission, which is blamed on lack of follow-up, is critical. Lack

of discharge plans and follow-up results in an inappropriate level of care that is insufficient to
meet the needs of patients. While receiving treatment as outpatients is integral, failure to

match the discharge plans and follow-up fails to resolve the patients’ health issues (Del

Favero et al., 2020; Donisi et al., 2016). (These papers are also not in the table? If

they were selected as relevant, they should be there. If you got the information from a

review, then you need to reference it as XX date, cited in YY date). The presence of

follow-up and discharge plans is essential in reducing readmission. The review noted that

while follow-up is instrumental in reducing readmissions, it increases the risk of hospital

revisit by forensic patients. The surprising findings are attributable to what Reif et al. (2017)

term an inappropriate level of care. They said, "Patients’ discharge plans may have referred

them to an inappropriate level of care—that is, outpatient treatment may have been

insufficient to meet their needs for addiction treatment." Reif et al. (2017) posit that the lack

of follow-up could be attributable to financial and geographical barriers since it is difficult to

find practitioners capable of doing follow-ups within 30 days for all patients, some of whom

may be living in difficult-to-reach areas.

The review noted that the coordination and quality of post-discharge treatment is an issue of

concern as it reduces patient follow-up. Lack of communication between healthcare providers

and patients makes follow-up challenging. Reif et al. (2017) conclude that successful

recovery from disease depends on factors such as follow-up, effective discharge plans, health

status, quality of care, and ability to purchase medication. High readmission rates of patients

in healthcare facilities within a shorter period reflect the inappropriate discharge plan of care

and the quality of hospitals' services. Healthcare facilities face severe penalties when they

have excessive readmissions to make hospitals accountable. Reif et al. (2017) argue that

while the effort is laudable to increase the focus on the quality of care with a focus on

discharge plans and follow-up, patients could be a source of readmission. Phillips et al.

(2019) added that readmission rates increase when healthcare facilities fail to implement
proper discharge plans and follow-ups. The study noted that readmission is often linked to

hospital, patient, and community-level factors.

2. Hospital and Patient-Level Factors

The review (Do you mean This review? (Ie this work). revealed that increased cases

of patient readmissions are attributable to patient-level factors. Hariman et al. (2020) cite a

lack of social support, while Phillips et al. (2019) cited chronic medical illness, psychiatric

comorbidities, disabled status, prior hospitalisation, and bipolar disorder diagnosis. The

findings of the review note that substance abuse and mental disorder impact patients'

recovery and health, increasing the likelihood of readmissions. The aftercare, service history,

noncompliance with treatment and prior hospitalisation, and length of stay are predisposing

factors that propagate increased hospital readmissions. Phillips et al. (2019) believe that

readmissions are increased by clinical factors such as affective disorders, psychosis, and

behavioural disorders, as well as the development and medical comorbidities. The severity of

the symptoms and prior suicide ideations are believed to be predictors of hospital

readmissions of forensic patients with dual diagnosis. The review noted that patient-level

factors such as previous diagnoses with chronic psychiatric disorders increase the risk of

hospital readmission (Reif et al., 2017). The clinical diagnosis of diseases such as psychotic

disorder, schizoaffective disorder, bipolar disorder, depressive disorder, and seasonal affective

disorder increases the risk of readmission.

Also, the review noted that length of hospital stays and demographic factors such as the

patient’s age and the severity of their disorder influences readmission rates for forensic

patients with dual diagnosis. A study by Zhou et al. (2022) (As above, not in your

table.) showed that "schizophrenia, schizoaffective disorder, bipolar disorder, and psychosis"
are the main diagnosis of depression associated with an increased risk of hospital

readmission. Phillips et al. (2019) add that patient-level factors such as the body mass index,

shorter hospital stays, treatment using clozapine, and patients with problems with obesity and

weight are predictors of increased readmission. Besides, the study showed that the length of

hospitalisation for forensic patients with dual diagnosis influences their risk of readmission

(Weinstein et al., 2020). The review noted that patients admitted at a shorter duration at the

healthcare facility are likely to be readmitted when there is insufficient care in the

community. Shorter hospital stays are advantageous to healthcare facilities since it reduces

operations costs and hospital-associated infections; however, the review showed that lack of

proper discharge plans and transition to a community with inadequate care facilities harms

patients. Effective integration of community-based services and inpatient units is instrumental

in reducing the risk of readmission (Hariman et al., 2020). The patient readmission rates are

higher when discharged from the hospital, meaning the longer the discharge, the reduced the

readmission risk.

The review noted that the risk of readmission includes issues such as involuntary admission,

shorter length of hospital stay, availability of intermediate healthcare staff, and community-

based services. The study revealed that treatment factors increase the hospital readmission of

forensic patients with dual diagnosis. Phillips et al. (2019) posit that treatment factors such as

prior hospitalisation and medication non-compliance increase hospital readmission risk. The

availability of quality aftercare and length of hospital stays are predictors of hospital

readmission among forensic patients with dual diagnosis. Philips et al. (2019) explain,

"patient-level characteristics including a diagnosis of schizophrenia or psychosis, younger

age at first admission, greater numbers of previous admissions, unemployment at index

admission, noncompliance with medication and therapy, and drug and alcohol problems are

associated with multiple readmissions." The community level, hospital characteristics, and
patient demographics are critical readmission predictors. The review showed that the

availability of mental healthcare providers and sufficient discharge plans is instrumental in

promoting a smooth transition from hospital to society, improving adherence to medication

and reduction.

3. Reducing Hospital Readmission

The review showed that providing residential treatment services is critical in reducing

hospital readmission of forensic patients with dual diagnosis. Greater access to community-

based residential treatment services enhances the smooth transition of patients from hospitals

to society. The study noted that the approach helps enhance crisis prevention since there is

congregate care setting for patients, which minimises the risk of hospital readmission (Penny

et al., 2017). A residential treatment facility that offers therapy for mental illness, substance

abuse disorders, and behavioural problems is integral in reducing the readmission of patients

and promoting adherence to medication and treatment. Live-in healthcare facilities are critical

in managing patients' psychopathology, which helps reduce hospital readmission (Phillips et

al., 2020). The study noted that offering better inpatient care that helps manage the presenting

problem and helps to stabilise the psychiatric status of patients is a critical intervention that

reduces readmission rates.

The review emphasised the need for healthcare practitioners to develop proper patient

discharge plans. The approach will help reduce hospital readmission since the patients have

access to follow-up, discharge services, bridge visits, short-term case management, and

psychoeducation (Heslin & Weiss, 2015; Owusu et al., 2022). An adequate discharge plan

helps guarantee patients access to quality care in their community. Similarly, the study has

established that providing psychological support enhances adherence to medication and

treatment. According to Owusu et al. (2022), the state needs could be considered to improve

specific and individualised support individualised a relapse and readmission." After

transitioning to their community, many patients face the challenge of lacking adequate

support and facilities that guarantee access to care services and medication, which increases

the risk of readmission. Forensic patients with dual diagnosis require psychological support

in their community to help enhance the quality of their lives and reduce readmission.

Similarly, there is a need for staff training and education to enhance their knowledge in

developing effective discharge plans. Clinicians and care planners should emphasise staff

supervision and training to help enhance their skills in managing and accessing patients with

suicidal ideation (Reif et al., 2017). The approach guarantees effective collaboration with

aftercare providers and referring physicians. Owusu et al. (2022) (When you give.

Direct quote, you must add the page numbers e.g. Owusu et al. (2022, PAGES) Check

all quotes.) add that there should be a focus on transitional efforts and care coordination. The

author noted, “To reduce these rates, initiatives should focus on care coordination and

transitional efforts to gain appropriate outpatient care for those with these specific mental

health and substance abuse (MHSA) conditions." There is a need for care providers to

guarantee that outpatient treatment is improved for patients who are obese and overweight to

help reduce the readmission of forensic patients with dual diagnosis. The goal is to ensure

that there is a commitment from healthcare providers that patient needs are addressed.

Also, the study noted that medical and treatment adherence is an influential factor that

enhances hospital readmission. Therefore, efforts should be directed to ensure adequate

adherence to medication by providing social support and proper discharge plans. Owusu et al.

(2022) describe medical adherence as "the extent to which a patient’s behaviour corresponds

with the prescribed medication dosing regimen." Medication adherence is critical since it

ensures that patients are committed to treatment and medication as prescribed by the medical
practitioner. Conducting follow-up and social support is instrumental in ensuring the patients

partake in the medication with the right dosage, time, and intervals (Weinstein et al., 2020;

Hariman et al., 2020). Medication adherence reduces hospital readmission as the patients

recover faster from their ailments.

CHAPTER 5: DISCUSSION

5.0 Introduction

The study sought to establish the influential factors in reducing re-admission risk and in

recovery promotion focusing on forensic outpatients with dual diagnosis. The research

underscores the challenges that forensic patients face, such as the high costs of forensic

services and the loss of liberty for the patients (Becker et al., 2017; Del Favero et al., 2020;

Donisi et al., 2016). The rise of forensic patients has a significant economic burden on the

healthcare system, patients, and their families (Owusu et al., 2022). The challenge is

exacerbated by the length of hospitalisation required for forensic patients and higher

readmission rates for patients after discharge. Previous studies showed that readmission to

secure care for forensic patients is associated with increased financial, emotional, and social

costs to caregivers, patients, and service providers (Penny et al., 2017). Penny et al. (2017)

add, “Return to hospital after a lengthy forensic admission may be equated with treatment

failure, and may signal challenges that forensic service users often face upon transitioning to

the community.” The lack of proper discharge plans and ineffective transition to the

community is an issue that increases the risk of readmission. The review noted that lack of

family and social support, unstable housing, and increased costs increase patient readmission

risk (Phillips et al., 2020; Heslin s, 2015). Hospital readmission for forensic patients with

dual diagnosis impacts workers' morale, and the job satisfaction concept is associated with

low-quality care.

The review showed a strong correlation between hospital readmission and length of hospital

stays. The study noted that shorter hospital stays increases the risk of readmission for forensic

patients with dual diagnosis even though the finding is contradictory, noting that longer
hospital stays are expensive. Owusu et al. (2022) surmised the influential factors to hospital

readmission to include "a short period of hospitalisation for first admitted patients and non-

adherence to medication and patients with suicidal ideation." Though the longer length of

hospital stays is expensive for forensic patients with dual diagnosis, there is a need for them

to stay longer to guarantee reduced risk of readmission. The longer hospital stays increases

the chance of adequate preparation for a well-coordinated and adequately planned patient

discharge from healthcare facilities (Penny et al., 2017). The approach ensures a focused

transition effort critical in reducing patient readmission, particularly in acute psychiatric

hospitals. Owusu et al. (2022) concluded, “Adequate, ffective (Spelling. In the

discussion, try not to use direct quotes from your selected studies unless you really have

to. The discussion should be using the findings to discuss what you have learned, and

how it reflects/ contradicts or adds to other literature. How relevant it is to the UK

situation etc.) inpatient treatment, well-coordinated psychological care, and medication

management after discharge are crucial to reducing the risk of readmission." The approach

reduces readmission since patients' adherence to medication is high as they receive follow-up

services. Healthcare practitioners should ensure an informal network of support for patients

with mental health issues to enhance the quality of their lives and reduce the risk of hospital

readmission.

The finding of the review correlate with previous findings, which showed that forensic

patients with dual diagnosis are likely to be readmitted to the hospital when they have mental

health issues. Patients suffering from substance abuse disorder, suicide ideations, or

schizophrenia are at risk of readmission owing to non-adherence to medication and treatment

and the risk of self-harm. Owusu et al. (2022) said hospital readmission "indicates that these

patients experience suicidal behaviour to communicate and regulate feelings and as a way of

getting help when more constructive coping strategies are insufficient.” Lack of sufficient
social support plays a role in increasing the suicidal thoughts that propagate hospital

readmission. The finding shows that there is a need for medical practitioners and clinicians to

focus on identifying patients with mental health issues such as suicidal ideation and

effectively plan for their transition to community care facilities (Becker et al., 2017; Cakir et

al., 2017; and Donisi et al., 2016). Educating patients on the effective preventive measures

and interventions for psychopharmacological and psychosocial is integral in reducing

readmission rates. The review showed a strong association between substance abuse and

hospital readmission, hence, the need for clinicians to screen patients for mental health issues

(Reif et al., 2017; Weinstein et al., 2020). Establishing the early-onset or late-onset of

substance abuse in patients helps to evaluate appropriate treatment effectively. Owusu et al.

(2022) contend that providing patients with sufficient inpatient care helps address their

psychiatric status and manage problems on time. The approach guarantees that patients with

substance and alcohol abuse access exceptional interventions that reduce hospital readmission

(Becker et al., 2017; Donisi et al., 2016). In essence, clinical and healthcare practitioners

should ensure that good support and a psychological network are available for patients.

5.1 Limitations

The limitation of the study is its exclusion criteria that articles included in the study were

those written in English only. The challenge of accessing interpreters, such as the cost

implications and time-consuming, made it difficult for the review to include articles in other

languages. As such, the study missed valuable information and insights from articles

published in other languages. Also, the articles included in the study discussed hospital

readmissions without providing influential interventions or risk factors. The issue made it

difficult to understand the barriers to the efforts in reducing hospital readmission among

forensic patients with dual diagnosis. Further, the study limitation included the failure of the
authors to register or document the protocol for review, which means that the review did not

publish its to enable reproducibility (I understand what you mean but the sentence

needs to be re-written.). The study conducted an extensive electronic search for data from

databases, strict exclusive and inclusive assessment and quality assessment criteria, and

explored the variables under study. However, it was difficult to pool extracted significant risk

factors owing to differences in the included studies based on the assessed variables, different

diagnoses, and follow-up timelines embraced in identifying the readmission rates.

5.2 Implication for Practice and Policy

The study highlights the need to involve community healthcare and social workers in the

discharge plans for forensic patients with dual diagnoses. They are instrumental in enhancing

the transition to primary healthcare from the health system. The approach ensures hospital

adherence, provides social support and assists in follow-up services, which are integral in

reducing hospital readmission. The review showed the need for enhancing the role of nurses

and social workers in coordinating support to forensic patients through interprofessional and

interpersonal communication, as well as information transfer. Underwriting the above

findings, the study contends that future studies should explore the workload implications and

cost-effectiveness of coordinating the nurse and social care workers for forensic patients.

Future studies should integrate the primary care provider distribution and date of discharge

summary as part of the readmission risk factors. As Zhou et al. (2022) stated, there is a need

for shared information on hospitalisation between primary physicians and social workers to

promote effective patient assessment and ensure treatment and care are offered. The approach

will guarantee reduced hospital readmission of forensic patients with dual diagnosis.

5.3 Conclusion and Recommendation

In conclusion, the study has identified the influential factors that increase the risk of

readmission for forensic patients with dual diagnosis, including involuntary admission,

shorter length of hospital stay, discharge plans, mental health issues, and availability of

intermediate healthcare staff and community-based services. Therefore, developing and

executing strategies that mitigate the factors in reducing hospital readmission for forensic

patients is imperative. The increased readmission rates are expensive and affect workers’

morale since higher readmission is associated with poor quality of care and service.

Therefore, the review identified that providing sufficient inpatient care, residential treatment,

and proper discharge plans is imperative in reducing readmission.

Therefore, the study recommends:

 The involvement of social workers in developing hospital-home discharge plans

guarantees accommodation arrangements, social support, medical adherence, and

continuity of care in the community.

 Sufficient in-service training for care workers and nurses to acquire current

knowledge-based practices, upskill their knowledge of discharge plans, and monitor

medication adherence is critical in reducing readmission.

 To reduce readmission rates, provide community peer support services to provide

psychological support to forensic patients with dual diagnoses as part of the discharge

plans.
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