What this article is about
In brief
In this pilot RCT of 44 adults with severe mental illness, a nurse-led transitional care program combining pre-discharge education, coping-skills training, a post-discharge home visit, and biweekly telephone follow-up produced significantly greater improvements in symptoms, medication adherence, function, and...
For nursing students
Study summary
People living with severe mental illness (SMI) — conditions such as schizophrenia, bipolar disorder, and major depression — face one of their riskiest moments right after they leave the hospital. This transition from an inpatient psychiatric unit back to home and community life is when medication non-adherence, symptom relapse, and re-hospitalization are most likely. This pilot study, conducted at the All India Institute of Medical Sciences (AIIMS) Jodhpur between February 2021 and January 2022, tested whether a structured, nurse-led transitional care intervention could smooth that handoff.
The researchers screened 72 people with SMI and randomly assigned 44 of them to one of two groups: a transitional nursing care (TNC) group (n = 22) or a treatment-as-usual (TAU) group (n = 22). This was a two-arm, single-blind randomized controlled trial, meaning participants did not know which arm they were assigned to, and allocation was concealed using sequentially numbered opaque envelopes generated from a computer-based randomization sequence.
The TNC group received standard inpatient psychiatric care plus a structured program of nursing sessions delivered across four key hospital sessions: psychoeducation about the illness and relapse prevention, illness-related stress management, coping-skills training (including practicing deep breathing techniques), and a session addressing barriers to medication adherence, which ended with participants receiving a personal medication card at discharge. After discharge, a nurse conducted a home visit within 24 to 72 hours to check on the person's needs and reinforce adherence, followed by telephone booster calls every two weeks for three months to reinforce coping strategies and treatment engagement. The TAU group received only the hospital's standard routine psychiatric care, without these added sessions.
Both groups were assessed using standardized tools at baseline and then again at one, two, and three months after discharge: symptom severity (using scales appropriate to each diagnosis, such as the PANSS for schizophrenia), medication adherence (Medication Adherence Rating Scale), day-to-day functioning (Work and Social Adjustment Scale), and personal sense of recovery (Recovery Assessment Scale-Revised).
Engagement with the intervention was strong: 91% of TNC participants attended all six sessions, and all participants completed the follow-up assessments. By three months, the TNC group showed significantly greater improvement than the TAU group on every outcome measured, with large effect sizes. Symptom severity dropped substantially more in the TNC group. Medication adherence scores more than doubled in the TNC group over the study period (rising from about 3.6 to 8.7 on the MARS), while the TAU group's adherence actually declined after the first month. Functional ability and self-reported recovery also improved more in the TNC group than in the TAU group.
The authors describe this as a feasibility study — its main purpose was to show that a nurse-delivered transitional care program is practical and acceptable to implement in a resource-constrained tertiary care setting in India, not to produce a definitive, generalizable answer about effectiveness. The sample size, while adequate for a pilot, was small (a minimum of 17 per group was calculated as needed, and 22 per group were enrolled to allow for attrition), the trial ran at a single site, and follow-up was limited to three months, so nothing is known yet about whether these gains persist longer term.
For nursing students, this study is a useful, concrete example of how nurses can design and deliver a multi-component transitional care intervention — combining education, skills training, home visits, and telephone follow-up — and how outcomes across several domains (symptoms, adherence, function, recovery) can be tracked using validated instruments. It also illustrates why care transitions deserve deliberate nursing attention, especially for people whose conditions carry a high risk of relapse and re-hospitalization when support drops off after discharge. The next step the authors call for is a larger, multi-site trial with longer follow-up to confirm these encouraging pilot findings.
Original publication
Source abstract and study details
Read the source abstract
Abstract This feasibility study utilized two-arm, single-blind randomized controlled trial (RCT), conducted in a psychiatry unit of a tertiary care institution between February 2021 and January 2022. Seventy-two individuals with Severe Mental Illnesses (SMI) screened for eligibility, of which 44 were randomly assigned to receive transitional nursing care intervention (TNC, n = 22) or the treatment as usual (TAU, n = 22). Participants of both groups were initially assessed for symptom severity, medication adherence, functional ability, and process of recovery. TNC participants received six sessions of transitional nursing care interventions (TNCI) including home visit and telephonic booster intervention after discharge along with standard routine care at inpatient psychiatric unit. TAU group participants received only standard routine care. Post-intervention outcome variables were assessed at the first, second, and third months. Results showed that majority (91%) participants attended all six TNCI sessions. We observed that post-intervention, participants in the TNC group reported a significant reduction in symptom severity and improvement in medication adherence, functional ability, and process of recovery, compared to the TAU group with large effect sizes. TNCI led to improve mental health outcomes for SMI subgroups during the transition between inpatient to community or home settings. This study provides preliminary support for the hypothesis that implementing transitional nursing care interventions is feasible in individuals with severe mental illness. Trial registration No. CTRI/2020/12/029998, registered on: 23/12/2020.
Reviewed findings
Main findings
- In this pilot RCT of 44 adults with severe mental illness, participants who received a nurse-led transitional care intervention (TNCI) showed significantly greater reductions in symptom severity than those receiving treatment as usual (F = 12.21, p < .001, ηp² = 0.243).
- Medication adherence improved substantially more in the TNCI group (MARS scores rising from 3.60 to 8.70 by 3 months) compared to the treatment-as-usual group, whose adherence declined after the first month (F = 9.66, p < .001, ηp² = 0.203).
- Functional ability, measured with the Work and Social Adjustment Scale, improved significantly more in the TNCI group than the treatment-as-usual group over 3 months (F = 11.43, p < .001, ηp² = 0.231).
- Self-reported recovery, measured with the Recovery Assessment Scale-Revised, showed a significant between-group difference favoring TNCI, though with a smaller effect size than the other outcomes (F = 4.54, p < .05, ηp² = 0.107).
- The intervention was highly feasible and acceptable: 91% of TNCI participants attended all six intervention sessions, and 100% of participants across both groups completed the 3-month follow-up assessments.
Using the findings
Practice considerations
- Nurses can play a central, structured role in bridging the transition from inpatient psychiatric discharge to community life through education, skills training, home visits, and scheduled telephone follow-up.
- Building a dedicated medication-adherence session into discharge preparation, including a take-home medication card, may help address a leading driver of relapse and re-hospitalization in severe mental illness.
- Brief coping-skills training delivered before discharge, such as structured breathing exercises and problem-solving practice, may support patients in managing illness-related stress once they leave the inpatient setting.
- Post-discharge contact within the first 24 to 72 hours, followed by regular telephone check-ins, may help sustain treatment engagement during the highest-risk early transition period.
- Because this is a pilot study, clinicians should view these findings as supportive but preliminary; adopting similar transitional care protocols should be paired with local monitoring and, ideally, wait for confirmatory larger-scale trials.
For educators
Teaching and appraisal notes
This pilot, two-arm, single-blind randomized controlled trial (Mudakavi, Rentala & Nebhinani, 2025, Discover Mental Health) tested a nurse-led transitional care intervention (TNCI) for adults with severe mental illness (SMI) transitioning from inpatient psychiatric care to community living, conducted at AIIMS Jodhpur, India (Feb 2021–Jan 2022; CTRI/2020/12/029998).
Design and methods: Of 72 individuals screened, 44 were randomized (computer-generated sequence, sequentially numbered opaque sealed envelopes for allocation concealment) to TNCI (n = 22) or treatment-as-usual (TAU, n = 22); participants were blind to allocation. A priori power analysis indicated a minimum of 17 participants per arm, with 22 enrolled per arm to accommodate anticipated attrition (final analyzed n = 20 per arm after dropout). The TNCI comprised four structured inpatient sessions — psychoeducation on illness and relapse prevention, illness-related stress management, coping-skills training (including diaphragmatic breathing practice), and a medication-adherence session culminating in a take-home medication card — followed by a post-discharge home visit within 24–72 hours and biweekly telephone booster calls (~40–45 minutes each) for three months. TAU received routine inpatient care only. Outcomes — symptom severity (diagnosis-appropriate scales: PANSS, HAM-D, YMRS), medication adherence (MARS), functional ability (WSAS), and recovery (RAS-R) — were assessed at baseline and 1, 2, and 3 months post-discharge.
Key results for classroom discussion: engagement was strong (91% attended all six TNCI sessions; 100% follow-up completion). Between-group repeated-measures analyses favored TNCI across all domains with large effect sizes: symptom severity (F = 12.21, p < .001, ηp² = 0.243; TNC 47.45→26.65 vs. TAU 45.15→35.20), medication adherence (F = 9.66, p < .001, ηp² = 0.203; TNC 3.60→8.70 vs. TAU 3.20→5.80, with TAU adherence declining after month 1), functional ability (F = 11.43, p < .001, ηp² = 0.231; TNC 26.75→16.20 vs. TAU 27.90→25.70), and recovery (F = 4.54, p < .05, ηp² = 0.107; TNC 55.25→71.40 vs. TAU 53.95→59.20).
Critical appraisal points for students: this is explicitly a feasibility/pilot trial, so effect estimates should be read as hypothesis-generating rather than confirmatory. Strengths include randomization with concealed allocation, use of validated, diagnosis-appropriate outcome measures across multiple domains, a theoretically coherent multi-component intervention (education + skills + adherence support + continuity via home visit and phone follow-up), and strong retention/adherence data, which itself supports feasibility. Weaknesses to probe with students: small per-arm sample (adequate for pilot power calculations but underpowered for definitive efficacy claims), single-site design in one Indian tertiary hospital limiting generalizability across health systems and cultures, short (3-month) follow-up leaving durability of gains unknown, single-blind (not double-blind) design leaving assessor/provider blinding unclear, and the heterogeneity of the SMI sample (schizophrenia, bipolar, depression) assessed with different diagnosis-specific severity scales, which complicates pooled interpretation of the "symptom severity" outcome.
Teaching uses: this article works well for journal-club discussions on transitional care models, discharge planning, and nurse-led interventions for high-risk psychiatric populations; for a methods seminar on pilot/feasibility trial design versus definitive RCTs, including sample-size justification and effect-size reporting; and for discussing how psychiatric-mental health nurses can extend continuity of care into the community via structured, protocolized follow-up. Instructors may ask students to design a hypothetical adequately powered, multi-site follow-up trial addressing the stated limitations, or to compare this intervention model against transitional care models used in North American or Canadian mental health systems.
Critical appraisal
Limitations
- The sample size (22 participants randomized per arm, calculated from a minimum requirement of 17 per arm) was adequate for a feasibility pilot but is too small to draw definitive conclusions about efficacy.
- The trial was conducted at a single tertiary care institution in India, which limits generalizability to other health systems, cultural contexts, and resource settings, including Canadian practice environments.
- Follow-up was limited to 3 months post-discharge, so the durability of improvements in symptoms, adherence, function, and recovery beyond that window is unknown.
Classroom use
Discussion Questions
- What specific components of the transitional nursing care intervention (psychoeducation, stress management, coping skills, medication adherence support, home visit, telephone boosters) do you think contributed most to the outcomes seen, and why?
- How might allocation concealment using sequentially numbered opaque envelopes reduce bias in a trial like this, compared to non-concealed randomization?
- Why is medication adherence often described as one of the most modifiable risk factors for relapse in severe mental illness, and how did this intervention specifically target it?
- What does it mean that this was a 'feasibility' pilot trial rather than a definitive efficacy trial, and how should that shape how much weight clinicians place on the reported effect sizes?
- Given the small, single-site sample, what would need to change in a follow-up trial design to allow for more generalizable conclusions?
- How could a similar nurse-led transitional care model be adapted for a Canadian mental health system, considering differences in community mental health infrastructure, telehealth access, and staffing models?
Source-based questions
Frequently asked questions
How many people participated in this transitional care study?
Of 72 people screened, 44 were randomized: 22 to the transitional nursing care group and 22 to the treatment-as-usual group, at a tertiary care hospital in India.
Is this transitional care intervention proven to work for all patients with severe mental illness?
No. This was a small, single-site pilot feasibility trial with only 3-month follow-up, so the authors describe it as preliminary support rather than definitive proof; larger, multi-site trials with longer follow-up are needed.
What does a home visit involve in this transitional care model?
A nurse visited the patient's home within 24 to 72 hours of hospital discharge to assess health needs, ensure engagement with care, and motivate continued medication adherence.
What is the trial registration number for this study?
The trial was registered under CTRI/2020/12/029998 on 23 December 2020.
What were the main limitations of this transitional care study?
Key limitations include a small per-arm sample size, a single-site design limiting generalizability, and only 3 months of follow-up, so the durability of the improvements beyond that period remains unknown.