Taking the next step: Improving care transitions from a first‐episode psychosis service

Abstract

Aims: First-episode services (FES) improve outcomes in recent onset psychosis, but there is growing concern about how patients fare after discharge from these timelimited services.Methods: A quality improvement approach (QI) was used to improve patient engagement in the discharge planning process (disposition), and successful engagement in care 3 months after discharge from the FES (transfer). Data from 144 consecutive discharges over 62 months are presented. A planning phase was followed by recurrent Plan-Do-Study-Act cycles (PDSA) that included the introduction of proactive efforts targeting disposition planning (with patients and families) and follow-up to facilitate transfer after discharge. Fisher's exact test was used to compare disposition and transfer outcomes across the QI phases.Results: This QI approach was sustained through a three-fold escalation in discharge volume. Transfer status at 3 months was significantly different between the pre-and post PDSA phases (p = .02). A greater proportion were confirmed transfers post-PDSA (54.3 vs. 37%), but of those with known status at 3 months, similar proportions were successfully transferred (76, 73%). Patients discharged post-PDSA were less likely to have unknown treatment status (26 vs. 51%). Disposition outcomes were also significantly improved post-PDSA (p = .03). Patients were more likely to engage with discharge planning (69.7 vs. 48.6%) and less likely to be lost to follow-up (13.8 vs. 25.7%), or to refuse assistance (11.0 vs. 20.0%). Conclusion:This QI approach offers a feasible way to improve disposition and transfer after FES and can be built upon in efforts to sustain functional gains in onward pathways.

First help-seeking attempt before and after psychosis onset: measures of delay and aversive pathways to care

“…This is considerably lower than prior reports of 30% [12] without confirmed prodromes, but were limited by a lack of psychometric assessment of early symptom onset and severity. The SIPS, which was designed to differentiate prodromal from threshold psychosis, demonstrates utility here in dating both these illness phases and their interaction with pathways to care [46].…”

Reasons for Discharge in a National Network of Early Psychosis Intervention Programs

“…For example, a Texas-based implementation study reported a 41% rate of disengagement within just 9 months 17 whereas a Connecticut-based clinic reported between 12 and 26% rates of disengagement over the entire two-year treatment duration. 18 Comparison is also challenging given the substantial variability in the operationalization of discharge or disengagement across studies. 6,8 For example, Melbourne's EPPIC program reported that only 7% of patients were disengaged by the end of their treatment program; 8 however, the authors characterized someone as re-engaged if they called the treatment team to explain that they no longer wanted services, which in our study would have been coded as unilateral termination.…”

Neglecting the care of people with schizophrenia: here we go again

“…They provide ongoing support to the receiving general practitioners and offer informal phone contacts to discharged patients about whom they are worried; they are understandably anxious about the adequacy of such an arrangement (Tibbo, 2022). Services in New Haven, Connecticut have reported on several cycles of a quality improvement project to improve 'this first critical hand off in care' (Gallagher et al, 2022). They describe good liaison with receiving clinicians.…”

“…This predicts that high-quality input during these initial years will lead to better outcomes and, for some patients, will even bring about full recovery (Jackson et al, 2019). There have been concerns that improved outcomes may not be maintained following discharge or transfer of care (Allison, Bastiampillai, Malhi, & Castle, 2019; Bosanac, Patton, & Castle, 2010; Gafoor et al, 2010; Gallagher et al, 2022; Hyatt, Hasler, & Wilner, 2022; Jones et al, 2020; McGorry, Ratheesh, & O'Donoghue, 2018; Pelosi & Birchwood, 2003; Puntis et al, 2020a) and that ‘the duration of treatment that [specialised early intervention] teams offer to patients is not sufficiently long enough to consolidate the therapeutic gains made during treatment…’ (Puntis et al, 2020a). These issues have been examined in recently published Cochrane reviews of international randomised controlled trials (RCTs) and in an important observational study of psychiatric services in Oxfordshire, England (Puntis et al, 2020a, 2020b; Puntis, Oke, & Lennox, 2018).…”