Continuity across inpatient and outpatient mental health care or specialisation of teams? A systematic review

Association between continuity of care and treatment outcomes in psychiatric patients in Germany: a prospective cohort study

BACKGROUND

Continuity of care is considered an important treatment aspect of psychiatric disorders, as it often involves long-lasting or recurrent episodes with psychosocial treatment aspects. We investigated in two psychiatric hospitals in Germany whether the positive effects of relational continuity of care on symptom severity, social functioning, and quality of life, which have been demonstrated in different countries, can also be achieved in German psychiatric care.

METHODS

Prospective cohort study with a 20-months observation period comparing 158 patients with higher and 165 Patients with lower degree of continuity of care of two psychiatric hospitals. Patients were surveyed at three points in time (10 and 20 months after baseline) using validated questionnaires (CGI Clinical Global Impression rating scales, GAF Global Assessment of Functioning scale, EQ-VAS Euro Quality of Life) and patient clinical record data. Statistical analyses with analyses of variance with repeated measurements of 162 patients for the association between the patient- (EQ-VAS) or observer-rated (CGI, GAF) outcome measures and continuity of care as between-subject factor controlling for age, sex, migration background, main psychiatric diagnosis group, duration of disease, and hospital as independent variables.

RESULTS

Higher continuity of care reduced significantly the symptom severity with a medium effect size (p 0.036, eta 0.064) and increased significantly social functioning with a medium effect size (p 0.023, eta 0.076) and quality of life but not significantly and with only a small effect size (p 0.092, eta 0.022). The analyses of variance suggest a time-independent effect of continuity of care. The duration of psychiatric disease, a migration background, and the hospital affected the outcome measures independent of continuity of care.

CONCLUSION

Our results support continuity of care as a favorable clinical aspect in psychiatric patient treatment and encourage mental health care services to consider health service delivery structures that increase continuity of care in the psychiatric patient treatment course. In psychiatric health care services research patients' motives as well as methodological reasons for non-participation remain considerable potential sources for bias.

TRIAL REGISTRATION

This prospective cohort study was not registered as a clinical intervention study because no intervention was part of the study, neither on the patient level nor the system level.

The Impact of 90-day Physician Follow-up Care on the Risk of Readmission Following a Psychiatric Hospitalization

AIMS

This study measures the impact of 90-day physician follow-up care after psychiatric hospitalization among 3,311 adults and youth, with risk of subsequent readmission within six months.

METHODS

A 5-year investigation was conducted based on Quebec (Canada) medical administrative databases. Cox proportional-hazards regression was performed, with 90-day follow-up care as the main independent variable, controlling for various sociodemographic, clinical, and other service use variables.

RESULTS

Within the 90-day follow-up period after patient discharge, or in the first 30 days, receiving at least one consultation per month as opposed to no consultation was associated with a reduced risk of psychiatric readmission. Women showed an increased readmission risk compared to men, while those living in less materially deprived areas a decreased risk as opposed to more deprived areas. Patients hospitalized for suicide attempt or schizophrenia spectrum and other psychotic disorders, and those with co-occurring mental and substance-related disorders or chronic physical illnesses, especially illnesses high on the severity index, also presented a heightened risk of hospitalization. Patients hospitalized for personality disorders or receiving a high continuity of physician care showed a reduced risk of readmission.

CONCLUSION

This study demonstrates that follow-up care, if provided within the first 30 days of discharge or monthly during the 90-day follow-up period, decreased the risk of readmission, as did having a high continuity of physician care prior to and within the 90-day follow-up period. However, few patients in this study had received such high-quality care, indicating that the Quebec system needs to considerably improve its discharge planning processes.

The importance of interdisciplinarity in accommodating patient needs among norwegian nurses

WHAT IS KNOWN ON THE SUBJECT

Previous studies of interdisciplinarity and nursing responsibilities have mainly focused on outcomes such as patient safety, job satisfaction and organizational factors. Mental health nurses often describe role confusion in relation to other health professionals. Opportunities for interdisciplinary communication with other professionals may benefit health care.

WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE

The current large-scale study is the first to investigate whether mental health and SUD nurses' perceptions of their opportunities to accommodate patients' needs are related to interdisciplinarity in the treatment unit and a nursing role with clearly defined responsibilities. Strong interdisciplinarity was associated with greater perceived opportunities to accommodate patients' psychosocial, somatic, and economic and legal needs, while strictly defined nursing roles/responsibilities were related to weaker opportunities to do so.

WHAT ARE THE IMPLICATIONS OF PRACTICE

The findings highlight the need to address how mental health and SUD nurses organize practice to meet patients' diverse needs Interdisciplinary teamwork could strengthen nurses' ability to address patient needs Finding the best possible balance of providing service in teams or individually could improve resource utilization at the same time as strengthening patient care, and making sure that the patients' various needs are met.

ABSTRACT

INTRODUCTION: Nurses' roles in specialist mental health and substance use disorder (SUD) treatment services are multidimensional and complex. Their responsibility, autonomy and interdisciplinary collaboration may be of importance for their perceived opportunities to accommodate patients' health needs. Previous studies of interdisciplinarity and nursing responsibilities have mainly focused on outcomes such as patient safety, job satisfaction and organizational factors, and included relatively small samples. The studies have also mainly been conducted in other sectors than the mental health and SUD nursing sectors.

AIM/QUESTION

The aim of this study is to examine the associations between nurses' roles, interdisciplinarity and their perceived opportunities to accommodate patients' psychosocial, somatic and economic/legal needs.

METHOD

A cross-sectional web-based questionnaire survey was conducted in a nationwide sample of Norwegian nurses in the mental health, SUD treatment and combined mental health and SUD treatment sectors. Of 5,501 contactable nurses (74% of the population), 1918 (35%) responded.

RESULTS

The results revealed that interdisciplinarity was significantly associated with greater perceived opportunity to accommodate patient needs, whereas strictly defined nursing roles/responsibilities were associated with less opportunity to accommodate these needs.

DISCUSSION/IMPLICATION FOR PRACTICE

Facilitation of interdisciplinary collaboration may improve quality of care for patients in mental health and SUD treatment services.

Modelling the balance of care: Impact of an evidence-informed policy on a mental health ecosystem

Major efforts worldwide have been made to provide balanced Mental Health (MH) care. Any integrated MH ecosystem includes hospital and community-based care, highlighting the role of outpatient care in reducing relapses and readmissions. This study aimed (i) to identify potential expert-based causal relationships between inpatient and outpatient care variables, (ii) to assess them by using statistical procedures, and finally (iii) to assess the potential impact of a specific policy enhancing the MH care balance on real ecosystem performance. Causal relationships (Bayesian network) between inpatient and outpatient care variables were defined by expert knowledge and confirmed by using multivariate linear regression (generalized least squares). Based on the Bayesian network and regression results, a decision support system that combines data envelopment analysis, Monte Carlo simulation and fuzzy inference was used to assess the potential impact of the designed policy. As expected, there were strong statistical relationships between outpatient and inpatient care variables, which preliminarily confirmed their potential and a priori causal nature. The global impact of the proposed policy on the ecosystem was positive in terms of efficiency assessment, stability and entropy. To the best of our knowledge, this is the first study that formalized expert-based causal relationships between inpatient and outpatient care variables. These relationships, structured by a Bayesian network, can be used for designing evidence-informed policies trying to balance MH care provision. By integrating causal models and statistical analysis, decision support systems are useful tools to support evidence-informed planning and decision making, as they allow us to predict the potential impact of specific policies on the ecosystem prior to its real application, reducing the risk and considering the population’s needs and scientific findings.

The role of local inpatient psychiatric units and general practitioner on continuity of care in Northern Norway: A case-register study

OBJECTIVES

The general practitioners' (GP) role in the care of mental health patients has received increased attention. The literature underlines the need for integration of primary and specialist services, but cross-boundary continuity for patients with severe conditions may be particularly poor. The aim of this study was to analyze the collaboration between primary care and different models of specialized psychiatric services for patients with severe conditions.

METHODS

We compared a local and a centralized model of mental health care. Service utilization over a 5-year period was studied.

RESULTS

Findings suggest that a local institution-based model of services positively affects the use of both GP and specialist outpatient care, with most inpatients utilizing both GP and specialist outpatient consultations. In the centralized model, a substantial proportion of inpatients only used GP outpatient care. Furthermore, inpatients that used both GP and specialist outpatient services received more of both services compared to those who did not enter specialist outpatient care at all.

CONCLUSION

Local inpatient units may positively affect continuity of care and collaboration between general practitioners and specialist psychiatric services compared to more traditional hospital units, probably because better functional integration of services, better facilitation of clinical alliances/relationships, or a more network-oriented treatment philosophy.

Predictors of Recurrent High Emergency Department Use among Patients with Mental Disorders

Few studies have examined predictors of recurrent high ED use. This study assessed predictors of recurrent high ED use over two and three consecutive years, compared with high one-year ED use. This five-year longitudinal study is based on a cohort of 3121 patients who visited one of six Quebec (Canada) ED at least three times in 2014–2015. Multinomial logistic regression was performed. Clinical, sociodemographic and service use variables were identified based on data extracted from health administrative databases for 2012–2013 to 2014–2015. Of the 3121 high ED users, 15% (n = 468) were recurrent high ED users for a two-year period and 12% (n = 364) over three years. Patients with three consecutive years of high ED use had more personality disorders, anxiety disorders, alcohol or drug related disorders, chronic physical illnesses, suicidal behaviors and violence or social issues. More resided in areas with high social deprivation, consulted frequently with psychiatrists, had more interventions in local community health service centers, more prior hospitalizations and lower continuity of medical care. Three consecutive years of high ED use may be a benchmark for identifying high users needing better ambulatory care. As most have multiple and complex health problems, higher continuity and adequacy of medical care should be prioritized.

Psychiatric readmission rates in a multi-level mental health care system - a descriptive population cohort study

BACKGROUND

Readmission rates are frequently used as a quality indicator for health care, yet their validity for evaluating quality is unclear. Published research on variables affecting readmission to psychiatric hospitals have been inconsistent. The Norwegian specialist mental health care system is characterized by a multi-level structure; hospitals providing specialized -largely unplanned care and district psychiatric centers (DPCs) providing generalized -more often planned care. In certain service systems, readmission may be an integral part of individual patients' treatment plan. The aim of the present study was to describe and examine the task division in a multi-level health care system. This we did through describing differences in patient population (age, sex, diagnosis, substance abuse comorbidity and length of stay) and admissions types (unplanned vs. planned) treated at different levels (hospital, DPC or both), and by examining whether readmission risk differ according to type and place of treatment of index-admission and travel-time to nearest hospital and DPC.

METHODS

In this population-based cohort study using administrative data we included all individuals aged 18 and older who were discharged from psychiatric inpatient care with an ICD-10 diagnosis F2-F6 ("functional mental disorders") in 2012. Selecting each individual's first discharge during 2012 as index gave N = 16,185 for analyses following exclusions. Analysis of readmission risk were done using Kaplan-Maier failure curves.

RESULTS

Overall, 15.1 and 47.7% of patients were readmitted within 30 and 365 days, respectively. Unplanned admission patients were more likely to be readmitted within 30 days than planned patients. Those transferred between hospital and DPC during index admission were more likely to be readmitted within 365 days, and to experience planned readmission. Patients with short travel time were more likely to have unplanned readmission, while patients with long travel time were more likely to have planned readmission.

CONCLUSIONS

DPCs and hospitals fill different purposes in the Norwegian health care system, which is reflected in different patient populations. Differences in short term readmission rates between hospitals and DPCs disappeared when type of admission (unplanned/planned) was considered. The results stress the importance of addressing differences in organisation and task distribution when comparing readmission rates between mental health systems.

"People just don't understand their role in it." Collaboration and coordination of care for service users with complex and severe mental health problems

PURPOSE

To explore professionals' and service users' experiences and perceptions of interprofessional collaboration and coordination for service users with complex and severe mental health issues.

DESIGN AND METHODS

A qualitative study involving semi-structured interviews of professionals and individual interviews of service users. Data were analyzed by thematic analysis.

FINDINGS

Participants described challenges and suggested improvements concerning Distribution of roles, responsibilities, and tasks; Communication; and Knowledge and attitudes.

PRACTICE IMPLICATIONS

Mental health nurses and other professional helpers should have a particular focus on common aims, clear division of roles, planning and timing of interventions, and communication with other professionals and service users.

Impact of the Mental Health Care Continuity-Chain among Individuals Expressing Suicidal Behaviour in a Spanish Sample

Poor coordination between different healthcare services means that the proper follow-up of patients cannot be guaranteed, thus increasing the risk of relapse in cases of attempted suicide. This study describes the sociodemographic variables related to suicidal behaviour in a Spanish sample and analyses how the use of a continued nursing care protocol influences the follow-up of patients who have shown suicidal behaviour. A cohort of 213 patient was identified from the emergency department medical records because of suicide attempters during 2011; 51.6% were included in the intervention group (n = 110) and 48.4% (n = 103) in the control group. We used a specific continuity of care chain protocol with the patients in the intervention group. More than half of all the initial suicide attempts were made by women; 80.3% had a previous history of a mental disorder and 65.7% of the attempts were made by ingesting medications. Significantly more patients in the intervention group attended their first follow-up visit. This study highlights the need to implement protocols that favour the continuity of mental health care processes-especially those designed to treat individuals expressing suicidal behaviour-with the aim of reducing the risk of suicide in them by intensifying their monitoring.

Using patient experience data to support improvements in inpatient mental health care: the EURIPIDES multimethod study

Background

All NHS providers collect data on patient experience, although there is limited evidence about what to measure or how to collect and use data to improve services. We studied inpatient mental health services, as these are important, costly and often unpopular services within which serious incidents occur.

Aims

To identify which approaches to collecting and using patient experience data are most useful for supporting improvements in inpatient mental health care.

Design

The study comprised five work packages: a systematic review to identify evidence-based patient experience themes relevant to inpatient mental health care (work package 1); a survey of patient experience leads in NHS mental health trusts in England to describe current approaches to collecting and using patient experience data in inpatient mental health services, and to populate the sampling frame for work package 3 (work package 2); in-depth case studies at sites selected using the work package 2 findings, analysed using a realist approach (work package 3); a consensus conference to agree on recommendations about best practice (work package 4); and health economic modelling to estimate resource requirements and potential benefits arising from the adoption of best practice (work package 5). Using a realist methodology, we analysed and presented our findings using a framework based on four stages of the patient experience data pathway, for which we coined the term CRAICh (collecting and giving, receiving and listening, analysing, and quality improvement and change). The project was supported by a patient and public involvement team that contributed to work package 1 and the development of programme theories (work package 3). Two employed survivor researchers worked on work packages 2, 3 and 4.

Setting

The study was conducted in 57 NHS providers of inpatient mental health care in England.

Participants

In work package 2, 47 NHS patient experience leads took part and, in work package 3, 62 service users, 19 carers and 101 NHS staff participated, across six trusts. Forty-four individuals attended the work package 4 consensus conference.

Results

The patient experience feedback cycle was rarely completed and, even when improvements were implemented, these tended to be environmental rather than cultural. There were few examples of triangulation with patient safety or outcomes data. We identified 18 rules for best practice in collecting and using inpatient mental health experience data, and 154 realist context–mechanism–outcome configurations that underpin and explain these.

Limitations

The study was cross-sectional in design and we relied on examples of historical service improvement. Our health economic models (in work package 5) were therefore limited in the estimation and modelling of prospective benefits associated with the collection and use of patient experience data.

Conclusions

Patient experience work is insufficiently embedded in most mental health trusts. More attention to analysis and interpretation of patient experience data is needed, particularly to ways of triangulating these with outcomes and safety data.

Future work

Further evaluative research is needed to develop and evaluate a locally adapted intervention based on the 18 rules for best practice.

Study registration

The systematic review (work package 1) is registered as PROSPERO CRD42016033556.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 21. See the NIHR Journals Library website for further project information.

Patients prefer a continuity model of inpatient psychiatric consultant care: a patient survey in the Louth Mental Health Service

OBJECTIVES

The objective of the paper was to survey patients' preference in relation to a continuity, or split, model of inpatient consultant care in the Louth Mental Health Service.

METHODS

A written survey was administered to all patients attending the Louth Mental Health Service over a 2-week period. Participants were asked for their preferred model of care and clinical information was obtained from their clinical notes.

RESULTS

In total, 149 patients completed the survey questionnaire and 103 respondents (69%) indicated a preference for a continuity model of inpatient consultant psychiatric care. There was a trend for those who reported a past experience of inpatient hospitalisation to indicate a preference for the continuity model (76% v. 61%, respectively, χ2 3.67, p=0.056).

CONCLUSIONS

Patients indicate a preference for a continuity model of inpatient psychiatric care and this is important to consider in service planning. More research is needed to evaluate if any model of consultant care is associated with better patient outcomes.

Should all community mental health teams be sectorised?

OBJECTIVES

Sectorised catchment areas have characterised Irish mental health service delivery since the devolution of institutional care. Unlike other catchment areas, the Cluain Mhuire Community Mental Health Service (CMCMHS) never sectorised. With the development of Community Health Networks (CHNs) and Primary Care Centres, the CMCMHS has come under renewed pressure for structural change. We aimed to consider the implications of these proposed changes on staff and service users.

METHOD

We obtained demographic information comparing the CHNs with respect to attendee numbers, new referrals and admissions over a 1- year period. Secondly, we conducted an anonymous survey seeking opinions on the proposals to switch to a sector-based model and/or specialist inpatient care.

RESULTS

Referral and admission rates differed across CHNs, broadly consistent with populations. About 36% of staff and 33% of service users supported changing to a sector-based system. In the event of a sector-based system of care being implemented, 66% of service users felt that existing service users should remain under the care of their current team. There was little support among any group for the development of specialist inpatient teams.

CONCLUSIONS

We discuss the benefits and drawbacks of sectorisation of mental health service provision. Most patients did not want to change teams either as current service users or as re-referrals (indicating it will take a significant time to transition to a sector-based system). Without clear pathways towards integration with primary care teams, the advantages of sectorisation may not outweigh the challenges associated with its implementation.

Personal continuity versus specialisation of care approaches in mental healthcare: experiences of patients and clinicians-results of the qualitative study in five European countries

BACKGROUND

The current debate on organisation of the mental health care raises a question whether to prioritise specialisation of clinical teams or personal continuity of care. The article explores the experiences of patients and clinicians regarding specialisation (SC) and personal continuity (PCC) of care in five European countries.

METHODS

Data were obtained via in-depth, semi-structured interviews with patients (N = 188) suffering from mental disorders (F20-49) and with clinicians (N = 63). A maximum variation sampling was applied to assume representation of patients and of clinicians with different characteristics. The qualitative data from each country were transcribed verbatim, coded and analysed through a thematic analysis method.

RESULTS

Many positive experiences of patients and clinicians with the PCC approach relate to the high quality of therapeutic relationship and the smooth transition between hospital and community care. Many positive experiences of patients and clinicians with the SC approach relate to concepts of autonomy and choice and the higher adequacy of diagnosis and treatment. Clinicians stressed system aspects of providing mental health care: more effective management structure and higher professionalization of care within SC approach and the lower risk of disengagement from treatment and reduced need for coercion, restraint, forced medication or involuntary admission within PCC.

CONCLUSIONS

Neither the PCC, nor the SC approach meets the needs and expectations of all patients (and clinicians). Therefore, future reforms of mental health services should offer a free choice of either approach, considering that there is no evidence of differences in patient outcomes between PCC and SC approaches.

Assessing and Improving the Quality in Mental Health Services

Background: The mental health of the population consists of the three essential pillars of quality of life, economy, and society. Mental health services take care of the prevention and treatment of mental disorders and through them maintain, improve, and restore the mental health of the population. The purpose of this study is to describe the methodology for qualitative and quantitative evaluation and improvement of the mental health service system. Methods: This is a narrative review study that searches the literature to provide criteria, indicators, and methodology for evaluating and improving the quality of mental health services and the related qualitative and quantitative indicators. The bibliography was searched in popular databases PubMed, Google Scholar, CINAHL, using the keywords “mental”, “health”, “quality”, “indicators”, alone or in combinations thereof. Results: Important quality indicators of mental health services have been collected and presented, and modified where appropriate. The definition of each indicator is presented here, alongside its method of calculation and importance. Each indicator belongs to one of the eight dimensions of quality assessment: (1) Suitability of services, (2) Accessibility of patients to services, (3) Acceptance of services by patients, (4) Ability of healthcare professionals to provide services, (5) Efficiency of health professionals and providers, (6) Continuity of service over time (ensuring therapeutic continuity), (7) Efficiency of health professionals and services, (8) Safety (for patients and for health professionals). Discussion/Conclusions: Accessibility and acceptability of service indicators are important for the attractiveness of services related to their use by the population. Profitability indicators are important economic indicators that affect the viability and sustainability of services, factors that are now taken into account in any health policy. All of the indicators mentioned are related to public health, affecting the quality of life, morbidity, mortality, and life expectancy, directly or indirectly. The systematic measurement and monitoring of indicators and the measurement and quantification of quality through them, are the basis for evidence-based health policy for improvement of the quality of mental health services.

Psychiatric-related Revisits to the Emergency Department Following Rapid Expansion of Community Mental Health Services

OBJECTIVES

Repeat visits (revisits) to emergency departments (EDs) for psychiatric care reflect poor continuity of care and impose a high financial cost. We test whether rapid expansion of community health centers (CHCs)-which provide regional, low-cost primary care-correspond with fewer repeat psychiatric-related ED visits (PREDVs).

METHODS

We obtained repeated cross-sectional time-series data for 7.8 million PREDVs from the State Emergency Department Database for four populous U.S. states (California, Florida, North Carolina, and New York) from 2006 to 2011. We specified as the outcome variable the count of repeat visits per ED visitor with a psychiatric diagnosis. We retrieved aggregate-level mental health visits at CHCs from the Uniform Data System. Negative binomial regression methods controlled for individual-level confounders, county health system and sociodemographic attributes, year fixed effects, and county fixed effects.

RESULTS

The risk of a repeat PREDV decreased with a county-level increase in mental health patients seen at CHCs (incidence rate ratio = 0.986, 95% confidence interval = 0.98 to 0.99). Conversion of this rate ratio to the number of revisits averted indicated 34,000 fewer repeat PREDVs in these four states statistically associated with a 1% expansion in CHC mental health visits. Exploratory analyses found that revisits decline for relatively mild/moderate illnesses (e.g., mood, anxiety disorders) but not for severe illnesses (e.g., schizophrenia/psychoses).

CONCLUSION

An increase in mental health services at CHCs corresponds with a modest decline in repeat PREDVs. This decline concentrates among those with less severe mental illnesses.

Healthcare system performance in continuity of care for patients with severe mental illness: A comparison of five European countries

Most healthcare systems struggle to provide continuity of care for people with chronic conditions, such as patients with severe mental illness. In this study, we reviewed how system features in two national health systems (NHS) - England and Veneto (Italy) - and three regulated-market systems (RMS) - Germany, Belgium, and Poland -, were likely to affect continuing care delivery and we empirically assessed system performance. 6418 patients recruited from psychiatric hospitals were followed up one year after admission. We collected data on their use of services and contact with professionals and assessed care continuity using indicators on the gap between hospital discharge and outpatient care, access to services, number of contacts with care professionals, satisfaction with care continuity, and helping alliance. Multivariate regressions were used to control for patients' characteristics. Important differences were found between healthcare systems. NHS countries had more effective longitudinal and cross-sectional care continuity than RMS countries, though Germany had similar results to England. Relational continuity seemed less affected by organisational mechanisms. This study provides straightforward empirical indicators for assessing healthcare system performance in care continuity. Despite systems' complexity, findings suggest that stronger regulation of care provision and financing at a local level should be considered for effective care continuity.

Laying new foundations for 21st century community mental health services: An Australian perspective

While there has been a significant increase in investment in community mental health in Australia since the advent of the National Mental Health Strategy in the early 1990s, there has been little guidance on service design and delivery. This has led to a growing diversity of approaches and concern about the adequacy of care with repeated calls for a system overhaul. Consumers and carers have very largely been absent from decision-making about service design and development which has led to a system primarily designed by healthcare professionals. However, with the emergence of recovery as a core principle in mental health, it is time for consumers and carers to be centrally engaged in co-designing services with service providers. This raises the question of whether dominant service delivery models - such as the growth of specialist teams/services, the changing balance between profession-specific and generic case management roles in multidisciplinary teams, and the separation of inpatient from community care - will prevail. Contentious issues in these three service delivery areas are outlined to stimulate debate and highlight the pressing need for national guidance on the configuration of community mental health services. Building on the lessons learned from the first National Mental Health Strategy, we outline a proposal for a co-designed National Framework for Community Mental Health Services to guide the delivery of care in a way which satisfies the aspirations of consumers, carers, and mental health professionals alike.

Forensic Competency Assessment with Digital Technologies

PURPOSE OF THE REVIEW

We review the application of videoconferencing (VC) to pretrial forensic assessments of competence to stand trial (CST). We summarize the benefits, legal considerations, and reliability of VC evaluations. Based on our experience with VC in forensic settings, we provide illustrations of challenges and recommendations regarding this capability to meet increasing demands for services.

RECENT FINDINGS

CST evaluations are the most frequent type of forensic mental health assessment within the American legal system. VC can be a reliable method for conducting interviews with most defendants, including those with psychotic symptoms. Videoconferencing can improve the overall efficiency of evaluations while also improving the safety of the professionals involved with the competency evaluation. VC provides an opportunity to meet the increasing demand for evaluations and improve their efficiency. Forensic clinicians should become familiar with the uses of VC in delivering services so that VC is implemented ethically and effectively.

Predictors of personal continuity of care of patients with severe mental illness: A comparison across five European countries

BACKGROUND

In Europe, at discharge from a psychiatric hospital, patients with severe mental illness may be exposed to one of two main care approaches: personal continuity, where one clinician is responsible for in- and outpatient care, and specialisation, where various clinicians are. Such exposure is decided through patient-clinician agreement or at the organisational level, depending on the country's health system. Since personal continuity would be more suitable for patients with complex psychosocial needs, the aim of this study was to identify predictors of patients' exposure to care approaches in different European countries.

METHODS

Data were collected on 7302 psychiatric hospitalised patients in 2015 in Germany, Poland, and Belgium (patient-level exposure); and in the UK and Italy (organisational-level exposure). At discharge, patients were exposed to one of the care approaches according to usual practice. Putative predictors of exposure at patients' discharge were assessed in both groups of countries.

RESULTS

Socially disadvantaged patients were significantly more exposed to personal continuity. In all countries, the main predictor of exposure was the admission hospital, except in Germany, where having a diagnosis of psychosis and a higher education status were predictors of exposure to personal continuity. In the UK, hospitals practising personal continuity had a more socially disadvantaged patient population.

CONCLUSION

Even in countries where exposure is decided through patient-clinician agreement, it was the admission hospital, not patient characteristics, that predicted exposure to care approaches. Nevertheless, organisational decisions in hospitals tend to expose socially disadvantaged patients to personal continuity.

The same or different psychiatrists for in- and out-patient treatment? A multi-country natural experiment

AIMS

A core question in the debate about how to organise mental healthcare is whether in- and out-patient treatment should be provided by the same (personal continuity) or different psychiatrists (specialisation). The controversial debate drives costly organisational changes in several European countries, which have gone in opposing directions. The existing evidence is based on small and low-quality studies which tend to favour whatever the new experimental organisation is.We compared 1-year clinical outcomes of personal continuity and specialisation in routine care in a large scale study across five European countries.

METHODS

This is a 1-year prospective natural experiment conducted in Belgium, England, Germany, Italy and Poland. In all these countries, both personal continuity and specialisation exist in routine care. Eligible patients were admitted for psychiatric in-patient treatment (18 years of age), and clinically diagnosed with a psychotic, mood or anxiety/somatisation disorder.Outcomes were assessed 1 year after the index admission. The primary outcome was re-hospitalisation and analysed for the full sample and subgroups defined by country, and different socio-demographic and clinical criteria. Secondary outcomes were total number of inpatient days, involuntary re-admissions, adverse events and patients' social situation. Outcomes were compared through mixed regression models in intention-to-treat analyses. The study is registered (ISRCTN40256812).

RESULTS

We consecutively recruited 7302 patients; 6369 (87.2%) were followed-up. No statistically significant differences were found in re-hospitalisation, neither overall (adjusted percentages: 38.9% in personal continuity, 37.1% in specialisation; odds ratio = 1.08; confidence interval 0.94-1.25; p = 0.28) nor for any of the considered subgroups. There were no significant differences in any of the secondary outcomes.

CONCLUSIONS

Whether the same or different psychiatrists provide in- and out-patient treatment appears to have no substantial impact on patient outcomes over a 1-year period. Initiatives to improve long-term outcomes of psychiatric patients may focus on aspects other than the organisation of personal continuity v. specialisation.

How clinicians make decisions about CTOs in ACT: a qualitative study

BACKGROUND

The first 12 Norwegian assertive community treatment (ACT) teams were piloted from 2009 to 2011. Of the 338 patients included during the teams' first year of operation, 38% were subject to community treatment orders (CTOs). In Norway as in many other Western countries, the use of CTOs is relatively high despite lack of robust evidence for their effectiveness. The purpose of the present study was to explore how responsible clinicians reason and make decisions about the continued use of CTOs, recall to hospital and the discontinuation of CTOs within an ACT setting.

METHODS

Semi-structured interviews with eight responsible clinicians combined with patient case files and observations of treatment planning meetings. The data were analysed using a modified grounded theory approach.

RESULTS

The participants emphasized that being part of a multidisciplinary team with shared caseload responsibility that provides intensive services over long periods of time allowed for more nuanced assessments and more flexible treatment solutions on CTOs. The treatment criterion was typically used to justify the need for CTO. There was substantial variation in the responsible clinicians' legal interpretation of dangerousness, and some clinicians applied the dangerousness criterion more than others.

CONCLUSIONS

According to the clinicians, many patients subject to CTOs were referred from hospitals and high security facilities, and decisions regarding the continuation of CTOs typically involved multiple and interacting risk factors. While patients' need for treatment was most often applied to justify the need for CTOs, in some cases the use of CTOs was described as a tool to contain dangerousness and prevent harm.

The Use of Access Groups for Engagement in Community Mental Health Post Hospitalization

This paper describes a novel approach to engaging psychiatric patients in care after discharge from inpatient or ER treatment. The Access Group model provides rapid, flexible, high-volume intake for up to 20 patient referrals per day. Patients are scheduled for intake by referring hospital clinicians using an online scheduling software and can be seen within 1-3 days of hospital discharge. Access allows flexibility, easy rescheduling, and limited wait time. At intake, patients and family members participate in a structured group intake procedure from which they are scheduled for follow-up psychiatry, therapy, and social work appointments. Same-day appointments are available for urgent needs. Initial evidence suggests that the Access Group model is effective at providing rapid access to and engagement in care, and is acceptable to patients. Generalizability and funding approaches for the model are discussed.

In-patient treatment in functional and sectorised care: patient satisfaction and length of stay

BACKGROUND

Debate exists as to whether functional care, in which different psychiatrists are responsible for in- and out-patient care, leads to better in-patient treatment as compared with sectorised care, in which the same psychiatrist is responsible for care across settings. Aims To compare patient satisfaction with in-patient treatment and length of stay in functional and sectorised care.

METHOD

Patients with an ICD-10 diagnosis of psychotic, affective or anxiety/somatoform disorders consecutively admitted to an adult acute psychiatric ward in 23 hospitals across 11 National Health Service trusts in England were recruited. Patient satisfaction with in-patient care and length of stay (LoS) were compared (trial registration ISRCTN40256812).

RESULTS

In total, 2709 patients were included, of which 1612 received functional and 1097 sectorised care. Patient satisfaction was significantly higher in sectorised care (β = 0.54, 95% CI 0.35-0.73, P<0.001). This difference remained significant when adjusting for locality and patient characteristics. LoS was 6.9 days shorter for patients in sectorised care (β = -6.89, 95% CI -11.76 to -2.02, P<0.001), but this difference did not remain significant when adjusting for clustering by hospital (β = -4.89, 95% CI -13.34 to 3.56, P = 0.26).

CONCLUSIONS

This is the first robust evidence that patient satisfaction with in-patient treatment is higher in sectorised care, whereas findings for LoS are less conclusive. If patient satisfaction is seen as a key criterion, sectorised care seems preferable. Declarations of interest None.

How mental health service systems are organized may affect the rate of acute admissions to specialized care: Report from a natural experiment involving 5338 admissions

Objectives:

Studies on the dynamics between service organization and acute admissions to psychiatric specialized care have given ambiguous results. We studied the effect of several variables, including service organization, coercion, and patient characteristics on the rate of acute admissions to psychiatric specialist services. In a natural experiment-like study in Norway, we compared a “deinstitutionalized” and a “locally institutionalized” model of mental health services. One had only community outpatient care and used beds at a large Central Mental Hospital; the other also had small bed-units at the local District Psychiatric Centre.

Methods:

From the case registries, we identified a total of 5338 admissions, which represented all the admissions to the psychiatric specialist services from 2003 to 2006. The data were analyzed with chi-square tests and Z-tests. In order to control for possible confounders and interaction effects, a multivariate analysis was also performed, with a logistic regression model.

Results:

The use of coercion emerged as the strongest predictor of acute admissions to specialist care (odds ratio = 7.377, 95% confidence interval = 4.131–13.174) followed by service organization (odds ratio = 3.247, 95% confidence interval = 2.582–4.083). Diagnoses of patients predicted acute admissions to a lesser extent. We found that having psychiatric beds available at small local institutions rather than beds at a Central Mental Hospital appeared to decrease the rate of acute admissions.

Conclusion:

While it is likely that the seriousness of the patients’ condition is the most important factor in doctors’ decisions to refer psychiatric patients acutely, other variables are likely to be important. This study suggests that the organization of mental health services is of importance to the rate of acute admissions to specialized psychiatric care. Systems with beds at local District Psychiatric Centers may reduce the rate of acute admissions to specialized care, compared to systems with local community outpatient services and beds at Central Mental Hospitals.

Overview of post-discharge predictors for psychiatric re-hospitalisations: a systematic review of the literature

BACKGROUND

High levels of hospital readmission (rehospitalisation rates) is widely used as indicator of a poor quality of care. This is sometimes also referred to as recidivism or heavy utilization. Previous studies have examined a number of factors likely to influence readmission, although a systematic review of research on post-discharge factors and readmissions has not been conducted so far. The main objective of this review was to identify frequently reported post-discharge factors and their effects on readmission rates.

METHODS

Studies on the association between post-discharge variables and readmission after an index discharge with a main psychiatric diagnosis were searched in the bibliographic databases Ovid Medline, PsycINFO, ProQuest Health Management, OpenGrey and Google Scholar. Relevant articles published between January 1990 and June 2014 were included. A systematic approach was used to extract and organize in categories the information about post-discharge factors associated with readmission rates.

RESULTS

Of the 760 articles identified by the initial search, 80 were selected for this review which included a total number of 59 different predictors of psychiatric readmission. Subsequently these were grouped into four categories: 1) individual vulnerability factors, 2) aftercare related factors, 3) community care and service responsiveness, and 4) contextual factors and social support. Individual factors were addressed in 58 papers and were found to be significant in 37 of these, aftercare factors were significant in 30 out of the 45 papers, community care and social support factors were significant in 21 out of 31 papers addressing these while contextual factors and social support were significant in all seven papers which studied them.

CONCLUSIONS

This review represents a first attempt at providing an overview of post-discharge factors previously studied in association with readmission. Hence, by mapping out the current research in the area, it highlights the gaps in research and it provides guidance future studies in the area.

Engagement-focused care during transitions from inpatient and emergency psychiatric facilities

OBJECTIVES

As many as 40% of those with serious mental illness (SMI) do not attend any outpatient visits in the 30 days following discharge. We examined engagement-focused care (EFC) versus treatment as usual in a university-based transitional care clinic (TCC) with a 90-day program serving individuals with SMI discharged from hospitals and emergency rooms. EFC included a unique group intake process (access group) designed to get individuals into care rapidly and a shared decision-making coach.

METHODS

Assessments of quality of life, symptomatology, and shared decision-making preferences were conducted at baseline, at 3 months corresponding to the end of TCC treatment and 6 months after TCC discharge. Communication among the patients and providers was assessed at each visit as was service utilization during and after TCC.

RESULTS

Subjective quality of life improved in EFC. Prescribers and patients saw communication more similarly as time went on. Ninety-one percent of patients wanted at least some say in decisions about their treatment.

CONCLUSIONS

SDM coaching and improved access improve quality of life. Most people want a say in treatment decisions.

Loss of relational continuity of care in schizophrenia: associations with patient satisfaction and quality of care

BACKGROUND

Users of mental health service are concerned about changes in clinicians providing their care, but little is known about their impact.

AIMS

To examine associations between changes in staff, and patient satisfaction and quality of care.

METHOD

A national cross-sectional survey of 3379 people aged 18 or over treated in secondary care for schizophrenia or schizoaffective disorder.

RESULTS

Nearly 41.9% reported at least one change in their key worker during the previous 12 months and 10.5% reported multiple changes. Those reporting multiple changes were less satisfied with their treatment and less likely to report having a care plan, knowing how to obtain help when in a crisis or to have had recommended physical health assessments.

CONCLUSIONS

Frequent changes in staff providing care for people with psychosis are associated with poorer quality of care. Greater efforts need to be made to protect relational continuity of care for such patients.

DECLARATION OF INTEREST

M.J.C. was co-chair of the expert advisory group on the NICE quality standard on Service User Experience in Adult Mental Health. S.J.C. has previously been a member of the Health and Social Care Board Northern Ireland Formulary Committee. D.S. received a speaker's fee from Janssen Cilag in 2011. He is a topic expert on NICE guideline for psychosis and schizophrenia in children and young people and a board member of National Collaborating Centre for Mental Health.

COPYRIGHT AND USAGE

© The Royal College of Psychiatrists 2016. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) license.

Specialised teams or personal continuity across inpatient and outpatient mental healthcare? Study protocol for a natural experiment

INTRODUCTION

Mental healthcare organisation can either pursue specialisation, that is, distinct clinicians and teams for inpatient and outpatient care or personal continuity of care, that is, the same primary clinician for a patient across the two settings. Little systematic research has compared these approaches. Existing studies subject have serious methodological shortcomings. Yet, costly reorganisations of services have been carried out in different European countries, inconsistently aiming to achieve specialisation or personal continuity of care. More reliable evidence is required on whether specialisation or continuity of care is more effective and cost-effective, and whether this varies for different patient groups and contexts.

DESIGN AND METHODS

In a natural experiment, we aim to recruit at least 6000 patients consecutively admitted to inpatient psychiatric care in Belgium, Germany, Italy, Poland, and the UK. In each country, care approaches supporting specialisation and personal continuity coexist. Patients will be followed up at 1 year to compare outcomes, costs and experiences. Inclusion criteria are: 18 years of age or older; clinical diagnosis of psychosis, affective disorder or anxiety/somatisation disorder; sufficient command of the language of the host country; absence of cognitive deterioration and/or organic brain disorders; and capacity to provide informed consent.

ETHICS AND DISSEMINATION

Ethical approval was obtained in all countries: (1) England: NRES Committee North East-Newcastle & North Tyneside (ref: 14/NE/1017); (2) Belgium: Comité d'Ethique hospitalo-facultaire des Cliniques St-Luc; (3) Germany: Ethical Board, Technische Universität Dresden; (4) Italy: Comitati Etici per la sperimentazione clinica (CESC) delle provincie di Verona, Rovigo, Vicenza, Treviso, Padova; (5) Poland: Komisja Bioetyczna przy Instytucie Psychiatrii i Neurologii w Warszawie. We will disseminate the findings through scientific publications and a study-specific website. At the end of the study, we will develop recommendations for policy decision-making, and organise national and international workshops with stakeholders.

TRIAL REGISTRATION NUMBER

ISRCTN registry: ISRCTN40256812.

Local inpatient units may increase patients' utilization of outpatient services: a comparative cohort-study in Nordland County, Norway

OBJECTIVES

In the last few decades, there has been a restructuring of the psychiatric services in many countries. The complexity of these systems may represent a challenge to patients that suffer from serious psychiatric disorders. We examined whether local integration of inpatient and outpatient services in contrast to centralized institutions strengthened continuity of care.

METHODS

Two different service-systems were compared. Service-utilization over a 4-year period for 690 inpatients was extracted from the patient registries. The results were controlled for demographic variables, model of service-system, central inpatient admission or local inpatient admission, diagnoses, and duration of inpatient stays.

RESULTS

The majority of inpatients in the area with local integration of inpatient and outpatient services used both types of care. In the area that did not have beds locally, many patients that had been hospitalized did not receive outpatient follow-up. Predictors of inpatients' use of outpatient psychiatric care were: Model of service-system (centralized vs decentralized), a diagnosis of affective disorder, central inpatient admission only, and duration of inpatient stays.

CONCLUSION

Psychiatric centers with local inpatient units may positively affect continuity of care for patients with severe psychiatric disorders, probably because of a high functional integration of inpatient and outpatient care.