Coordinated Specialty Care Discharge, Transition, and Step-Down Policies, Practices, and Concerns: Staff and Client Perspectives

Novel Occupational Therapy Program (Step Up) to Facilitate the Transition from Early Intervention in Psychosis Services

The purpose of this program evaluation was to examine preliminary outcomes associated with a novel stepdown program for clients of early intervention in psychosis services ("Step Up") that featured occupational therapy (OT) as a critical treatment component. Clients participated in Step Up for at least 6 months and were administered pre-post assessments of clinician-rated performance of daily living activities and self-perceived performance and satisfaction with daily occupational functioning. Paired samples Wilcoxon tests were used to compare outcomes across the two time points. Data from 23 participants of Step Up were analyzed. Clinician-rated performance of daily living (especially in the areas of money and time management and leisure engagement) and client-rated performance and satisfaction with daily occupational functioning improved significantly over time. Results demonstrate the promise of programs such as Step Up that capitalize on OT and promote functional outcomes during the transition from early intervention.

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

BACKGROUND

Discharge from early psychosis intervention is a critical stage of treatment that may occur for a variety of reasons. This study characterizes reasons for discharge among participants in early psychosis intervention programs participating in the Early Psychosis Intervention Network (EPINET) which comprises >100 programs in the United States organized under 8 academic hubs.

STUDY DESIGN

We analyzed 1787 discharges, focusing on program completion, unilateral termination by the client/family, and lost contact with the client/family. We performed exploratory analyses of demographic, clinical, and functional predictors of discharge reason. Variables predictive of discharge type were included in multilevel logistic regressions, allowing for the estimation of predictors of discharge reason and variability in rates by program and hub.

STUDY RESULTS

An estimated 20%-30% of enrolled patients completed the program. Program completion rates were higher among participants who were older on admission, had lower negative symptoms severity, spent more time in education, employment, or training, and who were covered by private insurance (a close proxy for socioeconomic status). Programs were more likely to lose contact with male participants, Black participants, and participants who were never covered by private insurance. After accounting for patient-level factors, there was substantial program-level variation in all 3 discharge outcomes, and hub-level variability in the proportion of participants who completed the program. The impact of race on program completion varied substantially by program.

CONCLUSIONS

Participants were discharged from early psychosis intervention services for diverse reasons, some of which were associated with sociocultural factors. Disengagement is a widespread problem affecting all hubs.

Using Electronic Health Records to Facilitate Precision Psychiatry

The use of clinical prediction models to produce individualized risk estimates can facilitate the implementation of precision psychiatry. As a source of data from large, clinically representative patient samples, electronic health records (EHRs) provide a platform to develop and validate clinical prediction models, as well as potentially implement them in routine clinical care. The current review describes promising use cases for the application of precision psychiatry to EHR data and considers their performance in terms of discrimination (ability to separate individuals with and without the outcome) and calibration (extent to which predicted risk estimates correspond to observed outcomes), as well as their potential clinical utility (weighing benefits and costs associated with the model compared to different approaches across different assumptions of the number needed to test). We review 4 externally validated clinical prediction models designed to predict psychosis onset, psychotic relapse, cardiometabolic morbidity, and suicide risk. We then discuss the prospects for clinically implementing these models and the potential added value of integrating data from evidence syntheses, standardized psychometric assessments, and biological data into EHRs. Clinical prediction models can utilize routinely collected EHR data in an innovative way, representing a unique opportunity to inform real-world clinical decision making. Combining data from other sources (e.g., meta-analyses) or enhancing EHR data with information from research studies (clinical and biomarker data) may enhance our abilities to improve the performance of clinical prediction models.

What happens after early intervention? Mapping early intervention in psychosis care pathways in the 12 months after discharge

AIM

Early intervention services are the established and evidence-based treatment option for individuals with first-episode psychosis. They are time-limited, and care pathways following discharge from these services have had little investigation. We aimed to map care pathways at the end of early intervention treatment to determine common trajectories of care.

METHODS

We collected health record data for all individuals treated by early intervention teams in two NHS mental health trusts in England. We collected data on individuals' primary mental healthcare provider for 52 weeks after the end of their treatment and calculated common trajectories of care using sequence analysis.

RESULTS

We identified 2224 eligible individuals. For those discharged to primary care we identified four common trajectories: Stable primary care, relapse and return to CMHT, relapse and return to EIP, and discontinuity of care. We also identified four trajectories for those transferred to alternative secondary mental healthcare: Stable secondary care, relapsing secondary care, long-term inpatient and discharged early. The long-term inpatient trajectory (1% of sample) accounted for 29% of all inpatient days in the year follow-up, with relapsing secondary care (2% of sample and 21% of inpatient days), and Relapse and return to CMHT (5% of sample, 15% of inpatient days) the second and third most frequent.

CONCLUSIONS

Individuals have common care pathways at the end of early intervention in psychosis treatment. Understanding common individual and service features that lead to poor care pathways could improve care and reduce hospital use.

Promoting the Success and Sustainability of Coordinated Specialty Care Teams in Ohio

Recent COVID-19-related federal legislation has resulted in time-limited increases in Mental Health Block Grant (MHBG) set-aside dollars for coordinated specialty care (CSC) throughout the United States. The state of Ohio has opted to apply these funds to establish a learning health network of Ohio CSC teams, promote efforts to expand access to CSC, and quantify the operating costs and rates of reimbursement from private and public payers for these CSC teams. These efforts may provide other states with a model through which they can apply increased MHBG funds to support the success of their own CSC programs.

Relapse prevention through health technology program reduces hospitalization in schizophrenia

BACKGROUND

Psychiatric hospitalization is a major driver of cost in the treatment of schizophrenia. Here, we asked whether a technology-enhanced approach to relapse prevention could reduce days spent in a hospital after discharge.

METHODS

The Improving Care and Reducing Cost (ICRC) study was a quasi-experimental clinical trial in outpatients with schizophrenia conducted between 26 February 2013 and 17 April 2015 at 10 different sites in the USA in an outpatient setting. Patients were between 18 and 60 years old with a diagnosis of schizophrenia, schizoaffective disorder, or psychotic disorder not otherwise specified. Patients received usual care or a technology-enhanced relapse prevention program during a 6-month period after discharge. The health technology program included in-person, individualized relapse prevention planning with treatments delivered via smartphones and computers, as well as a web-based prescriber decision support program. The main outcome measure was days spent in a psychiatric hospital during 6 months after discharge.

RESULTS

The study included 462 patients, of which 438 had complete baseline data and were thus used for propensity matching and analysis. Control participants (N = 89; 37 females) were enrolled first and received usual care for relapse prevention followed by 349 participants (128 females) who received technology-enhanced relapse prevention. During 6-month follow-up, 43% of control and 24% of intervention participants were hospitalized (χ2 = 11.76, p<0.001). Days of hospitalization were reduced by 5 days (mean days: b = -4.58, 95% CI -9.03 to -0.13, p = 0.044) in the intervention condition compared to control.

CONCLUSIONS

These results suggest that technology-enhanced relapse prevention is an effective and feasible way to reduce rehospitalization days among patients with schizophrenia.

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

Specialist early intervention teams consider clinician-patient engagement and continuity of care to be a driving philosophy behind the treatment they provide to people who have developed schizophrenia or a related psychotic illness. In almost all countries where this service model has been implemented there is a dearth of available data about what is happening to patients following time-limited treatment. Information on discharge pathways in England indicates that some early intervention specialists are discharging most of their patients from all psychiatric services after only 2 or 3 years of input. Some ex-patients will be living in a state of torment and neglect due to an untreated psychosis. In the UK, general practitioners should refuse to accept these discharge pathways for patients with insight-impairing mental illnesses.

The History of Coordinated Specialty Care for Early Intervention in Psychosis in the United States: A Review of Effectiveness, Implementation, and Fidelity

Coordinated Specialty Care (CSC) is a multidisciplinary team approach to providing care for young and emerging adults having their first episode of psychosis. CSC programs have expanded rapidly throughout the United States going from 12 programs in 2008 to over 160 programs a decade later. The purpose of this historical review is to document the process and conditions that led to the accelerated dissemination of these programs across the country. CSC models began in the US in the early 2000s, but nationwide expansion followed the 2008 Recovery After an Initial Schizophrenia Episode trial. As programs have grown, debates have risen about fidelity to CSC models. The challenges facing CSC programs today include lack of evidence on what are the core components of CSC and how fidelity monitoring relates to positive client outcomes.

What happens after early intervention in first-episode psychosis? Limitations of existing service models and an agenda for the future

PURPOSE OF REVIEW

Early intervention in first-episode psychosis (FEP) improves symptomatic and functional outcomes while programs last. However, these gains may not be sustained over time and not all individuals benefit equally from such programs. This review examines the efficacy of FEP programs, as well as step-down practices and long-term outcomes to identify ways to extend the gains made in FEP programs.

RECENT FINDINGS

FEP programs improve outcomes while services last, but effects diminish over time. Step-down and discharge practices vary widely with little randomized evidence guiding practice. Extending the duration of FEP programs for all does not consistently improve outcomes, but there is some encouraging evidence that targeted psychosocial interventions after program end may extend symptomatic and functional benefits. Members of marginalized groups and individuals with poorer outcomes during the FEP period may benefit from further specialized intervention after FEP.

SUMMARY

Step down practices from FEP programs should be structured and tailored to individual needs, and benefit from sustained connections to community resources. Psychosocial interventions like social skills training, peer support, and supported education and employment may help extend the benefit of FEP programs after more intensive services end.

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

AIMS

First-episode services (FES) improve outcomes in recent onset psychosis, but there is growing concern about how patients fare after discharge from these time-limited 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.

Development and external validation of an admission risk prediction model after treatment from early intervention in psychosis services

Early Intervention in psychosis (EIP) teams are the gold standard treatment for first-episode psychosis (FEP). EIP is time-limited and clinicians are required to make difficult aftercare decisions that require weighing up individuals' wishes for treatment, risk of relapse, and health service capacity. Reliable decision-making tools could assist with appropriate resource allocation and better care. We aimed to develop and externally validate a readmission risk tool for application at the point of EIP discharge. All persons from EIP caseloads in two NHS Trusts were eligible for the study. We excluded those who moved out of the area or were only seen for assessment. We developed a model to predict the risk of hospital admission within a year of ending EIP treatment in one Trust and externally validated it in another. There were n = 831 participants in the development dataset and n = 1393 in the external validation dataset, with 79 (9.5%) and 162 (11.6%) admissions to inpatient hospital, respectively. Discrimination was AUC = 0.76 (95% CI 0.75; 0.77) in the development dataset and AUC = 0.70 (95% CI 0.66; 0.75) in the external dataset. Calibration plots in external validation suggested an underestimation of risk in the lower predicted probabilities and slight overestimation at predicted probabilities in the 0.1-0.2 range (calibration slope = 0.86, 95% CI 0.68; 1.05). Recalibration improved performance at lower predicted probabilities but underestimated risk at the highest range of predicted probabilities (calibration slope = 1.00, 95% CI 0.79; 1.21). We showed that a tool for predicting admission risk using routine data has good performance and could assist clinical decision-making. Refinement of the model, testing its implementation and further external validation are needed.

First-Person Accounts of Change Among Young Adults Enrolled in Coordinated Specialty Care for First-Episode Psychosis

OBJECTIVE

This study investigated how clients of a coordinated specialty care (CSC) program for first-episode psychosis perceived how they changed while attending the program, what the most important changes were, and what mechanisms they believed helped bring about these changes.

METHODS

Study participants were 121 individuals (71 men and 50 women) from 35 CSC programs across 22 U.S. states. Responses to the primary questions of interest were procured through a semistructured interview. Data on the length of time in the CSC program were also obtained. The authors used systematic content analyses to analyze these qualitative data.

RESULTS

Participants reported a greater number of changes the longer they had received CSC services. Half of the participants reported improved psychiatric symptoms, and this change was the most important for almost one-third (31%; N=32) of the sample. In addition, 39% (N=45) of participants also reported improved social and interpersonal skills, changes in their attitude to and perspective on life, and more treatment engagement. Participants most frequently endorsed therapy as the mechanism underlying their improvement.

CONCLUSIONS

Standardized outcome measures allow systematic assessment of clinical and functional status, but they do not provide a nuanced understanding of the underlying mechanisms or the areas of improvement most important to individual clients. The findings reinforce the value of mixed methods in both research and quality improvement efforts as well as for greater integration of patient-selected outcome measures.

Predictors of Early Discharge From Early Intervention Services for Psychosis in New York State

OBJECTIVE

Although specialized early intervention services (EISs) for psychosis promote engagement in care, a substantial number of individuals who receive these services are discharged from care earlier than expected. The main goal of this study was to examine predictors of early discharge in a large sample of individuals enrolled in an EIS program in the United States.

METHODS

This cohort study (N=1,349) used programmatic data from OnTrackNY, an EIS program that delivers evidence-based interventions to youths across New York State experiencing a first episode of nonaffective psychosis. The main outcome was "early discharge," which was operationalized as discharge prior to completing 12 months of treatment. Cox proportional hazard regression models were used to assess the association between sociodemographic, clinical, and support system predictors and early discharge.

RESULTS

The estimated probability of discharge before 1 year was 32%. Participants who at baseline had poor medication adherence, had no health insurance, were living alone or with nonparental family, or were using cannabis were at higher risk of leaving services within the first 12 months after enrollment. Individuals with higher social functioning were at lower risk of being discharged early from OnTrackNY, but those with higher occupational functioning were at a higher risk.

CONCLUSIONS

Predictors of early discharge from EISs largely overlapped with previously identified predictors of poor prognosis in early psychosis. However, the association between early discharge and high occupational functioning indicates that trajectories leading up to discharge are heterogeneous.