- Email: [email protected]
Identifying trends and transitions in the hospital outpatient management of patients with schizophrenia
ORIGINAL ARTICLE
Identifying trends and transitions in the hospital outpatient management of patients with schizophrenia David Koczerginski, MD, FRCPC; Lorna Thompson, RN, BScN (C)
Abstract—Schizophrenia is associated with multiple relapses and substantial acute and non-acute hospital costs. We are studying schizophrenia management patterns of six outpatient mental health programs to identify best practices in hospital outpatient services for this patient population. This report discusses the preliminary themes and trends contributing to adherence to treatment, and positive clinical outcomes. Themes include continuity of care and managing transitions, managing medical comorbidities, treating to wellness, the importance of communication within the multidisciplinary teams, and medication management. Ideas that support the promotion of these themes are also presented.
S
chizophrenia is a chronic mental illness associated with recurrent episodes of psychosis. Symptoms typically begin in adolescence or young adulthood, and this disorder often takes a severe toll on the emotional, cognitive, medical, family, social, and occupational domains of the patient’s function. Moreover, it is extraordinarily costly; in Canada in 2004, approximately 235,000 people suffered from schizophrenia, and some 70% of the total costs associated with this condition were attributable to losses in productivity (eg, unemployment). The remainder of the costs were ascribed to healthcare and nonhealthcare expenditures. In particular, Canadian data for 2004 suggest that schizophrenia accounted for ⬎670,000 acute hospital days (costing Can$474 million) and 1.7 million nonacute hospital days (costing Can$761 million. These two hospital costs comprised 61% of the total health and non-healthcare costs. Prescription medications and psychiatric and community mental health clinics accounted for 7.5% and 7.1%, respectively. The key healthcare costs associated with schizophrenia in Canada in 2004 are summarized in Table 1.1 The treatment needs of this group of patients are correspondingly complex, ranging from acute emergency and inpatient care to long-term outpatient medication maintenance with attention to multiple psychosocial issues and medical comorbidities. Unfortunately, schizophrenia often impairs patients’ judgment and insight into the need for treatment; they frequently From the Mental Health and Addictions Health System (Koczerginski), and the Adult Outpatient Mental Health Schizophrenia Program (Thompson), William Osler Health System, Brampton, Ontario, Canada. Correspondence: David Koczerginski, MD, FRCPC, Mental Health and Addictions Health System/William Osler Health System, Brampton Civic Hospital, 2100 Bovaird Drive East, Brampton, Ontario L6R 3J7, Canada. e-mail: [email protected] This article was supported through an educational grant from Janssen, Inc. Healthcare Management Forum 2012 25:S59 –S64 0840-4704/$ - see front matter © 2012 Canadian College of Health Leaders. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.hcmf.2012.07.018
discontinue follow-up treatment, suffer multiple relapses, and re-enter the healthcare system multiple times with yet another acute psychotic episode. Moreover, people with schizophrenia are at risk of a variety of medical comorbidities, which not only complicate the clinical picture, but are often exacerbated by lapses in continuity of care. There is a great deal of evidence in the literature that good adherence to treatment improves clinical outcomes.2 To the best of our knowledge, research into the impact of hospital systems (such as programming and resources) on clinical outcomes have been less studied. Although there is little published literature, it is reasonable to believe that individual institutions have developed their own best practices and care models. Our current study is to explore the variations and practices that help contribute to successful clinical outcomes.
METHODOLOGY We are currently studying schizophrenia management patterns in six representative Canadian hospital outpatient programs. Semistructured, qualitative interview sessions will be conducted at each of the institutions. Interview participants include psychiatrists and other members of the healthcare team (eg, nurses, occupational therapists, social workers). The goal of the focus group is to identify themes and trends relating to the promotion of adherence to treatment. Data on the administrative structures of the programs, the available pathways for patients flowing into and out of the system, and inpatient and outpatient medical management of patient comorbidities will be analysed. In conjunction with these interview sessions, focus groups of experts will assist in adapting the identified themes and trends into best practices, all striving toward the goal of optimal adherence. Reported herein are preliminary insights gleaned from observations of the first three sites and the first focus group of this study.
PRELIMINARY RESULTS Although the populations served by the programs surveyed to date all have broadly similar profiles and treatment needs, they organize their services for their pa-
Koczerginski and Thompson
Table 1. Utilization of key healthcare programs by patients with schizophrenia (Canada, 2004) Healthcare program
$Million (CAD)
Non-acute hospital care Acute hospital care Residential care facilities Prescription medications Psychiatric and community mental health clinics Professional billings Attempted and completed suicide* Total
761.05 473.93 340.44 150.00 142.41 61.49 6.09 1,935.41
Adapted from Goeree R, et al. 2017, Curr Med Res Opin 2005;21. *Includes police, autopsy, and funeral costs.
tients differently. In this preliminary report, we discuss the key themes of continuity of care and managing transitions, managing medical comorbidities, treating to wellness, the importance of communication within the multidisciplinary teams, and medication management.
Management of medical comorbidities Patients with schizophrenia are at increased risk of having medical comorbidities such as diabetes and cardiovascular disease. Among a Finnish database of almost 13,000 subjects who were followed for ⬎30 adult years, those with schizophrenia had a 1.65-fold higher risk of hospitalization for coronary heart disease (95% confidence interval [CI], 1.03–2.57) and almost triple the mortality risk from this condition (hazard ratio [HR], 2.92; 95% CI, 1.70 –5.00).3 The result is that the lifespan of patients with schizophrenia are shortened by ⱕ20%, often from cardiovascular death.4,5 Unfortunately, this group of patients is also at increased risk of receiving inadequate medical care. Many factors contribute to this situation: cognitive deficits and other negative symptoms such as lack of volition and social withdrawal, side effects of medications, sedentary lifestyles with poor dietary habits, poverty, inability to Table 2. Ideas for maintaining continuity of care between inpatient and outpatient settings ●
Continuity and transitions in treatment Clinicians at all the hospitals surveyed believe that the transition between inpatient and outpatient settings is a stage of potential vulnerability. During the transition from a relatively structured and restrictive inpatient setting to a less restrictive outpatient and/or community-based setting, it is not difficult for messages to the patient to become inconsistent, treatment plans to become inconsistent or incomplete, and the patient to become disengaged and non-adherent as hardwon insight dissipates. Thus, the transition period—particularly between inpatient and outpatient settings—is a clinically high-risk interval, and because the vast majority of patients require multiple hospital admissions, they will have to navigate this high-risk transition period multiple times. A robust linkage between inpatient and outpatient settings can help to mitigate the possible adverse effects of transitioning between these settings. It is important to note that in addition to the inpatient/ outpatient setting, patients also transition between other hospital systems. These may include transitions between the healthcare and the Assertive Community Treatment team, and between hospital and community settings. These transitions also lead to the potential for lost follow-up. To address these concerns, the centres surveyed have developed a variety of practical approaches to enhance continuity and facilitate effective inpatient/outpatient transitions (Table 2). Many of these approaches arrange for ongoing contact between the patient and a relatively familiar group of healthcare professionals, as well making use of a consistent geographic setting that supports the patient’s adherence to medication treatment. S60
● ●
●
●
●
●
Transitions should be recognized to occur repeatedly over the course of the patient’s disease; they are not isolated events. Arrange for the patient to retain the same psychiatrist for inpatient and outpatient care. In cases where retaining the same psychiatrist is not possible, it might be advantageous for the outpatient psychiatrist and/ or the outpatient clinic nurse to make contact with the patient before discharge (even relatively early in the admission). During the inpatient admission, the patient could visit the outpatient department for a tour and could start attending transition group sessions (also attended by outpatients) designed to bridge between discharge and the start of outpatient appointments. The discussion topics, which are not pre-set, might include counselling, nutritional advice, medication advice, and peer support. The patient should have a consistent, familiar, and trusted point of contact with the healthcare system—for example, a case manager or nurse in the outpatient clinic—who follows the patient through every stage of treatment, helps with logistics, advocates for needed resources, and promotes the patient’s engagement with treatment. Where possible, resources should be physically located near each other. For example, the outpatient clinic could be within the same hospital, on-site family physicians can easily assess the patient, and exercise equipment can be available as part of promoting cardiovascular and metabolic health. Consistency of medication administration is also an important consideration. Treatment could be coordinated with both the inpatient and outpatient team so that it begins during the inpatient treatment phase and continues in the outpatient centre. Medications such as long-acting injectable antipsychotics, which have been shown to promote adherence, could be considered early in treatment.
Healthcare Management Forum ● Forum Gestion des soins de sante´ – Fall/Automne 2012
IDENTIFYING TRENDS/TRANSITIONS IN HOSPITAL OUTPATIENT MANAGEMENT OF SCHIZOPHRENIA PATIENTS
access healthcare resources, inability or unwillingness to articulate medical concerns, and biases arising from the social stigma associated with mental illness.6 In recognition of these challenges, the hospitals participating in the focus group have begun to integrate the management of medical comorbidities—particularly metabolic and cardiac conditions—into their overall management plans for their patients with schizophrenia. For example, within the hospital psychiatric outpatient clinic, some teams are taking a more active role in monitoring general physical health (eg, blood pressure screening), using medications such as antihypertensives, educating patients about lifestyle factors in disease, linking more closely with primary care providers for assessment and monitoring, and even arranging access to exercise equipment within the hospital.
Table 3. Ideas for promoting communication for patients with schizophrenia ●
●
● ●
●
Treating to wellness These hospitals also regard the return to functionality as an aspect of treating to wellness. They have adopted additional systems and programming to help patients gain functionality (eg, return to work, school, and family). Examples of these programs include occupational therapy, day treatment programs focused on skills development, addiction counselling, cognitive– behavioural therapy, and psychosocial rehabilitation. The hospitals in the focus group also recognize the importance of psychoeducation for patients and families. This helps to establish and maintain insight by addressing such issues as the nature of the illness, the need for medications as a cornerstone of treatment, the range and types of medication regimens available, expected side effects and their management, medical health and comorbidities, and helpful community resources.
Communication and a multidisciplinary team approach Continuity of care during the transition from inpatient to outpatient settings requires that both teams maintain excellent contact and communication with the patient and with each other (Table 3). Often, the outpatient team has a longitudinal view of the patient that complements the more cross-sectional view of the inpatient team. Moreover, both teams can keep up-to-date with any revisions to the treatment plans, present consistent plans and messages to the patient, and help the patient engage more comfortably with the destination outpatient program. It is impossible for a single healthcare professional to fulfil the roles of psychiatrist, family physician, nurse, pharmacist, addiction counsellor, occupational therapist, recreational therapist, dietician, family therapist, social worker, and case manager. However, hospital-based programs of care are often fragmented into professional “silos,” poorly serving the patient whose required lifelong care is very likely to cut across
●
Ensure outpatient and inpatient staff attend weekly joint meetings where information is shared and treatment plans of all patients are reviewed to help ensure smooth transitions; community-based staff could also attend. Make treatment records such as inpatient discharge summaries and outpatient injection clinic records readily accessible to all team members as part of the electronic medical record. Hold regular meetings to discuss challenging or higher-risk cases. Adopt an open-access policy to the different members of the healthcare team to allow a quick response time in cases where one team member identifies something in the appointment that might have immediate impact on treatment. Extend clinical documentation beyond recording mental status and treatment to include note of any factors that might impact the continuity of care. Encourage collaboration among all staff, including inpatient and outpatient teams, to be aware of and to track a variety of useful clinical outcome measures, for example, not simply length of inpatient stay, but also rates of presentation to emergency rooms and of readmissions shortly after hospital discharge.
the traditional disciplines. A cohesive and well-functioning multidisciplinary team can share a variety of perspectives on the patient’s circumstances that might not otherwise be available to individual team members. Within the hospitals surveyed, there seemed to be various adaptations of the team model. Team members such as nurses, who do home visits, and case managers, who see the patient in the community setting, can be “eyes and ears,” responding in a timely fashion if the patient should encounter a crisis, begin to be nonadherent to follow-up, or develop prodromal symptoms of relapse. One example of a cost-effective multidisciplinary program is a voluntary mobile outreach program in which acutely ill patients are visited at home by staff in a mobile unit, sometimes several times daily, depending on their needs. The visiting staff members are thus able to forestall hospital admission, engage the patient and patient’s family, and gain useful knowledge about their circumstances that might not be apparent in the context of an office or clinic visit.
Medication management and non-medical adherence strategies For the vast majority of patients with schizophrenia, adherence to antipsychotic medication is indispensable to prevent relapse. Conversely, non-adherence is consistently associated with poorer clinical outcomes7; for example, the relapse rate within 1 year of discontinuing antipsychotic
Healthcare Management Forum ● Forum Gestion des soins de sante´ – Fall/Automne 2012
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Table 4. Ideas for adherence strategies ●
●
● ●
●
Use a formalized adherence assessment tool to capture relevant information about potential barriers to medication adherence. Encourage the affiliation of a clinical pharmacist or specialist nurse-clinician who assesses and educates patients about medications and side effects, and who can teach other team members about a variety of medication issues. Choose simplified regimens, including antipsychotic monotherapy whenever possible. Employ long-acting injectable atypical antipsychotics, delivered at weekly/biweekly/monthly intervals via an injection clinic where the patient can access multiple related resources (eg, education about medical comorbidities). Make appropriate use of court-mandated community treatment orders when necessary.
medication has been estimated at 80%.8 Simpler medication regimens are easier to adhere to than complex regimens, particularly for the patient with chronic schizophrenia who frequently suffers from some degree of cognitive impairment. Antipsychotic monotherapy should be favoured over polytherapy whenever possible. To improve adherence to treatment, one must be able not only to identify non-adherence, but also to identify and address contributing factors. During the focus group, one of the hospitals shared a formalized assessment tool that they use to promote adherence to treatment. It is used to regularly evaluate patients’ beliefs, perceptions, and insights about their illness, as well their treatment options/ choices, efficacy, and potential side effects. At this centre, the clinical pharmacologist conducts this assessment. Although this assessment requires a time investment, it has yielded valuable information about the patient’s concerns, both expressed and unexpressed. From this information, the clinical pharmacologist then matches the patient to an appropriate treatment. Other ideas for treatment adherence are outlined in Table 4. There is substantial (although not unanimous9) evidence that treatment with Long-Acting Injectable (LAI) antipsychotic medications in the setting of an injection clinic as an integral component of outpatient treatment may improve adherence and thereby reduce relapse rates.10 LAIs can serve as a direct way to improve adherence for patients who are willing to take antipsychotic medication but whose symptoms (such as cognitive impairment, sleep cycle disturbances, mental disorganization, or concurrent substance abuse problems) prevent them from being able to consistently manage a daily oral medication regimen. In addition, the use of LAIs can help to track the patient’s adherence status accurately. Although discrepancies between prescribed and actual oral regimens can go undetected for considerable periods, the treatment team will know immediately when a patient has S62
missed an LAI, and can follow up with the patient in a timely fashion. The use of LAIs might also yield additional economic benefits. For example, one recent retrospective chart review of 25 patients with schizophrenia at a single site compared clinical outcomes before and after switching from oral atypical antipsychotics to LAI risperidone (the only such formulation available at the time), given in the injection clinic setting.11 Switching to LAI risperidone decreased mean hospital length of stay per patient (13.2 vs 20.6 days), as well as mean annual number of admissions (0.2 vs 1.7) and emergency department visits (0.4 vs 2.2), suggesting that the improved hospital length of stay was not simply because of premature discharge. The estimated annual medication cost per patient increased by Can$5423, but annual hospital costs decreased Can$22,778, for a net annual saving of Can$17,355 per patient (Can$569,450 for the 25 patients in this study). Clinical experience also suggests that, contrary to what their physicians might have anticipated, patients often prefer injectable medications given at intervals of weeks over daily oral medications, which serve as painful reminders of their illness.12 The group also discussed the court-mandated outpatient treatment order (community treatment orders) as a means to start patients on treatment and there is some belief that this tool might be underused. However, because of the many considerations associated with the court-mandated treatment order, there was some debate on the use of this tool. For example, terms and associated procedures vary across provincial jurisdiction. Physicians might hesitate to deploy this adherence tool because it is timeconsuming and because they are (perhaps unduly) concerned about potential damage to the therapeutic relationship. By contrast, the untreated acutely psychotic patient could have very limited capacity to achieve insight or form a therapeutic relationship, and longer durations of untreated psychosis are clearly associated with worse longterm prognoses.
DISCUSSION The themes of effectively managing transitions, addressing medical comorbidities, and maintaining good communication between different elements of the care system all promote the key theme of promoting adherence to treatment. These themes have each been explored separately, but this division is unrealistic. First, all the themes are different aspects of a single overarching goal: to treat the patient with chronic psychotic illness to his or her best possible state of emotional, psychological, medical, social, and occupational function. Second, the themes are highly interdependent; for example, the patient is likely to be more adherent to his or her medication regimen if the patient’s transitions from the inpatient to the outpatient setting are being well managed; medical health
Healthcare Management Forum ● Forum Gestion des soins de sante´ – Fall/Automne 2012
IDENTIFYING TRENDS/TRANSITIONS IN HOSPITAL OUTPATIENT MANAGEMENT OF SCHIZOPHRENIA PATIENTS
Table 5. Promoting integration in hospital care systems for patients with schizophrenia ●
●
●
●
●
●
●
●
●
Outpatient clinics could be open outside regular working hours, and patients would able to drop in without appointments to ask questions, engage with the treatment team, or have a chance to interact socially with peers. Mobile outreach teams could be used to engage proactively with patients in their homes and communities, as well as within the institutional setting. The hospital setting could geographically integrate several services together—primary care, metabolic and cardiac wellness, injection clinics, social work, etc. A patient who is experiencing prodromal symptoms of relapse should have relatively quick access to more intense treatment, such as a timely review of medication treatment, frequent home visits, or access to a day treatment program, potentially forestalling an emergency hospital admission. A more stable patient needs less involvement, but is not discharged from the outpatient clinic after an arbitrary mandated time interval. Avoid organizing care according to specific diagnostic “silos” to decrease the risk of additional transitions for patients who present diagnostic dilemmas or who have multiple diagnoses (such as mental illness and substance abuse). Transitions should be recognized beyond the inpatient/outpatient time point and resources could be allocated to provide patient support during these clinically high-risk intervals. Engaging multidisciplinary teams would provide richer, more integrated, and more multidimensional care than management organized primarily along the lines of the care provider’s professional discipline. Additional resources could be allocated to injection clinics (eg, dedicated nursing staff with specific training in the area of long-acting injectable antipsychotics) to accommodate the increasing demand over time, keeping in mind the significant cost savings associated with reduced inpatient and emergency department utilization.
concerns (including medication side effects) are being addressed; and the various treatment teams, patient, and family are maintaining good working channels of communication with each other. Third, it is critical to recognize the impact of the lifelong chronicity of schizophrenia. For example, patients with schizophrenia might have a dozen or more hospital readmissions, and correspondingly could transition from inpatient to outpatient several times. In addition, although most patients are still treated with oral antipsychotics, the use of second-generation LAIs is on the rise. Whereas first-generation LAIs were traditionally viewed as something of a last resort reserved for chronically non-adherent patients, the newer LAIs are now being considered as first-line choices for a wider range of patients, including patients with firstepisode psychosis, elderly or disabled patients, patients with concurrent substance abuse problems, and those who prefer an injection at intervals of weeks over the
complexities of a daily oral regimen. Thus, more patients will need to be followed for a longer period by outpatient injection clinics. These factors point to a need to integrate and adapt the systems of care to reflect the needs of the patients with schizophrenia. Table 5 outlines the ideas suggested by the initial focus group.
CONCLUSION In conclusion, the systems of care in place in three of the six study hospital outpatient schizophrenia programs that address the various themes described above cannot be engaged in a disjointed fashion at a few isolated points. Ideally, to maximize responsiveness to the patient, systems of care should be activated (a) early in the course of disease, (b) repeatedly and continuously over the patient’s clinical course, and (c) in a flexible and highly integrated fashion. This report contains our preliminary thoughts on potential themes that could help improve outpatient mental health services. Our next steps are to complete this study to formulate best practices. However, it is hoped that the preliminary ideas presented in this paper will provide administrators and policymakers with a rough framework to help spark their own individual reviews and best practice ideas that help meet the healthcare needs of people with schizophrenia.
REFERENCES 1. Goeree R, Farahati F, Burke N, et al. The economic burden of schizophrenia in Canada in 2004. Curr Med Res Opin. 2005;21: 2017–2028. 2. Kane JM. Treatment adherence and long-term outcomes. CNS Spectr. 2007;12(10 Suppl 17);suppl 17:21–26. Available at: http://www.cnsspectrums.com/aspx/articledetail.aspx?articleid⫽ 1290. Accessed July 10, 2012. 3. Lahti M, Tiihonen J, Wildgust H, et al. Cardiovascular morbidity, mortality and pharmacotherapy in patients with schizophrenia. Psychol Med. 2012; March 12:1–11. 4. Chang CK. Improving the life expectancy of people with serious mental illness. Br J Hosp Med (Lond). 2012;73:126 – 127. 5. Mitchell AJ, Lord O. Do deficits in cardiac care influence high mortality rates in schizophrenia? A systematic review and pooled analysis. J Psychopharmacol. 2010;24(4 suppl):69 – 80. 6. Saravane D, Feve B, Frances Y, et al. [Drawing up guidelines for the attendance of physical health of patients with severe mental illness]. Encephale. 2009;35:330 –339. 7. Acosta FJ, Bosch E, Sarmiento G, et al. Evaluation of noncompliance in schizophrenia patients using electronic monitoring (MEMS) and its relationship to sociodemographic, clinical and psychopathological variables. Schizophr Res. 2009;107:213– 217. 8. Gitlin M, Nuechterlein K, Subotnik KL, et al. Clinical outcome following neuroleptic discontinuation in patients with remit-
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ted recent-onset schizophrenia. Am J Psychiatry. 2001;158:1835– 1842. 9. Rosenheck RA, Krystal JH, Lew R, et al. Long-acting risperidone and oral antipsychotics in unstable schizophrenia. N Engl J Med. 2011;364:842– 851. 10. Kozma CM, Slaton T, Dirani R, et al. Changes in schizophreniarelated hospitalization and ER use among patients receiving paliperidone palmitate: results from a clinical trial with a
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52-week open-label extension (OLE). Curr Med Res Opin. 2011; 27:1603–1611. 11. Koczerginski D, Arshoff L. Hospital resource use by patients with schizophrenia: reduction after conversion from oral treatment to risperidone long-acting injection. Healthc Q. 2011;14:82– 87. 12. Walburn J, Gray R, Gournay K, et al. Systematic review of patient and nurse attitudes to depot antipsychotic medication. Br J Psychiatry. 2001;179:300 –307.
Healthcare Management Forum ● Forum Gestion des soins de sante´ – Fall/Automne 2012
Identifying trends and transitions in the hospital outpatient management of patients with schizophrenia David Koczerginski, MD, FRCPC; Lorna Thompson, RN, BScN (C)
Abstract—Schizophrenia is associated with multiple relapses and substantial acute and non-acute hospital costs. We are studying schizophrenia management patterns of six outpatient mental health programs to identify best practices in hospital outpatient services for this patient population. This report discusses the preliminary themes and trends contributing to adherence to treatment, and positive clinical outcomes. Themes include continuity of care and managing transitions, managing medical comorbidities, treating to wellness, the importance of communication within the multidisciplinary teams, and medication management. Ideas that support the promotion of these themes are also presented.
S
chizophrenia is a chronic mental illness associated with recurrent episodes of psychosis. Symptoms typically begin in adolescence or young adulthood, and this disorder often takes a severe toll on the emotional, cognitive, medical, family, social, and occupational domains of the patient’s function. Moreover, it is extraordinarily costly; in Canada in 2004, approximately 235,000 people suffered from schizophrenia, and some 70% of the total costs associated with this condition were attributable to losses in productivity (eg, unemployment). The remainder of the costs were ascribed to healthcare and nonhealthcare expenditures. In particular, Canadian data for 2004 suggest that schizophrenia accounted for ⬎670,000 acute hospital days (costing Can$474 million) and 1.7 million nonacute hospital days (costing Can$761 million. These two hospital costs comprised 61% of the total health and non-healthcare costs. Prescription medications and psychiatric and community mental health clinics accounted for 7.5% and 7.1%, respectively. The key healthcare costs associated with schizophrenia in Canada in 2004 are summarized in Table 1.1 The treatment needs of this group of patients are correspondingly complex, ranging from acute emergency and inpatient care to long-term outpatient medication maintenance with attention to multiple psychosocial issues and medical comorbidities. Unfortunately, schizophrenia often impairs patients’ judgment and insight into the need for treatment; they frequently From the Mental Health and Addictions Health System (Koczerginski), and the Adult Outpatient Mental Health Schizophrenia Program (Thompson), William Osler Health System, Brampton, Ontario, Canada. Correspondence: David Koczerginski, MD, FRCPC, Mental Health and Addictions Health System/William Osler Health System, Brampton Civic Hospital, 2100 Bovaird Drive East, Brampton, Ontario L6R 3J7, Canada. e-mail: [email protected] This article was supported through an educational grant from Janssen, Inc. Healthcare Management Forum 2012 25:S59 –S64 0840-4704/$ - see front matter © 2012 Canadian College of Health Leaders. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.hcmf.2012.07.018
discontinue follow-up treatment, suffer multiple relapses, and re-enter the healthcare system multiple times with yet another acute psychotic episode. Moreover, people with schizophrenia are at risk of a variety of medical comorbidities, which not only complicate the clinical picture, but are often exacerbated by lapses in continuity of care. There is a great deal of evidence in the literature that good adherence to treatment improves clinical outcomes.2 To the best of our knowledge, research into the impact of hospital systems (such as programming and resources) on clinical outcomes have been less studied. Although there is little published literature, it is reasonable to believe that individual institutions have developed their own best practices and care models. Our current study is to explore the variations and practices that help contribute to successful clinical outcomes.
METHODOLOGY We are currently studying schizophrenia management patterns in six representative Canadian hospital outpatient programs. Semistructured, qualitative interview sessions will be conducted at each of the institutions. Interview participants include psychiatrists and other members of the healthcare team (eg, nurses, occupational therapists, social workers). The goal of the focus group is to identify themes and trends relating to the promotion of adherence to treatment. Data on the administrative structures of the programs, the available pathways for patients flowing into and out of the system, and inpatient and outpatient medical management of patient comorbidities will be analysed. In conjunction with these interview sessions, focus groups of experts will assist in adapting the identified themes and trends into best practices, all striving toward the goal of optimal adherence. Reported herein are preliminary insights gleaned from observations of the first three sites and the first focus group of this study.
PRELIMINARY RESULTS Although the populations served by the programs surveyed to date all have broadly similar profiles and treatment needs, they organize their services for their pa-
Koczerginski and Thompson
Table 1. Utilization of key healthcare programs by patients with schizophrenia (Canada, 2004) Healthcare program
$Million (CAD)
Non-acute hospital care Acute hospital care Residential care facilities Prescription medications Psychiatric and community mental health clinics Professional billings Attempted and completed suicide* Total
761.05 473.93 340.44 150.00 142.41 61.49 6.09 1,935.41
Adapted from Goeree R, et al. 2017, Curr Med Res Opin 2005;21. *Includes police, autopsy, and funeral costs.
tients differently. In this preliminary report, we discuss the key themes of continuity of care and managing transitions, managing medical comorbidities, treating to wellness, the importance of communication within the multidisciplinary teams, and medication management.
Management of medical comorbidities Patients with schizophrenia are at increased risk of having medical comorbidities such as diabetes and cardiovascular disease. Among a Finnish database of almost 13,000 subjects who were followed for ⬎30 adult years, those with schizophrenia had a 1.65-fold higher risk of hospitalization for coronary heart disease (95% confidence interval [CI], 1.03–2.57) and almost triple the mortality risk from this condition (hazard ratio [HR], 2.92; 95% CI, 1.70 –5.00).3 The result is that the lifespan of patients with schizophrenia are shortened by ⱕ20%, often from cardiovascular death.4,5 Unfortunately, this group of patients is also at increased risk of receiving inadequate medical care. Many factors contribute to this situation: cognitive deficits and other negative symptoms such as lack of volition and social withdrawal, side effects of medications, sedentary lifestyles with poor dietary habits, poverty, inability to Table 2. Ideas for maintaining continuity of care between inpatient and outpatient settings ●
Continuity and transitions in treatment Clinicians at all the hospitals surveyed believe that the transition between inpatient and outpatient settings is a stage of potential vulnerability. During the transition from a relatively structured and restrictive inpatient setting to a less restrictive outpatient and/or community-based setting, it is not difficult for messages to the patient to become inconsistent, treatment plans to become inconsistent or incomplete, and the patient to become disengaged and non-adherent as hardwon insight dissipates. Thus, the transition period—particularly between inpatient and outpatient settings—is a clinically high-risk interval, and because the vast majority of patients require multiple hospital admissions, they will have to navigate this high-risk transition period multiple times. A robust linkage between inpatient and outpatient settings can help to mitigate the possible adverse effects of transitioning between these settings. It is important to note that in addition to the inpatient/ outpatient setting, patients also transition between other hospital systems. These may include transitions between the healthcare and the Assertive Community Treatment team, and between hospital and community settings. These transitions also lead to the potential for lost follow-up. To address these concerns, the centres surveyed have developed a variety of practical approaches to enhance continuity and facilitate effective inpatient/outpatient transitions (Table 2). Many of these approaches arrange for ongoing contact between the patient and a relatively familiar group of healthcare professionals, as well making use of a consistent geographic setting that supports the patient’s adherence to medication treatment. S60
● ●
●
●
●
●
Transitions should be recognized to occur repeatedly over the course of the patient’s disease; they are not isolated events. Arrange for the patient to retain the same psychiatrist for inpatient and outpatient care. In cases where retaining the same psychiatrist is not possible, it might be advantageous for the outpatient psychiatrist and/ or the outpatient clinic nurse to make contact with the patient before discharge (even relatively early in the admission). During the inpatient admission, the patient could visit the outpatient department for a tour and could start attending transition group sessions (also attended by outpatients) designed to bridge between discharge and the start of outpatient appointments. The discussion topics, which are not pre-set, might include counselling, nutritional advice, medication advice, and peer support. The patient should have a consistent, familiar, and trusted point of contact with the healthcare system—for example, a case manager or nurse in the outpatient clinic—who follows the patient through every stage of treatment, helps with logistics, advocates for needed resources, and promotes the patient’s engagement with treatment. Where possible, resources should be physically located near each other. For example, the outpatient clinic could be within the same hospital, on-site family physicians can easily assess the patient, and exercise equipment can be available as part of promoting cardiovascular and metabolic health. Consistency of medication administration is also an important consideration. Treatment could be coordinated with both the inpatient and outpatient team so that it begins during the inpatient treatment phase and continues in the outpatient centre. Medications such as long-acting injectable antipsychotics, which have been shown to promote adherence, could be considered early in treatment.
Healthcare Management Forum ● Forum Gestion des soins de sante´ – Fall/Automne 2012
IDENTIFYING TRENDS/TRANSITIONS IN HOSPITAL OUTPATIENT MANAGEMENT OF SCHIZOPHRENIA PATIENTS
access healthcare resources, inability or unwillingness to articulate medical concerns, and biases arising from the social stigma associated with mental illness.6 In recognition of these challenges, the hospitals participating in the focus group have begun to integrate the management of medical comorbidities—particularly metabolic and cardiac conditions—into their overall management plans for their patients with schizophrenia. For example, within the hospital psychiatric outpatient clinic, some teams are taking a more active role in monitoring general physical health (eg, blood pressure screening), using medications such as antihypertensives, educating patients about lifestyle factors in disease, linking more closely with primary care providers for assessment and monitoring, and even arranging access to exercise equipment within the hospital.
Table 3. Ideas for promoting communication for patients with schizophrenia ●
●
● ●
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Treating to wellness These hospitals also regard the return to functionality as an aspect of treating to wellness. They have adopted additional systems and programming to help patients gain functionality (eg, return to work, school, and family). Examples of these programs include occupational therapy, day treatment programs focused on skills development, addiction counselling, cognitive– behavioural therapy, and psychosocial rehabilitation. The hospitals in the focus group also recognize the importance of psychoeducation for patients and families. This helps to establish and maintain insight by addressing such issues as the nature of the illness, the need for medications as a cornerstone of treatment, the range and types of medication regimens available, expected side effects and their management, medical health and comorbidities, and helpful community resources.
Communication and a multidisciplinary team approach Continuity of care during the transition from inpatient to outpatient settings requires that both teams maintain excellent contact and communication with the patient and with each other (Table 3). Often, the outpatient team has a longitudinal view of the patient that complements the more cross-sectional view of the inpatient team. Moreover, both teams can keep up-to-date with any revisions to the treatment plans, present consistent plans and messages to the patient, and help the patient engage more comfortably with the destination outpatient program. It is impossible for a single healthcare professional to fulfil the roles of psychiatrist, family physician, nurse, pharmacist, addiction counsellor, occupational therapist, recreational therapist, dietician, family therapist, social worker, and case manager. However, hospital-based programs of care are often fragmented into professional “silos,” poorly serving the patient whose required lifelong care is very likely to cut across
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Ensure outpatient and inpatient staff attend weekly joint meetings where information is shared and treatment plans of all patients are reviewed to help ensure smooth transitions; community-based staff could also attend. Make treatment records such as inpatient discharge summaries and outpatient injection clinic records readily accessible to all team members as part of the electronic medical record. Hold regular meetings to discuss challenging or higher-risk cases. Adopt an open-access policy to the different members of the healthcare team to allow a quick response time in cases where one team member identifies something in the appointment that might have immediate impact on treatment. Extend clinical documentation beyond recording mental status and treatment to include note of any factors that might impact the continuity of care. Encourage collaboration among all staff, including inpatient and outpatient teams, to be aware of and to track a variety of useful clinical outcome measures, for example, not simply length of inpatient stay, but also rates of presentation to emergency rooms and of readmissions shortly after hospital discharge.
the traditional disciplines. A cohesive and well-functioning multidisciplinary team can share a variety of perspectives on the patient’s circumstances that might not otherwise be available to individual team members. Within the hospitals surveyed, there seemed to be various adaptations of the team model. Team members such as nurses, who do home visits, and case managers, who see the patient in the community setting, can be “eyes and ears,” responding in a timely fashion if the patient should encounter a crisis, begin to be nonadherent to follow-up, or develop prodromal symptoms of relapse. One example of a cost-effective multidisciplinary program is a voluntary mobile outreach program in which acutely ill patients are visited at home by staff in a mobile unit, sometimes several times daily, depending on their needs. The visiting staff members are thus able to forestall hospital admission, engage the patient and patient’s family, and gain useful knowledge about their circumstances that might not be apparent in the context of an office or clinic visit.
Medication management and non-medical adherence strategies For the vast majority of patients with schizophrenia, adherence to antipsychotic medication is indispensable to prevent relapse. Conversely, non-adherence is consistently associated with poorer clinical outcomes7; for example, the relapse rate within 1 year of discontinuing antipsychotic
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Table 4. Ideas for adherence strategies ●
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Use a formalized adherence assessment tool to capture relevant information about potential barriers to medication adherence. Encourage the affiliation of a clinical pharmacist or specialist nurse-clinician who assesses and educates patients about medications and side effects, and who can teach other team members about a variety of medication issues. Choose simplified regimens, including antipsychotic monotherapy whenever possible. Employ long-acting injectable atypical antipsychotics, delivered at weekly/biweekly/monthly intervals via an injection clinic where the patient can access multiple related resources (eg, education about medical comorbidities). Make appropriate use of court-mandated community treatment orders when necessary.
medication has been estimated at 80%.8 Simpler medication regimens are easier to adhere to than complex regimens, particularly for the patient with chronic schizophrenia who frequently suffers from some degree of cognitive impairment. Antipsychotic monotherapy should be favoured over polytherapy whenever possible. To improve adherence to treatment, one must be able not only to identify non-adherence, but also to identify and address contributing factors. During the focus group, one of the hospitals shared a formalized assessment tool that they use to promote adherence to treatment. It is used to regularly evaluate patients’ beliefs, perceptions, and insights about their illness, as well their treatment options/ choices, efficacy, and potential side effects. At this centre, the clinical pharmacologist conducts this assessment. Although this assessment requires a time investment, it has yielded valuable information about the patient’s concerns, both expressed and unexpressed. From this information, the clinical pharmacologist then matches the patient to an appropriate treatment. Other ideas for treatment adherence are outlined in Table 4. There is substantial (although not unanimous9) evidence that treatment with Long-Acting Injectable (LAI) antipsychotic medications in the setting of an injection clinic as an integral component of outpatient treatment may improve adherence and thereby reduce relapse rates.10 LAIs can serve as a direct way to improve adherence for patients who are willing to take antipsychotic medication but whose symptoms (such as cognitive impairment, sleep cycle disturbances, mental disorganization, or concurrent substance abuse problems) prevent them from being able to consistently manage a daily oral medication regimen. In addition, the use of LAIs can help to track the patient’s adherence status accurately. Although discrepancies between prescribed and actual oral regimens can go undetected for considerable periods, the treatment team will know immediately when a patient has S62
missed an LAI, and can follow up with the patient in a timely fashion. The use of LAIs might also yield additional economic benefits. For example, one recent retrospective chart review of 25 patients with schizophrenia at a single site compared clinical outcomes before and after switching from oral atypical antipsychotics to LAI risperidone (the only such formulation available at the time), given in the injection clinic setting.11 Switching to LAI risperidone decreased mean hospital length of stay per patient (13.2 vs 20.6 days), as well as mean annual number of admissions (0.2 vs 1.7) and emergency department visits (0.4 vs 2.2), suggesting that the improved hospital length of stay was not simply because of premature discharge. The estimated annual medication cost per patient increased by Can$5423, but annual hospital costs decreased Can$22,778, for a net annual saving of Can$17,355 per patient (Can$569,450 for the 25 patients in this study). Clinical experience also suggests that, contrary to what their physicians might have anticipated, patients often prefer injectable medications given at intervals of weeks over daily oral medications, which serve as painful reminders of their illness.12 The group also discussed the court-mandated outpatient treatment order (community treatment orders) as a means to start patients on treatment and there is some belief that this tool might be underused. However, because of the many considerations associated with the court-mandated treatment order, there was some debate on the use of this tool. For example, terms and associated procedures vary across provincial jurisdiction. Physicians might hesitate to deploy this adherence tool because it is timeconsuming and because they are (perhaps unduly) concerned about potential damage to the therapeutic relationship. By contrast, the untreated acutely psychotic patient could have very limited capacity to achieve insight or form a therapeutic relationship, and longer durations of untreated psychosis are clearly associated with worse longterm prognoses.
DISCUSSION The themes of effectively managing transitions, addressing medical comorbidities, and maintaining good communication between different elements of the care system all promote the key theme of promoting adherence to treatment. These themes have each been explored separately, but this division is unrealistic. First, all the themes are different aspects of a single overarching goal: to treat the patient with chronic psychotic illness to his or her best possible state of emotional, psychological, medical, social, and occupational function. Second, the themes are highly interdependent; for example, the patient is likely to be more adherent to his or her medication regimen if the patient’s transitions from the inpatient to the outpatient setting are being well managed; medical health
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IDENTIFYING TRENDS/TRANSITIONS IN HOSPITAL OUTPATIENT MANAGEMENT OF SCHIZOPHRENIA PATIENTS
Table 5. Promoting integration in hospital care systems for patients with schizophrenia ●
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Outpatient clinics could be open outside regular working hours, and patients would able to drop in without appointments to ask questions, engage with the treatment team, or have a chance to interact socially with peers. Mobile outreach teams could be used to engage proactively with patients in their homes and communities, as well as within the institutional setting. The hospital setting could geographically integrate several services together—primary care, metabolic and cardiac wellness, injection clinics, social work, etc. A patient who is experiencing prodromal symptoms of relapse should have relatively quick access to more intense treatment, such as a timely review of medication treatment, frequent home visits, or access to a day treatment program, potentially forestalling an emergency hospital admission. A more stable patient needs less involvement, but is not discharged from the outpatient clinic after an arbitrary mandated time interval. Avoid organizing care according to specific diagnostic “silos” to decrease the risk of additional transitions for patients who present diagnostic dilemmas or who have multiple diagnoses (such as mental illness and substance abuse). Transitions should be recognized beyond the inpatient/outpatient time point and resources could be allocated to provide patient support during these clinically high-risk intervals. Engaging multidisciplinary teams would provide richer, more integrated, and more multidimensional care than management organized primarily along the lines of the care provider’s professional discipline. Additional resources could be allocated to injection clinics (eg, dedicated nursing staff with specific training in the area of long-acting injectable antipsychotics) to accommodate the increasing demand over time, keeping in mind the significant cost savings associated with reduced inpatient and emergency department utilization.
concerns (including medication side effects) are being addressed; and the various treatment teams, patient, and family are maintaining good working channels of communication with each other. Third, it is critical to recognize the impact of the lifelong chronicity of schizophrenia. For example, patients with schizophrenia might have a dozen or more hospital readmissions, and correspondingly could transition from inpatient to outpatient several times. In addition, although most patients are still treated with oral antipsychotics, the use of second-generation LAIs is on the rise. Whereas first-generation LAIs were traditionally viewed as something of a last resort reserved for chronically non-adherent patients, the newer LAIs are now being considered as first-line choices for a wider range of patients, including patients with firstepisode psychosis, elderly or disabled patients, patients with concurrent substance abuse problems, and those who prefer an injection at intervals of weeks over the
complexities of a daily oral regimen. Thus, more patients will need to be followed for a longer period by outpatient injection clinics. These factors point to a need to integrate and adapt the systems of care to reflect the needs of the patients with schizophrenia. Table 5 outlines the ideas suggested by the initial focus group.
CONCLUSION In conclusion, the systems of care in place in three of the six study hospital outpatient schizophrenia programs that address the various themes described above cannot be engaged in a disjointed fashion at a few isolated points. Ideally, to maximize responsiveness to the patient, systems of care should be activated (a) early in the course of disease, (b) repeatedly and continuously over the patient’s clinical course, and (c) in a flexible and highly integrated fashion. This report contains our preliminary thoughts on potential themes that could help improve outpatient mental health services. Our next steps are to complete this study to formulate best practices. However, it is hoped that the preliminary ideas presented in this paper will provide administrators and policymakers with a rough framework to help spark their own individual reviews and best practice ideas that help meet the healthcare needs of people with schizophrenia.
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ted recent-onset schizophrenia. Am J Psychiatry. 2001;158:1835– 1842. 9. Rosenheck RA, Krystal JH, Lew R, et al. Long-acting risperidone and oral antipsychotics in unstable schizophrenia. N Engl J Med. 2011;364:842– 851. 10. Kozma CM, Slaton T, Dirani R, et al. Changes in schizophreniarelated hospitalization and ER use among patients receiving paliperidone palmitate: results from a clinical trial with a
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52-week open-label extension (OLE). Curr Med Res Opin. 2011; 27:1603–1611. 11. Koczerginski D, Arshoff L. Hospital resource use by patients with schizophrenia: reduction after conversion from oral treatment to risperidone long-acting injection. Healthc Q. 2011;14:82– 87. 12. Walburn J, Gray R, Gournay K, et al. Systematic review of patient and nurse attitudes to depot antipsychotic medication. Br J Psychiatry. 2001;179:300 –307.
Healthcare Management Forum ● Forum Gestion des soins de sante´ – Fall/Automne 2012