Managing the Transition from Acute to Community Setting in Schizophrenia
Time to read: 6 minutes
Many patients with schizophrenia fail to transition from inpatient settings to the community mental health centre following discharge from hospital. It has been previously estimated that nearly two-thirds of patients do not attend their initial outpatient appointment. [Boyer et al., 2000]
Research has also shown that approximately 40% of patients will not receive any outpatient visits within 30 days of discharge. [Olfson et al. 2010]
Continuity of care in the community setting is heavily influenced by patient characteristics, the clinical management environment, and geographical resource availability. The inpatient and community management of patients with schizophrenia have different goals and challenges, and research shows that multiple risk factors increase the risk of missing community mental health centre appointments:
- Priebe et al. 2005 highlighted the importance of the patient being involved in treatment decisions.
- Compton et al. 2006 went further to show that a lack of an established outpatient clinician was also an important factor.
- Stein et al. 2007 showed that ethnicity, involuntary patient admission, discharge against medical advice, and substance abuse were also relevant risk factors.
- Olfson et al. 2010 meanwhile showed that a short inpatient stay (<4 days), and the absence of prior outpatient mental health care were significant factors.
TRANSITIONAL CARE
The patient should be empowered to define their own goals and how to reach them (i.e. self-direction), and this should be based on that individual’s unique preferences (i.e. individualisation). [Velligan et al. 2017]
The process should also be non-linear and holistic and ideally be communicated from the beginning of hospital admission. [Frese et al. 2009]
Patients whose discharge plans were discussed by inpatient and outpatient clinicians were more likely to keep their initial outpatient appointment (43% vs 19%). [Boyer et al. 2000]
Creation of a strong therapeutic alliance between patient and inpatient/outpatient clinicians can improve QoL [Boyer et al. 2000] with effective transitioning significantly reducing the risk of future hospitalisation. [Lin and Lee 2008]
Overall, the following points should become an integral part of a transitional care checklist:
- Securing adequate housing before discharge (e.g. housing, food, clothing, and transportation).
- The provision of financial planning help post-discharge should also be discussed (e.g. financial aid, contact numbers for social services, and possible legal system issues).
- Referrals for education, employment, and social activity outpatient programs should be prepared and started before discharge.
- Continuity of care from the acute setting to the community setting needs to be established, including a joint-agreed schedule for patient follow-up.
MEDICATION ADHERENCE
The rate of adherence to medication in schizophrenia is reported to be 51-70%, and within two years of discharge, 75% of patients are nonadherent. [Velligan et al. 2009]
Missing medication for even 1-10 days significantly raises the risk of hospitalisation (p=0.004). [Weiden et al. 2004]
The relapsing nature of the schizophrenia, plus any ongoing residual symptoms, means that there is also a requirement for long-term medication. [Melrose 2009]
Therefore, it is recommended that there is a discussion on the utilisation of either oral or LAI antipsychotics, particularly given that
- Clinicians routinely overestimate medication adherence (43% vs 28%) [Kane et al. 2003] and
- Patients also self-report higher medication adherence (88% vs 58%). [Jónsdóttir et al. 2010]
Oral antipsychotics
- can be more convenient
- the patient feels in control over treatment choices
- medication can be discontinued relatively quickly. [Nasrallah 2010]
LAI antipsychotics
- eliminates covert non-adherence
- enables the clinician to distinguish between non-adherence and non-response.
- there is regular contact with the clinician, and therefore, reasons for non-adherence can be instantly addressed. [Agid et al. 2010; Robinson et al. 2011]
Cultural/religious beliefs, as well as language barriers, are obvious risk factors for non-adherence. [Borras et al. 2007]
However, specific patient-related risk factors include stigma, cognitive deficits, lack of social support, comorbidities, and medication side effects (i.e. weight gain, sedation, and movement disorders) can significantly affect a patient’s willingness to stay adherent. [Hudson et al. 2004]
Lacro et al. 2002 meanwhile showed that a lack of insight and a lack of perceived benefits were important medication-related barriers while Kazadi et al. 2009 showed that poor therapeutic alliance, complex medication regimes, and an absence of education on disease and medication were also factors that often need to be overcome.
Finally, Velligan et al. 2009 highlighted that an absence of medication efficacy was also an important variable. The benefit of acute treatment is predominantly due to the reduction in positive symptoms while other symptom domains, show less improvement.
In the real-world, some patients will also not respond to antipsychotic medication including clozapine. [Mortimer et al. 2010]
SUMMARY
Patients with schizophrenia that transition from the acute psychiatric care setting to the community possess unique and individualised challenges for case management.
Many patients may fail to effectively connect to community care due to various disease states and clinical and socioeconomic issues, which increase the risk of re-hospitalisation and reduce quality of life.
The most meaningful and successful linkage strategies appear to involve patient engagement in discharge planning.
Antipsychotic therapy is the cornerstone of the modern management of schizophrenia and should be viewed as a key component of the discharge plan; however, non-adherence is very common and solving this problem is multi-faceted.
QUIZ
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