Coordinated Specialty Care Discharge, Transition, and Step-Down Policies, Practices, and Concerns: Staff and Client Perspectives
Abstract
Objective:
Methods:
Results:
Conclusions:
HIGHLIGHTS
Methods
Design, Sampling, and Procedure
Study sites.
Recruitment and interview procedures.
Sample characteristics.
Data Analysis
Results
Staff Themes
Policies and practices related to discharge, transition, and step-down.
Programs | |||
---|---|---|---|
Program length | Description and context | N | % |
2-year target with flexibility to extend on a case-by-case basis | Program target is 2 years, but the program is able to extend the length of service for clients in need of extended services | 16 | 44 |
Fixed 2-year service limit, very limited ability to extend | Providers’ ability to extend services is very proscribed | 4 | 11 |
Expectation that clients will average 2 years in the program; no fixed limit | General expectation is that most clients will require 2 years, but this is not framed as a “target” or “goal,” and there is no upper limit on services | 3 | 8 |
Maximum 3-year service period | Program staff described the program as of 3 years in duration, or they identified 3 years as the upper limit | 4 | 11 |
Program serves clients beyond 3 years | Program staff reported an expectation that services may last more than 3 years, without specifying an exact target | 2 | 6 |
5-year service period | Regional guidance clearly specifies that services should be provided for up to 5 years | 4 | 11 |
Indefinite service period; no upper limit on service eligibility | Program is new or has not yet developed a discharge policy, or staff reported both no upper limit and no expectations or target for service duration | 3 | 8 |
Discharge and transition strategies.
Clinician discharge experiences and concerns.
We did kind of an informal calling back to say like, “Hey, how are you doing? What's happening?” and almost nobody had continued in outpatient care. It's a handful, maybe two or three [out of 20 successfully contacted]. And those were the ones with more active family members. They expressed several things. One, that none of the programs they went to were ever like [CSC program] and they wanted to come back to [CSC]. . . . And more than 50% have already dropped out of the care that they had been connected to: they couldn't get the appointments. So, the desire to get care was there, but they were dissatisfied with what they were able to get.
Programs | |||
---|---|---|---|
Concern | N | % | Example quotation |
A 2-year service time frame is inadequate | 9 | 25 | “Two years is not enough for a lot of people to develop the insight that they need to be able to be independent and understand that they will need some kind of ongoing treatment.” |
Area services not recovery oriented | 7 | 19 | “For step-up services postdischarge, we can send clients to [an assertive community treatment or an intensive case management] team, [but] they are very depressing, and they feel like the opposite of recovery. To the participant, they feel like a step in the wrong direction. Our participants never stay with those programs, I feel like, nor would I want them to, because they’re sort of like a holding place.” |
Disengagement or discontinuation of treatment or medication after discharge | 5 | 14 | “Someone could be in this program functioning beautifully . . . but then once they leave . . . they lose it. Suddenly they think they don’t need meds anymore . . . and no one’s there to catch them. . . . We’ve had a lot of really heartbreaking cases like that.” |
Difficulty of transition to status quo services after initial experience of high-quality CSC | 4 | 11 | “The quality of treatment in [our city], and I would imagine in a lot of these large urban areas, is just not good. And so, it's not good by itself, and then it's really not good when you've had such an amazing program like this wrapped around you for so long. You know you're going somewhere that's not good. You feel it as soon as you walk in the door, the smells, the paint job, the deterioration of the facilities, the staff are grumpy and not interested.” |
Shortage of and limited access to psychiatrists | 4 | 11 | “The other piece is just in terms of resources, going back even internally into our agency, so going back to adult services, there can often be a shortage in psychiatry.” |
Cost of care, particularly for privately insured (but not wealthy) young adults | 4 | 11 | “For a 19-year-old having to pay that much money on medication, that's a lot . . . [plus] copays for therapy, and . . . go[ing] from coming in whenever [they] need and want to, and getting lots of support, and not paying copays, to private insurance copays.” |
Access to clozapine and long-acting injectables | 3 | 8 | “And a lot of people are on clozapine . . . or at the injection clinic. So, if that'll have to change in addition to who they were seeing, it would just be a lot much more complex to coordinate and to find places that have those similar services.” |
Access to psychiatrists able or willing to prescribe antipsychotics | 2 | 22 | “It's a super big challenge getting a primary care or a private psychiatrist to continue medication. Those types of medications are really just specific to community mental health centers, primarily. That's where the bulk of those types of physicians are. To get someone with Medicaid connected to a private psychiatrist in a community that's going to provide an antipsychotic is pretty unlikely. There's a very low availability of those kinds of doctors. That's where our clients get stuck.” |
Client Themes
Theme and code | Example quotation |
---|---|
Client-provider discharge planning | |
Discussion of discharge plan | |
Plan discussed | “What's nice about [discharge] is [staff] and I are talking about it. We are addressing it. What are our future long-term goals. . . ? So yeah, I mean, we're addressing the outcomes and future now, which is good instead of just saying, ‘Oh, 2 years is done. You're on your own.’ It's not beating around the bush or anything.” |
Plan not discussed | Interviewer: “And have you talked at all about not being in the program, because you're going away to school?” Client: “We haven't talked about what's going to happen after I go to school and [have to leave the program].” |
Discharge awareness | |
Awareness of discharge policies regarding time limit | |
Unaware or didn’t know of any service limit or related policy | “[How long I can stay is] a good question because I have no idea. I was thinking about that myself. I have no idea how long this is going to continue for. I'm not really sure how that works.” |
Aware of specific service limit | “It’s a 2-year program.” |
Aware and believes there is not a limit | “No. There's not [a time limit]. I think as long as it's helpful. I mean, it's not like my diagnosis is going away anytime soon. So, I'll probably be in the program for the foreseeable future.” |
Perceived readiness for discharge | |
Ready for discharge | |
Feels confident, prepared, ready | “Honestly, I feel like this was a very good foundation. So, I feel like now that I've been really educated in many ways, that I feel like I can do it on my own.” |
Not ready for discharge | |
Doesn’t feel ready, does not want to be discharged | “Yeah, I'm actually being told that I'm done with the program. I've completed the program and that a different program is going to have to take over. So, I'm a little stressed out about that. How can I have completed and I'm not fully recovered? . . . I haven't been assisted with that [other services beyond the program]. I've only been asked questions.” |
Concerns and feelings about discharge | |
Positive feelings | |
Fine, okay, content, good | “It's just like I'll be done with it, but I won't be scared because I'll be facing it still with my family. I'll have family and loved ones. And I'll be better at handling situations that stress me because of [the program].” |
Happy, excited, proud, hopeful | “I think I'd be proud of myself for not only doing all that, but keeping my s**t together for that long. Because that would be a change, yeah. I think I would just be proud of myself, and I think I'd be slightly relieved to know that maybe this is a new chapter of my life that's starting now.” |
Grateful to program | “My doctor told me that I'm going to graduate from the program in about another 3 to 4 months and I’ll be happy that I'm graduating, but a little bit sad because . . . it's a transition. It is. But I'm very grateful [to the program], and I can't express it enough.” |
Negative feelings | |
Sad, distressed, anxious | “[I feel] very, very bad. I feel very bad because I'm not going to have the people and I'm not going to have the resources. So very bad.” |
Will miss the program; discharge viewed as a loss | “I would think I would lose like a place that I used to go to like if I couldn't come here, I think I'd lost a place I couldn't come to no mor. . . . I think I would feel like it was a loss.” |
Ambivalent feelings | |
Sad or will miss it, but also sees moving on as a positive step | “It'd be a little sad, 'cause I feel like this is my new community. But all things go, and all things change, so it'll be like finding a new shell.” |
Uneasy or unsure; may or may not turn out well | “Sometimes I do feel like I'm ready to move on, but then I don't feel like I'm ready to move on.” |
Vague feelings | |
Unsure how he or she feels | Interviewer: “What do you think it'll be like when you're not in the program anymore?” Client: “I don't know. I honestly don't know.” |
Specific areas of concern | |
Postdischarge service availability in client’s native language | “I'm going to miss it because of the help I've received here. And, I don't know how it's going to be in the next program. Here they have the therapy in Spanish.” |
Loss of supports still perceived as needed | “What if I need the support or something from them? Plus, I don't just look at them as work, I look at them like somebody I can depend on or something. Even though I'm trying to be independent, like I can depend on them or something.” |
Loss of structure | “Right now, I'd rather not have to [discharge]. I'd like to continue the program. I'm somebody that likes just to keep it the way it is, the schedule and everything. I mean, it helps me just to be able to come here and be able to talk to people and stuff like that. So, I'm somebody that would vote to stay indefinitely if need be.” |
Inability to handle future stressors without the program | “Just because, like, I don't think I'll ever be off my medication, because when the episodes happen, I can't tell if it's real or not. And I come from a very religious family, and so when stuff happens if I didn't have this program, I don't know what I would do.” |
Months in program | |||||||
---|---|---|---|---|---|---|---|
Theme or code mentionedb | |||||||
Domain, theme, and code | Domain mentioneda | N | % | 0–12 | 13–23 | ≥24 | Discharged or at discharge |
Client-provider discharge planning | 30 | 5 | 7 | 12 | 6 | ||
Discussion of discharge plan | |||||||
Plan discussed | 17 | 57 | 0 | 4 | 7 | 6 | |
Plan not discussed | 13 | 43 | 5 | 3 | 5 | 0 | |
Awareness of discharge policies regarding time limit | 67 | 26 | 16 | 19 | 6 | ||
Unaware or didn’t know of any service limit or related policy | 15 | 22 | 7 | 3 | 5 | 0 | |
Aware of an existing limit or discharge policy | 52 | 78 | 19 | 13 | 14 | 6 | |
Aware of specific service limit | 27 | 52 | 9 | 11 | 6 | 1 | |
Aware and believes there is not a limit | 25 | 48 | 10 | 2 | 8 | 5 | |
Discharge readiness | 31 | 7 | 6 | 13 | 5 | ||
Ready for discharge | |||||||
Feels confident, prepared, ready | 14 | 45 | 3 | 3 | 6 | 2 | |
Not ready for discharge | |||||||
Doesn’t feel ready, does not want to be discharged | 17 | 55 | 4 | 3 | 7 | 3 | |
Concerns and feelings about discharge | 47 | ||||||
Positive feelings | 17 | 36 | 9 | 1 | 3 | 4 | |
Fine, okay, content, good | 5 | 29 | 3 | 0 | 0 | 2 | |
Happy, excited, proud, hopeful | 6 | 35 | 3 | 1 | 1 | 1 | |
Grateful to program | 6 | 35 | 3 | 0 | 2 | 1 | |
Negative feelings | 15 | 32 | 4 | 3 | 4 | 4 | |
Sad, distressed, anxious | 8 | 53 | 2 | 1 | 3 | 2 | |
Will miss the program; discharge viewed as a loss | 7 | 47 | 2 | 2 | 1 | 2 | |
Ambivalent feelings | 15 | 32 | 3 | 4 | 6 | 2 | |
Sad or will miss it, but also sees moving on as a positive step | 9 | 60 | 3 | 2 | 3 | 1 | |
Uneasy or unsure; may or may not turn out well | 6 | 40 | 0 | 2 | 3 | 1 | |
Vague feelings; unsure how he or she feels | 8 | 17 | 6 | 1 | 0 | 1 | |
Specific areas of concern | 20 | 43 | 8 | 5 | 4 | 3 | |
Postdischarge service availability in client’s native language | 2 | 10 | 2 | 0 | 0 | 0 | |
Loss of supports still perceived as needed | 8 | 40 | 2 | 3 | 2 | 1 | |
Loss of structure | 4 | 20 | 2 | 1 | 0 | 1 | |
Inability to handle future stressors without the program | 6 | 30 | 2 | 1 | 2 | 1 |
Discussion
Main Findings
Clinical Implications and Future Directions
Limitations
Conclusions
Supplementary Material
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