IN 2004, THE Japanese government announced a. Development of a clinical pathway for long-term inpatients with schizophreniapcn_

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1 Psychiatry and Clinical Neurosciences 2010; 64: doi: /j x Short Communication Development of a clinical pathway for long-term inpatients with schizophreniapcn_ Miharu Nakanishi, PhD, 1 * Kanae Sawamura, PhD, 1 Sayaka Sato, MA, 2 Yutaro Setoya, PhD 2 and Nobuo Anzai, MD 3 1 Institute for Health Economics and Policy, 2 Department of Psychiatric Rehabilitation, National Institute of Mental Health, National Center of Neurology and Psychiatry, and 3 National Hospital of Neurology and Psychiatry, Tokyo, Japan Clinical pathways have been defined as an optimal sequencing and timing of interventions by staff for a particular diagnosis or procedure, designed to better utilize resources, maximize quality of care and minimize delays. The aim of the present study was to develop a clinical pathway for long-term inpatients with schizophrenia. A review of clinical records was conducted for 17 patients with schizophrenia who had stayed in one psychiatric hospital for >1 year, and who remained in the community >3 months after hospital discharge. A review of clinical routine records was conducted. The discharge process of each patient was expressed in a clinical pathway around phases and care components. They were integrated into one clinical pathway. The discharge process was divided into assessment and goalsetting, preparation, and discharge phases. Care components included discharge planning, daily activity, living environment, health management, and basic life skills. Discharge planning was an important care component that was combined with all three phases. A clinical pathway was developed from reviewing past patient records, and discharge planning was found to be an important care component, which was combined with all three phases: assessment and goalsetting, preparation, and discharge. Further study is needed to examine the validity of the pathway for use in other hospitals. Key words: critical pathways, discharge planning, hospital, psychiatric department, schizophrenia. IN 2004, THE Japanese government announced a policy for the transition from psychiatric inpatient care to community-based mental health services, known as Reform Vision of Mental Health Services. The majority of patients cared for in psychiatric units in Japan have a diagnosis of schizophrenia. 1 Rates of discharge decreased among patients who stayed in hospital >1 year, and patients with schizophrenia tended to stay for a longer period. 2 Clinical pathways are the suggested means to manage patient care more *Correspondence: Miharu Nakanishi, PhD, Institute for Health Economics and Policy, , Nishishinbashi, Minato-ku, Tokyo , Japan. mnakanishi-tky@umin.ac.jp Received 16 February 2009; revised 19 July 2009; accepted 30 September effectively and to coordinate and promote discharge of patients with schizophrenia. Clinical pathways have been defined as an optimal sequencing and timing of interventions by physicians, nurses and other staff for a particular diagnosis or procedure, designed to better utilize resources, maximize quality of care and minimize delays. 3 Extensive information about developing clinical pathways is available in the medical and surgical areas. In contrast, pathways in psychiatric care have not been widely published. 4 6 Although there are several emerging programs for deinstitutionalization of long-stay patients with schizophrenia, 7 10 most of the pathways are developed primarily for acute inpatient care There are few studies on the development of clinical pathways for long-stay inpatients with schizophrenia. The purpose of the present study 99

2 100 M. Nakanishi et al. Psychiatry and Clinical Neurosciences 2010; 64: was to develop a clinical pathway for patients with schizophrenia who have been long-term inpatients. METHODS The subjects were recruited from a rehabilitation unit in a psychiatric hospital. Each patient who met the DSM-IV criteria for schizophrenia as well as the following criteria was recruited: (i) discharged from the participating unit within a 3-year period from November 2004 to October 2007; (ii) stayed in hospital >1 year; and (iii) remained in the community >3 months after discharge. Of the 30 eligible patients, three patients were excluded because they were admitted to nursing homes that were staffed with medical personnel. Of the 27 remaining patients, clinical records were available for 17. The remaining 10 patients clinical records were excluded because of untraceable present condition (eight patients), readmission (one patient), or lack of sufficient information in records (one patient). A review of clinical records was conducted for the 17 patients to assess the discharge process, patient characteristics, clinical characteristics, and community life profiles after discharge. Information about the discharge process was organized as a clinical pathway around phases and care components. Phases were selected as the most suitable intervals to use for the study population due to the individuality of the illness. Duration of the discharge process was counted from the first meeting for discharge. Three phases were defined based on a review of the 17 patients: assessment and goalsetting; preparation; and discharge. For care components, eight categories have been previously suggested: test/diagnosis; medication; electroconvulsive therapy; occupational therapy; life skill profile; communication; psychoeducation for patient and family; and compliance therapy In addition, it is important for discharge planning to be one of the care components because it is the critical link between treatment in hospital and post-discharge care provided in the community. 15 Two independent investigators reviewed the charts of the 17 patients. After the review of clinical records, we found that these categories were unsuitable for the processes undertaken by the 17 patients. We then listed all procedures observed in clinical records, and consulted personnel who were involved in the discharge process in the participating unit. Reclassified care components based on life domains rather than types of interventions consists of discharge planning, daily activity living environment, health management, and basic life skills. Finally, the discharge procedure for each patient was expressed in a clinical pathway around phases and care components by one investigator to integrate into one clinical pathway. We had discussions with the personnel and reached consensus on the clinical pathway. The study was approved by the Ethics Committee of the National Center of Neurology and Psychiatry, Japan. RESULTS Eleven patients were male (64.7%), and the mean age at discharge was years (median, 11.3; range, years). Only one patient was married (5.9%), two patients (11.8%) were divorced, and 12 (70.6%) were single. Nine patients (52.9%) were employed before admission. Eight patients (47.1%) had graduated from primary school, seven (41.2%) from high school, and two (11.8%) from college. The mean length of stay in hospital was months (median, 45.0; range, months) and the mean duration of the discharge process was weeks (median, 87.0; range, weeks). Duration of care seemed to be prolonged by patient anxiety, changing physicians, and changing care units. Duration was loosely divided into assessment and goalsetting, preparation, and discharge phases. Triggers for admission were non-adherence to medication (n = 10, 58.8%), crime (n = 4, 23.5%), alcohol dependence (n = 3, 17.6%), long period without treatment (n = 3, 17.6%), and violence (n = 2, 11.8%). Twelve patients (70.6%) had difficulty in the community because of lack of insight and of non-adherence to medication, six (35.3%) due to family relationship problems, five (29.4%) because of housing unavailability, and five (29.4%) had problematic behavior. After discharge, eight patients (47.1%) lived in residential care facilities, seven (41.2%) lived alone in apartments, and two (11.8%) lived with family. Ten patients (58.8%) were treated at an outpatient clinic affiliated with the hospital; six (35.3%) attended an occupational therapy program, and three (17.6%) attended day care. The main community service was outreach nursing care (9 patients, 52.9%) ordered by the attending physician to check medication adherence regularly.

3 Psychiatry and Clinical Neurosciences 2010; 64: Clinical pathway for schizophrenia 101 Table 1. Care components of clinical pathway for discharge of long-term psychiatric inpatients Care components General care or selective care No. patients provided with service Discharge planning In team General 17 With patient General 17 With family General 14 Daily activity Progress of activity General 14 Connection with community resources General 14 Living environment Housing General 16 Public services General 10 Economic needs General 11 Health management Daily activity and adjustment General 15 Compliance therapy General 15 Disease management General 10 Physical health Selective 2 Basic life skills Diet Selective 6 Financial management Selective 6 Cleanliness Selective 1 Social adjustment Selective 1 Table 1 shows care components of a developed clinical pathway. Care components were divided into general care and selective care. General care was administered to most of the 17 patients and included discharge planning, daily activity, living environment, and health management excluding physical health. Selective care was administered to fewer than 10 and included physical health and basic life skills. Figure 1 shows outline of the pathway developed in the present study. The assessment and goalsetting phase involved seeking available housing and community resources in order to set outcome and implementation of selective care. Assessment and goalsetting were combined with discharge planning to determine the necessity of adding selective care in the discharge process. Discharge planning also had a role in reinforcing progress and identifying tasks in the current phase. The preparation phase followed decisions about housing, when patient and care staff prepared for community life after discharge. The patient and care staff sought available resources in the community, besides expanding daily activity and connection with community resources, and selecting care based on results of assessment in the assessment and goalsetting phase. The discharge phase followed the decision about the time of discharge. The patient simulated his/her community life after discharge in staying in new housing within a few days and attending activities in community resources. The patient and care staff arranged living environment after discharge, and applied for public services if necessary. DISCUSSION The developed pathway is unusual in that it includes discharge planning, general care, and selective care. The pathway may reflect psychiatric characteristics differently from other departments such as internal medicine and surgery that usually set a certain condition as outcomes in clinical pathways in each phase. 5 In contrast, the present patients had common triggers for admission and difficulty in community life: lack of insight and non-adherence to medication. Common characteristics were also found in the discharge process (general care) and in post-discharge care. In the review process, we found that the pathway could not be shaped according to the trigger for admission or difficulty in community life. The present study had three limitations. First, the review was based on clinical records, which lacked information that was not recorded. Second, the review was conducted in only one hospital. The discharge process may vary according to availability of community services in the hospital. Third, the number of patients was small and there was attrition. Further study is needed to examine the validity of the developed clinical pathway for use in other hospitals.

4 102 M. Nakanishi et al. Psychiatry and Clinical Neurosciences 2010; 64: setting outcome and implementation of selective care -seeking available housing and community resources DISCHARGE PLANNING -discuss discharge objectives -identify central tasks and outcomes -reinforce progress and review initial care plan -decisions about housing -preparing for community life after discharge -reinforce progress and review initial care plan -decision about the time of discharge -simulating community life after discharge -reinforce progress and review initial care plan DAILY ACTIVITY -attend treatment program in the hospital -attend activities in community resources on trial -stay in new housing within a few days -attend activities in community resources regularly HEALTH MANAGEMENT -compliance therapy -disease management -compliance therapy -disease management -review need for discharge referrals LIVING ENVIRONMENT -visit real estate office or residential facility -identify available housing -review need for public services, pension, welfare benefits -contract for housing occupancy -apply for public services if necessary Select care from physical health and BASIC LIFE SKILLS needed by the patient Physical health -monitoring Diet -practice cooking if necessary Financial management -discuss strategies Cleanliness -prompt to maintain cleanliness -make referrals to physicians -nutritional guidance -practice self management -discuss arrangements in community life Social adjustment -reinforce self-care and social skills -discuss arrangements in community life Figure 1. Outline of clinical pathway for discharge of long-term psychiatric inpatients with schizophrenia. The left column indicates assessment and goalsetting phase. The central column indicates preparation phase. The right column indicates discharge phase. The white boxes indicate care components, which correspond to each phase. The latter five white boxes with arrows indicate that the process may be administered in the phase if necessary.

5 Psychiatry and Clinical Neurosciences 2010; 64: Clinical pathway for schizophrenia 103 In conclusion, we developed a clinical pathway from reviewing past patient records, and found discharge planning to be an important care component, which was combined with all three phases: assessment and goalsetting; preparation; and discharge. ACKNOWLEDGMENT THIS STUDY WAS supported by a grant for Research on Policy Planning and Evaluation from the Ministry of Health, Labor, and Welfare, Japan ( ). REFERENCES 1 Ministry of Health and Welfare. Patient Survey Statistics and Information Department, Minister s Secretariat, Ministry of Health and Welfare, Tokyo, 2005 (in Japanese). 2 Fujita T, Takeshima T. Discharge curve among psychiatric patients after admission and risk factors associated with long stay based on Patient Survey. Seishin Shinkeigaku Zasshi 2006; 108: (in Japanese). 3 Coffey RJ, Richards JS, Remmert CS, LeRoy SS, Schoville RR, Baldwin PJ. An introduction to critical paths. Qual. Manag. Health Care 1992; 1: Smith GB. Protocols in practice. Critical pathway and patient and family teaching protocol for major depression. Nurs. Case Manag. 1999; 2: Emmerson B, Fawcett L, Frost A, Lacey M, Todd C, Powell J. A tale of three pathways: The experience of RBWH Mental Health. Australas. Psychiatry 2004; 12: Chan SW, Wong K. The use of critical pathways in caring for schizophrenic patients in a mental hospital. Arch. Psychiatr. Nurs. 1999; 13: Kumagai N, Anzai N, Ikebuchi E. Randomized controlled trial on effectiveness of the community re-entry program to inpatients with schizophrenia spectrum disorder, centering around acquisition of illness self-management knowledge. Seishin Shinkeigaku Zasshi 2003; 105: (in Japanese). 8 Noda F, Clark C, Terada H et al. Community discharge of patients with schizophrenia: A Japanese experience. Psychiatr. Rehabil. J. 2004; 28: Ryu Y, Mizuno M, Sakuma K et al. Deinstitutionalization of long-stay patients with schizophrenia: The 2-year social and clinical outcome of a comprehensive intervention program in Japan. Aust. N. Z. J. Psychiatry 2006; 40: Omori H, Takami H, Omori N, Sato S, Anzai N, Ikebuchi E. A study of effectiveness of the community re-entry program to inpatients with schizophrenia in Kamo Psychiatry Medical Center. Seisin Igaku 2008; 50: (in Japanese). 11 Hashimoto K. The treatment of schizophrenic patients in acute phase by clinical pathways: Multi-analysis of BPRS, drug treatment and other factors. Seishin Igaku 2004; 46: (in Japanese). 12 Takahashi M, Fukuda M, Miyaoka H. Current status of clinical path using for inpatients with acute psychiatric disease in the psychiatric ward in the university hospitals. Seishin Igaku 2004; 46: (in Japanese). 13 Kusaka K, Kanoya Y, Sato C. Effects of introducing a critical path method to standardize treatment and nursing for early discharge from acute psychiatry unit. J. Nurs. Manag. 2006; 14: Watabe K. Characteristics of the process of acute treatment in the inpatients with the first or recurrent episodes of schizophrenia: As derived from analysis of the client pathway, the patient s self-assessments of the process of treatment. Seisin Igaku 2007; 49: (in Japanese). 15 Shepperd S, Parkes J, McClaren J et al. Discharge planning from hospital to home. Cochrane Database Syst. Rev. 2004; (1): CD