Mental Health Care Professionals’ Experiences with the Discharge Planning Process and Transitioning Patients Attending Outpatient Clinics into Community Care Ann Marie Noseworthy, Elizabeth Sevigny, Andrea M. Laizner, Claudine Houle, Pina La Riccia PII: DOI: Reference:

S0883-9417(14)00065-X doi: 10.1016/j.apnu.2014.05.002 YAPNU 50628

To appear in:

Archives of Psychiatric Nursing

Received date: Revised date: Accepted date:

5 December 2013 11 April 2014 11 May 2014

Please cite this article as: Noseworthy, A.M., Sevigny, E., Laizner, A.M., Houle, C. & La Riccia, P., Mental Health Care Professionals’ Experiences with the Discharge Planning Process and Transitioning Patients Attending Outpatient Clinics into Community Care, Archives of Psychiatric Nursing (2014), doi: 10.1016/j.apnu.2014.05.002

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Mental Health Care Professionals’ Experiences with the Discharge Planning Process and Transitioning Patients Attending Outpatient Clinics into Community Care

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Ann Marie Noseworthy, R.N., B.Sc.N., M.Sc.(A) student - McGill University Ingram School of

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Nursing; Elizabeth Sevigny R.N., M.Sc.(A) McGill University Ingram School of Nursing, Assistant Nurse Manager, Coronary Care Unit, McGill University Health Centre; Andrea M.

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Laizner, R.N., Ph. D., Nursing Practice Consultant - Research, McGill University Health Centre,

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and Assistant Professor, McGill University Ingram School of Nursing; Claudine Houle, R.N., M.Sc.N., CSPSM (C) Clinical Nurse Specialist, Allan Memorial Institute, McGill University

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Health Centre; and Pina La Riccia, R.N., M.Sc.N., Associate Director of Nursing- Emergency Services & Mental Health Mission, McGill University Health Centre, and Faculty Lecturer,

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McGill University Ingram School of Nursing.

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April 10, 2014 Author Note

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Correspondence concerning this manuscript should be addressed to Ann Marie

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Noseworthy and Elizabeth Sevigny, McGill University Ingram School of Nursing, Wilson Hall, 3506 University Street, Montréal, Québec, Canada H3A 2A7, (514)-398-4144. Email: [email protected] and [email protected] or Andrea Laizner, Claudine Houle and Pina La Riccia, McGill University Health Centre, Royal Victoria HospitalS11, 687 avenue des Pins ouest, Montréal, Québec, Canada, H3A 1A1, (514)-934-1934. Email: [email protected], [email protected], [email protected] The authors thank Dr. Christine Maheu, Dr. Margaret Purden and our fellow McGill students for their valuable feedback and ongoing support. The authors also appreciate the time health care professionals gave to share their stories and experiences.

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Abstract Background. Health care reform promotes delivery of mental health care in the community.

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Outpatient mental healthcare professionals (HCPs) are pressured to discharge patients. This

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study’s purpose: to understand the experience and perceptions of mental HCPs with discharge planning and transitioning patients into community care. Methods. Twelve HCPs participated in

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semi-structured qualitative interviews. Findings. Three main categories: engaging in the

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discharge planning process, making the transition smooth, and guiding values emerged. A conceptual framework was created to explain the phenomenon. Conclusion. HCPs valued

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strengthening partnerships and building relationships to ensure smooth transition. Sufficient resources and trust imperative for safe patient discharge.

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Keywords: discharge planning, mental health professional, transition, community care,

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trust

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Current healthcare reform promotes the premise that mental health (MH) care delivery should be primarily based in the community (Federal Provincial Territorial Committee on Health

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Services, 1995; Ministère de la Santé et Services Sociaux [MSSS], 2005; World Health

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Organization [WHO], 2009). However, the bulk of patient care in MH continues to be delivered in hospital care rather than being concentrated in primary care (Kates, 2008;MSSS, 2005). The

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Mental Health Action Plan (Plan d’action en santé mentale - PASM) was developed in Quebec,

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Canada. The goal of PASM was to ensure specialized MH resources are used effectively and appropriately (Menear & Poirier, 2011; MSSS, 2005). MH patients in the Canadian healthcare

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system are expected to be transferred from hospital psychiatric ambulatory care services to primary care services in the community in order to improve their quality of life and recovery.

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The McGill model of nursing emphasizes that whenever possible people should recover in their

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own communities because it is there they will continue to develop and live their lives (Gottlieb & Rowat, 1987).

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Universal health care coverage in Canada gives all Canadians access to medically

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necessary health care services (Health Canada, 2014). How health care is organized is determined by the provinces and territories. Quebec is a francophone province in Canada and through its governance structure is responsible for providing health and social services that include hospital centres and community care which includes local community service centres (CLSCs) and general practitioners (GPs) (MSSS, 2014). Hospital centres offer hospital and ambulatory care services while CLSCs offer primary care services. Hospital care offers MH inpatient services for acutely ill patients who are unable to cope at home. The psychiatric ambulatory care services offers many specialized MH services by interdisciplinary MH teams and psychiatrists for patients who live in the community and require complex treatment

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adjustment. The psychiatric ambulatory care services provide care for patients with a variety of MH disorders including schizophrenia spectrum disorders, mood disorders, personality disorders

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and substance abuse in regular clinics, day hospitals and evaluation services. The community

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primary care CLSCs offer many kinds of general services including home care and walk-in clinics for people of all ages and a variety of health conditions. Patients with stabilized MH

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disorders can be seen in GP’s offices and in CLSC MH teams or psychosocial services.

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MH disorders affect 1 in 6 people living in Quebec (MSSS, 2005). This study’s research setting is an academic quaternary health care centre that offers both inpatient and ambulatory

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care services. The research setting has reported long waiting lists for new complex patients to be treated in psychiatric ambulatory care services. This is especially important given the provincial

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government’s perception that psychiatric ambulatory services were not transferring a sufficient

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number of MH patients into community care (MSSS, 2005). For the purpose of this study, psychiatric ambulatory care services will hereon be referred to as psychiatric outpatient

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department (P-OPD) and outpatient department (OPD) will refer to ambulatory services for a

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variety of health care populations. The PASM report highlighted that care in psychiatric ambulatory services is most appropriate for patients with complex MH disorders who require specialized MH services from psychiatrists and HCPs. Once stabilized, patients are better served in community care by GPs and CLSC services (MSSS, 2005). HCPs organize the transition of patients through the discharge planning process. Nurses are considered vital to this process (Ali Pirani, 2010) as they work within interdisciplinary MH teams, provide liaison services between health institutions and coordinate care for patients as they transition into community care (Laflamme, 2010). To better understand the phenomena of

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patients being transferred to community care, an examination of the perspectives and experiences of the HCPs who are involved in transferring these patients is necessary.

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Literature Review

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The literature about discharge planning in general highlights that there is ambiguity in defining the terms around the discharge planning process and transitional care (Holland &

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Harris, 2007; Watts & Gardner, 2005). For the purpose of this study, discharge planning is

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defined as “… an ongoing process that facilitates the discharge of the patient to the appropriate level of care. It involves a multidisciplinary assessment of patient/family needs and coordination

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of care, services and referrals” (McGinley et al., 1996, p.55). Transitional care refers to a process that includes a range of services and care settings that aims to promote the safe and timely

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transfer of patients from one care setting to another (Holland & Harris, 2007; Naylor, 2002) and

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unlike the discharge planning process is not bound by setting borders (Holland & Harris, 2007). Recommendations for Discharging Patients

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In general discharge planning research, the discharge planning process aims to facilitate

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the transition of a patient from one care environment to another seamlessly (Canadian Health Services Research Foundation [CHSRF], 2011; Champagne, Roy, & Michaud, 2003; Jensen et al., 2010). An integrated review looking at hospital inpatient staff nurses’ roles in the discharge planning process of general patients concluded that this process should begin upon admission, use a designated care coordinator, and a discharge protocol (Maramba, Richards, Myers, & Larrabee, 2004). Specific to MH, hospitalized inpatients discharged into the community with overlapping services experienced significantly lower readmission rates, better follow-up attendance and improved satisfaction rates (Jensen et al., 2010; Reynolds et al., 2004). In

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summary, to achieve a seamless transition for MH populations the literature suggests planning and collaboration will help to achieve this goal.

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Effective communication and collaboration between institutions, providers, patients and

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their families is essential to the MH discharge planning process. It is vital that these key players work together to accurately transfer information (CHSRF, 2011; Champagne et al., 2003;

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Fitzpatrick & Dawber, 2008). Collaboration between mental HCPs has been linked to better

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health outcomes in MH populations (Gilbody, Bower, Fletcher, Richards, & Sutton, 2006 ) and facilitated the transfer of MH patients into community care (CHSRF, 2011). According to

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Connolly et al. (2010), HCPs in general can have varying opinions regarding patients’ readiness for discharge. Effective communication between HCPs working with general patient populations

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and their families has been linked to increased user satisfaction (Maramba et al., 2004). Mental

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HCPs need to conduct the discharge planning process as a team with patients and their families as active participants to facilitate patient transfers into community care (Champagne et al., 2003;

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Hautala-Jylhä, Nikkonen, & Jylhä, 2006; MSSS, 2005).

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The therapeutic relationship between HCPs and patients is the essence of MH care and strong therapeutic relationships have been linked to improved outcomes in both hospital and community settings in MH populations (Hautala-Jylhä, Nikkonen, & Jylhä, 2005; Masson & Sheeshka, 2009). A transfer into community care ends an established relationship between mental HCPs and patients (Reynolds et al., 2004). Literature emphasizes the transition from hospital to community care is particularly challenging for MH patients as readmission rates are high and utilization of aftercare is low (Nolan, Bradley, & Brimblecombe, 2011; Steffen et al., 2009). Little is known about what this transition is like for mental HCPs working in P-OPDs and

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how their experience may affect the discharge planning process and the transition of patients to community care.

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Realities in Practice - Challenges in Discharging Patients

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Transitioning MH patients into community care can be a complex process for both patients and HCPs. General challenges in the discharge planning process, for all types of

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patients, include a lack of time (Watts & Gardner, 2005) and concerns for the adequacy of

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resources in the community (Masson & Sheeshka, 2009). The post-discharge period is a critical time for all patients (Grant & Pan, 2011; Steffen et al., 2009; van Staa, Jedeloo, van Meeteren, &

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Latour, 2011). There are potentially more serious consequences for MH patients: high rates of medication non-compliance, relapse (Hui et al., 2013) and increased re-hospitalization (Reynolds

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et al., 2004). No studies were found that specifically examined the transition of MH patients

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from P-OPDs into community care. Research highlights the discharge planning process is critical for MH patients, though the majority of studies examined focused on transferring MH

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patients from inpatient settings.

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Health Care Professionals’ Perceptions in P-OPDs In order to understand the challenges of the discharge planning process for MH patients from P-OPDs into community care, there needs to be an understanding of the HCPs' perceptions. One study examined mental HCPs’ and patients’ perceptions of what happened during a typical outpatient visit after discharge from hospital and discharge planning was notably absent from the topics discussed (Hautala-Jylhä et al., 2006). Studies have examined mental HCPs' perceptions of the discharge planning process but only in inpatient populations (Hautala-Jylhä et al., 2005; Jones et al., 2009; Ryan-Nicholls & Haggarty, 2007). In conclusion, there was a paucity of

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literature found on the perceptions of P-OPD HCPs on the transition of patients from P-OPD clinics to community care.

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The purpose of this study was to understand the experience of P-OPD HCPs with the

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discharge planning process and to understand their perceptions about transitioning MH patients into community care in order to facilitate patient transitions. This study asked: (1) What is the

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experience of mental HCPs during the discharge planning process of transferring patients into

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community care? (2) What are the mental HCPs' perceptions about transitioning patients from their care into community care? Understanding mental HCPs’ views will provide insight that can

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be used to facilitate the number of patients discharged from P-OPD clinics into community care. Methods

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Design

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In order to obtain a deep, rich description of what HCPs think and feel about the discharge planning process and transitioning MH patients from P-OPD clinics into community

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care, a qualitative descriptive design using semi-structured interviews was employed (Fossey,

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Harvey, McDermott, & Davidson, 2002; Speziale & Carpenter, 2003). Qualitative designs are well suited for research in health care by allowing researchers to immerse themselves in the data and explore a specific human experience (Fossey et al., 2002; Speziale & Carpenter, 2003). Sample Twelve participants (hereinafter referred to as HCPs) were recruited using convenience sampling from the P-OPD of one university teaching hospital in Quebec, Canada. Inclusion criteria were the following: English speaking, experience with the discharge planning process and/or opinions and thoughts to share regarding the transition of MH patients into community care. The HCPs represented four health professional groups: nursing, psychiatric medicine,

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social work and occupational therapy and worked with a variety of MH populations including psychotic and mood disorders (Table 1). Study HCPs were all female and university prepared.

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The majority (7/12) had at least fifteen years of experience working in the P-OPD. A large

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majority (10/12) had worked in the MH field for more than fourteen years. The HCPs’

more than one hundred patients into community care.

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Data Collection

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experience in discharging patients ranged from transferring one or two patients to transferring

Scientific and ethical approval was obtained from institutional review boards from both

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the investigators’ university and at the participating site. Data collection occurred between September 2012 and January 2013. HCPs were recruited via emails, postcards and presentations

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to the P-OPD staff and were asked to contact the investigators to set up an appointment. One

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time, face to face, semi-structured interviews lasting approximately 45-60 minutes were performed. An interview guide (Table 2) was used to organize and focus the interview (Rubin &

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Rubin, 2005). Pertinent non-verbal data were recorded in field notes during the interview to

Data Analysis

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provide context to the transcripts and triangulate data (Morse & Field, 1995).

Interviews were audio taped and transcribed verbatim and were analyzed modeling Burnard’s (1991) constant-comparison method. Transcripts were reread over in their entirety to immerse the investigators in the data. Two investigators independently open coded each transcript line by line to apply provisional headings by highlighting and extracting sections that described the HCPs' experience of the discharge planning process and perceptions about transitioning patients into community care. Investigators met to achieve consensus on data interpretation for each transcript (Graneheim & Lundman, 2004). Additionally, to enhance the

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trustworthiness of the study findings, a subset of the data was coded and analyzed by two other members of the research team with expertise in qualitative analysis. Similar headings were then

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grouped together and collapsed into a category system which comprised of subheadings,

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headings and categories. The dependability of the findings was increased through regular debriefing sessions with the research team by ensuring that decisions made about similarities and

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Findings

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differences of content were consistent (Carnevale, 2002; Graneheim & Lundman, 2004).

A conceptual framework along with three categories emerged during the initial analysis

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of the interview data and was further reinforced by the remaining interviews (Figure 1). The conceptual framework provides a visual representation of the three categories: engaging in the

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discharge planning process, making the transition smooth, and guiding values. The first category,

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engaging in the discharge planning process, depicts how the HCPs described their experience going through the discharge planning process as involving several key steps and that this process

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was continuing to evolve. The second category, making the transition smooth, described the

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HCPs’ perceptions about transitioning patients to community care. Making the transition smooth is depicted in the conceptual framework in part by two magnets which represent the P-OPD and community care labelled “OPD” and “community” respectively. The forces between the magnets represent the conditions that make the transition easy, difficult or not possible. Shared care was described as occurring when a full transfer was either difficult or not possible due to certain conditions and therefore the patient was cared for by both the P-OPD and the community care HCPs. The relationship between HCPs and patients was described as evolving over the course of the transition. Looking back on transferred patients, HCPs were able to identify benefits for both themselves and patients. The final category, guiding values, described six

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overarching values that influenced the perceptions and experiences of the HCPs as they transitioned patients from their care into community care.

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Engaging in the Discharge Planning Process

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This first main category had two headings: steps of the process and evolving process. To understand how HCPs engage in the discharge planning process, it is necessary to comprehend

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the steps of the process as well as how the HCPs are experiencing this evolving process.

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Steps of the process. The HCPs identified six steps in the discharge planning process: roles and key players, making the decision, preparing the patient, gathering the information,

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transferring the information, and following up. Since the purpose of this study was not to describe the discharge planning process itself see Table 3 for further description of the steps.

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Evolving process. HCPs described the discharge planning process as evolving, it had

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improved over time, there continued to be challenges and they shared their recommendations for improvement. The majority of HCPs (10/12) described their experience with the process as

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having been positive and that many of their transfers went well with only a few that went poorly.

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HCPs felt the discharge planning process should ideally be smooth and seamless, “So the goal is just to… have a smooth transition” (S03). The majority of HCPs felt the discharge planning process had improved over time, supports and resources had been put in place but that improvements were still needed. A quarter of HCPs thought the previous informal process was easier for them compared to the current more structured approach. These HCPs felt the process now involved more paperwork and bureaucracy to manage. A third of HCPs noted a change in mentality within the P-OPD in the last few years. Historically patients were admitted to the P-OPD “for life” and now a more

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recovery oriented approach to care is used to prepare patients for discharge when they were stable.

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HCPs described challenges with the discharge planning process. A quarter of the HCPs

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described the process as time consuming, “onerous” (S12) and “cumbersome” (S07). A third found it unclear, “the protocol is very complicated. It’s not even clear in my mind” (S07).They

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expressed lacking knowledge about the different community services provided and how they

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functioned. Half of the HCPs felt that community services lacked standardization, CLSCs were organized differently, lacked standardized tools and methods of communication and this made

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discharge planning challenging. Only two HCPs understood the organization of community services well. One explained that although it was clear to them “it’s just really opaque for most

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the end the effort was worth it.

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people” (S08). Two HCPs highlighted that regardless of how long it took to transfer a patient, in

HCPs shared suggestions for how they thought the discharge planning process could be

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improved. Half of the HCPs thought it was important to plan ahead by preparing patients from

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their admission to the P-OPD, “I think that really when we have a new patient we should right away work on the discharge” (S01). For example, it was important for the case manager to start the process of finding a GP as early as possible as it often took a long time. HCPs expressed a need for more feedback related to outcomes after patients were discharged from their care. HCPs thought the process needed to be formally evaluated to look at patient and system outcomes such as how many patients had returned to the P-OPD and how patients were coping in the community.

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In the category, engaging in the discharge planning process, HCPs described several identifiable steps and felt the process continued to have challenges. Regardless, HCPs were

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committed to finding strategies to make it work and thus the process was continuing to evolve.

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Making the Transition Smooth

In the second category three main headings emerged related to HCPs’ perceptions of

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transitioning patients from the P-OPD to community care: conditions that made the transition

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smooth or not, how the relationship evolved and the perceived transition benefits. Conditions. Conditions, represented in the framework as the forces between the magnets,

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made transitioning patients into community care: easy, difficult or not possible and sometimes lead to shared care. HCPs identified patient, community and P-OPD conditions (Table 4). More

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than half of HCPs (7/12) expressed that they found it easier to transfer patients who were

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familiar with their community HCPs. HCPs expressed frustration when patients were refused by community care because of their diagnosis or situation “we followed a lot of people with

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dementia … we couldn’t understand why other MH care providers couldn’t ...” (S04).

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Two thirds of HCPs thought there was a general lack of community and MH resources. The lack of professionals (especially GPs) made it difficult or impossible to send stable patients to community care. HCPs also identified issues related to GPs, pertaining to GPs’ comfort level in caring for MH patients, as a major factor facilitating or hindering the discharge planning process. Three HCPs highlighted that they found it harder to transfer patients outside their local health territory because the P-OPD HCPs were less familiar with the HCPs and patients would not return to their P-OPD if they relapsed “[It’s] easier when we’re transferring [patients] to our own [local health territory] … simply because the relationship at some level can continue” (S02). When reviewing P-OPD conditions, it was noteworthy that none of the HCPs were completely

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opposed to discharging patients to the community. All HCPs were able to identify patients they felt were appropriate to be transferred and patients that should not be transferred. What they

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believed would delay a transfer was P-OPD HCPs’ disagreement of patients’ readiness. Almost

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half of the HCPs (5/12) described a past negative experience of feeling external pressure to transfer patients. HCPs felt very uncomfortable doing so, “there’s the frustration that some of the

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patients we were discharging … although, relatively stable … could easily relapse” (S04). One

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HCP expressed feeling awful about having “given in” to the pressure to transfer patients they felt were inappropriate.

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HCPs cited several examples of patients that required shared care because of conditions that made it difficult to transfer, or HCPs felt that community services could not fully support the

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patient. A third of HCPs described shared care as an intermediate step, an alternative to a full

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transfer from the P-OPD to community care when patients were not ready for a full transfer. HCPs’ opinions on shared care varied, some felt it was more time consuming, redundant and that

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everything should be done in one place. Others preferred shared care to a complete transfer as

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they felt it was safer to maintain contact with patients longer and provided an opportunity to get to know the community HCPs. The relationship experience. The relationship experience, depicted in the framework as evolving over the transition, describes HCPs’ perceptions as they ended the therapeutic relationship with their patients. They discussed their attachments, feelings of loss and finally how they disengaged to help patients create new relationships. The majority of HCPs (10/12) expressed that many patients were strongly attached to the hospital institution and their P-OPD HCPs. These attachments could make the transition a difficult and frightening experience for both patients and HCPs, “patients become attached to the hospital and to …care takers and vice

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versa. So some of the challenges have been that we have a hard time letting go…and the patients have trouble letting go”(S02). Some patients attended the P-OPD for many years and the

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relationship with their case manager was one of the only relationships they had. Transitioning

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these patients took time and extra preparation. HCPs worked hard to ensure patients did not feel they were being abandoned and emphasized the need to alleviate patients’ fears and support them

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throughout the transition. HCPs described moving on and letting go of the therapeutic

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relationship they had with their patients, “it’s a loss for me, it’s a loss for them”(S01). HCPs

over and provide care in their own way.

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explained this loss could be difficult but ultimately accepted that a community HCP would take

When discussing disengagement, the majority of HCPs (7/12) believed that patients could

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build trusting relationships with new community HCPs. They voiced that it was important to

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respect professional boundaries post discharge and not undermine the new HCPs. It was important for HCPs to stay available to the patient and “nurture the transfer of that alliance to

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someone else”(S02). One HCP explained “tell [the patient] … ‘you’ll see me again, we’ll bump

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into each other’… you know but make it less formal”(S07). HCPs felt disengaging and letting the new HCP take over allowed the patient to create new relationships in the community. Transition benefits. HCPs identified benefits of the transition for both patients and themselves. The benefits are depicted in the framework at the end of the transition as HCPs identified benefits when looking back on past transfers. All HCPs agreed that receiving care closer to home was preferred and more convenient for the patient, “[The patient] likes being in the community close to where she lives”(S01). HCPs often viewed the transition of patients to community care like a “graduation” (S02), celebrating patients’ improvement, “it’s a positive step, they’re healthier and stable and can manage more on their own”(S09). HCPs felt being

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followed in community care had a de-stigmatizing and normalizing effect on patients. More than half of the HCPs (7/12) expressed that being cared for in the community lead to better access to

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community services. One HCP described her experience, “letting him go to the community it

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normalized…he became well, he joined activities… The nurses over there knew other resources that I didn’t know and it’s working out very very well” (S03). The vast majority of HCPs (10/12)

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believed that when appropriate, care in the community was positive and helpful for stable

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patients.

Half of the HCPs described benefits that impacted their own practice through learning

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experiences and feeling rewarded, “…it’s fulfilling to see someone move on and do well… it’s very good” (S06). Transitioning patients allowed HCPs to care for more acute patients and

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reduced the P-OPD waiting list, “it’s definitely been an advantage that way, by discharging

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patients we get to absorb new ones …and give the care we need to give” (S04). In summary, the second category describes the HCPs’ perceptions of transitioning patients from the P-OPD to

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community care through the conditions that made the transition smooth or not, how the

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relationship evolved and the perceived transition benefits. Guiding Values

The final category, guiding values, illustrated how values surrounded and shaped the HCPs’ perceptions and experiences as depicted in the outer circle of the framework. The six key values that HCPs discussed were: patient centered approach to care, responsibility, safety, expertise, teamwork and communication. Patient centered approach to care. The patient played a pivotal role in the discharge planning process and transition to community care “we’re a team here and… [the patient is] the center player. If we can’t have that then we’re useless”(S05). The majority of HCPs (7/12) felt

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that if the patient did not want to be discharged then ultimately the transition could not occur nor would it be successful. HCPs explained the importance of seeing patients as human beings, “to

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look at them as a whole…not only a diagnosis” (S01), as well as “keeping the patient in the loop

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at all times” (S05) to ensure they are involved and supported in the process. Often HCPs individually tailored the discharge planning by focusing on patient’s strengths and learned skills,

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“you have to have a kind of individualized approach for each case” (S10).

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Responsibility. HCPs expressed a professional sense of responsibility to ensure the transition went well for their patients. HCPs wanted to do a good job, it was important to ensure

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patients had sufficient resources and support in the community once discharged. HCPs used their own personal and clinical judgment to guide their actions and make decisions as there was no

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standard way to approach each case “I think I use my own judgment all the time. It’s not written

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in a protocol” (S03). Five of the HCPs talked about making it work, how they would find ways to solve problems and coordinate care in order to speed up and facilitate the transition.

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Safety. All HCPs emphasized it was important to safely transition patients. They had

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safety concerns with regards to: opportunity for gaps, lack of follow-up and continuity of care. Two thirds of HCPs were worried patients would or could “fall through the cracks” by relapsing and returning to the hospital after a transfer. Their suggestions to avoid this included having overlapping visits during the transition period to ensure patients attended community appointments. Also, the P-OPD could follow-up with community and vice versa to ensure patients were attending appointments and were doing well. HCPs had concerns about continuity of personnel in the community. For example, HCPs were not comfortable when patients went for injections and did not see the same nurse each time at the CLSC, “have a nurse that is assigned to each client. So there is continuity and yes it’s better and safer”(S01).

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Expertise. HCPs shared their opinions about the community’s expertise in MH. Half of HCPs feared the community may not have enough MH experience and ability to pick up on the

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warning signs and triggers of decompensation so they could intervene and possibly prevent

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hospitalization. The other half felt the community HCPs were knowledgeable and skilled, “[they are] real life people who know what they’re doing” (S02). Three HCPs felt that with time the

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knowledge and experience of the community HCPs will grow and improve as they care for more

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MH patients. Through maintaining relationships and knowledge sharing, HCPs felt the P-OPD could contribute to the growth of community HCPs’ expertise.

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Teamwork. Two thirds of HCPs expressed the importance of teamwork amongst P-OPD HCPs, community HCPs and patients and families. Teamwork was essential for a transfer to be

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successful. Within the P-OPD the discharge planning process was done as a team with many

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professionals collaborating together. Three HCPs highlighted the importance of team cohesiveness and “send[ing] the same message” (S07) to the patient about the transfer, “so the

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team all comes together and things really work out nicely” (S06).

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Communication. HCPs emphasized how crucial communication was in contributing to a successful transfer, the “bottom line is ... honest, clear and transparent communication” (S02). The three subheadings of communication were: finding out about community services, getting to know the community and keeping lines open. HCPs communicated with community HCPs to find out what services were available and verified that the patient case was appropriate. Through meetings, retreats and personal interactions, HCPs got to know and develop connections with community HCPs. Interactions with the community were positive learning experiences that helped HCPs feel more comfortable and confident about transferring patients. The majority of HCPs (9/12) felt it was imperative to maintain communication with the patient and community to

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make the transition smooth. HCPs thought it was important to encourage two-way communication and make themselves available in case the community needed help or support,

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“keeping open lines of communication…I’m available anytime for any questions … makes a big

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difference” (S06). In summary, guiding values highlighted the importance of effective communication with the community HCPs to build trust as well as the need for community

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HCPs to have sufficient MH knowledge to safely care for patients.

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Discussion

The findings from this study uniquely highlight the P-OPD HCPs’ experience with the

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discharge planning process as they transitioned MH patients into community care. Communication, expertise, lack of resources in the community along with the need for

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evaluation and feedback about the process are some of the important findings that will be

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discussed. Central to a smooth transition was building trusting relationships through effective communication and increasing community expertise through knowledge sharing. The challenges

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related to a lack of resources and the need for more evaluation and feedback need to be

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addressed in order to facilitate the transition of patients into community care. Building Trusting Relationships Inherent to transferring MH patients into the community for HCPs was engaging in effective communication and collaboration activities with community partners. HCPs who did not have much experience transferring patients expressed more hesitance and concerns possibly because they had not yet developed strong relationships with the community HCPs and expressed lacking knowledge about how community services were organized and functioned. It is possible that HCPs who had little experience transferring patients were not as comfortable with the process because their patient population was more acute and therefore less appropriate

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and less likely to be discharged to the community. Conversely, HCPs who worked closely with community HCPs appeared to have more trust and confidence in the community’s ability to care

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for MH patients. Through accompanying visits, frequent communication, and personally

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following up after transfers, HCPs were personally engaged in the discharge planning process. Similarly, literature emphasized building personal contacts through frequent communication

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(Kates et al., 2011) was necessary in order to build trust between community care and P-OPD

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HCPs. HCPs also described being involved in formal collaborative activities such as interagency rounds, meetings and attending retreats to get to know the community partners. Other authors

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have highlighted the key role communication and collaboration play in fostering the development of trust between HCPs and community agencies (Hassan, Toylan, Semerciöz, &

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Aksel, 2012; McElheran, Eaton, Rupcich, Basinger, & Johnston, 2004).

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HCPs expressed it was more difficult to transfer patients to other health territories because of less contact and familiarity with those HCPs. The literature supports the need to

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develop networks between sectors and build stronger relationships with community partners

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(Kates et al., 2011; WHO, 2007). Both personal engagement and formal collaborative activities helped to facilitate the transition of patients into community care. Building P-OPD’s trust in community partners will likely increase willingness to transfer patients. Knowledge Sharing Inherent to HCPs trusting in the transition was ensuring the community had adequate expertise and knowledge to safely care for MH patients. HCPs were particularly concerned about the communities’ ability to pick up on patient triggers and warning signs of decompensation. The Kirby report states that knowledge transfer is essential to the integration and development of MH services in the community (Kirby & Keon, 2006). Through maintaining collaborative

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relationships and knowledge sharing, HCPs felt the P-OPD could contribute to the growth of community HCPs’ expertise and this follows recommendations from the Canadian Mental

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Health Initiative (Gagné, 2005). HCPs also shared their perceptions that some GPs were

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reluctant to care for MH patients. Interestingly, statistics have shown that GPs autonomously managed close to half of the mental health population in Montreal, Quebec (Agence de la Santé

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et des Services Sociaux de Montréal, 2007). Other literature suggests that some GPs do not feel

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properly prepared to care for MH patients (Leigh, Stewart, & Mallios, 2006). This demonstrates that community HCPs require ongoing support and advice from specialized MH HCPs to

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confidently care for MH patients (Fleury, Grenier, Bamvita, & Caron, 2011). Interestingly, other studies found when GPs developed and deepened their relationships with mental HCPs this

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improved their practice, increased their knowledge, confidence and resulted in improved patient

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care (Chomienne et al., 2011; McElheran et al., 2004). Shared care experiences allowed for bi-directional knowledge sharing where P-OPD

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HCPs came to understand their community partners’ strengths, expertise and roles. This finding

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was similar to other studies that found through shared care mental HCPs gained respect, increased comfort and understanding of community partners’ realities (Eagar, Pirkis, Owen, Burgess, & et al., 2005; McElheran et al., 2004). P-OPD HCPs and community HCPs need to be aware of their roles and those they work with to foster mutual respect and support effective collaborative practice (Kates et al., 2011; Registered Nurses' Association of Ontario, 2006). It is important to highlight that all nurses (Desrosiers, 2007) and all HCPs have a professional responsibility, in all care settings, to assess both the mental and physical health of patients. Lack of Resources

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HCPs emphasized that there was a general lack of human resources in the community, not only within the community MH team but particularly with GPs. Most HCPs felt this was one

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of the main reasons patients could not be fully transferred to the community. These findings

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reflect the current state of the Canadian healthcare system in which there is a shortage of community HCPs and where access to community health services is limited (Doey, Hines,

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Myslik, Leavey, & Seabrook, 2008; Fleury, Armelle, Denise, & Lambert, 2012). HCPs’ short

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term solution was to search for a GP as soon as possible, preferably on admission to the P-OPD. Implementing healthcare policy such as the PASM requires ongoing planning and budget

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reallocation. To facilitate patient transfers there needs to be adequate and sustainable funding as well as sufficient human resources to meet the needs of the community MH population. Funds

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need to shift appropriately as patient care is more concentrated in the community (WHO, 2007).

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With sufficient resources and access to community HCPs more patients can be transferred and MH services can be further developed and integrated into community care (Doey et al., 2008;

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Fleury et al., 2012; Kates et al., 2011; WHO, 2009).

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Evaluation and Feedback

HCPs wanted more feedback on patient and system outcomes and to know how the process was being evaluated. The follow-up step in the discharge planning process had the most varied description and was the least consistently performed. Half of the HCPs did not systematically follow-up with the patient or community and expressed not really knowing how the patients they transferred were doing. Literature suggests the need for systematic, proactive follow-up such as a telephone call with the patient (Kates et al., 2011). For HCPs to have confidence in the process, they require frequent formal and informal feedback on patient and system outcomes.

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HCPs were not aware of any formal evaluations that looked at system outcomes when transitioning their patients to community care. For example they wanted to know the number of

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successful transfers, the number of patients returned to the P-OPD or hospital, financial and

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resource implications. Studies that evaluated the system outcomes of integrating MH services into community care reported: improved quality of care, better access to services, cost savings

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and efficient use of resources (Eagar et al., 2005; Fleury et al., 2012; WHO, 2007). In order to

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address HCPs’ need for more feedback related to patient and system outcomes, it is imperative that formal evaluations are performed and shared with HCPs and all partners involved.

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Conclusion

Implications for Practice

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Findings for this study have implications for HCPs, administrators, educators, and

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government. These key players can contribute to facilitating the process of transitioning patients from P-OPDs to community care. Some strategies that build on those mentioned in the

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discussion section are listed in Table 5.

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HCPs can play a direct role in facilitating the discharge planning process through personal engagement to build trusting relationships. This can be accomplished by accompanying patients to community visits, making phone calls to receiving HCPs, following-up after transfers and attending knowledge sharing forums. Moreover, HCPs need to celebrate successful transfers as a team (Clarke et al., 2012) to identify what worked and use unsuccessful transfers as learning opportunities to improve the process. Administrators can play a central role in building trusting relationships by building on existing collaborative partnerships (WHO, 2009), activities (retreats, inter-agency meetings, continuing education sessions) and working to create new partnerships (inter-hospital and with

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out-of-territory partners) ( Marion et al., 2004). Improving communication channels was linked to improved user satisfaction (Maramba et al., 2004) and can help to ensure evaluations and

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reviews filter down to the HCPs and the HCPs’ feedback travels up to reach decision makers.

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Limitations

The findings of this study are specific to a P-OPD in one academic health care centre and

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may not be congruent with the realities of other P-OPD HCPs. The study sample was quite

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homogenously composed of female HCPs with a lot of experience in MH. The convenient sampling method may have attracted participants who were more optimistic about the process.

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Future Research

Knowledge gained from this study provides an initial understanding of P-OPD HCPs’

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experience and perceptions about transferring patients into community care. Future studies could

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validate the study’s findings by using a quantitative survey with a larger sample size or duplicate the study in a similar setting. Additionally, other studies could potentially triangulate this study’s

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findings with patient chart reviews, and qualitative studies on patients’, families’ and community

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HCPs’ perspectives. These qualitative studies could provide further insight on this phenomenon and build on the knowledge gained from this study. Finally, the conceptual framework could be validated in similar MH settings and tested with other patient populations being transitioned from specialized OPDs into community care. This study is unique in that it described the P-OPD HCPs’ experience and their perceptions about transitioning patients into community care. The framework that emerged is distinct in helping to better conceptualize the complex HCPs’ experience and perceptions about transitioning MH patients to community care. Findings from this study highlight how effective communication and knowledge sharing contributes to building trusting relationships and

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expertise. Addressing challenges related to lack of resources, evaluation and feedback is

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imperative to facilitate the transition of patients into community care.

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Figure 1. Conceptual Framework for Transitioning Patients into Community Care

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Table 1. Sample Characteristics (N=12)

6 6

Gender

Female

12

Education

Undergraduate Degree Post Graduate Degree

Profession

Nurses Social Workers Physicians Occupational Therapist

Employment Status

Full-Time Part-time

Years worked in MH

Mean 22.6 (3-43)

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Mean 13.0 (.75-28)

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Years worked in P-OPD

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6 6

50.0 50.0

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41 – 59 60 +

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Age (years)

%

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n

100.0 50.0 50.0

6 3 2 1

50.0 25.0 17.0 8.0

10 2

83.0 17.0

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Table 2. Interview Guide

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Purpose The aim of this study is to understand the experience of mental health care professionals, working in specialized outpatient clinics with the discharge planning process and transitioning patients attending outpatient clinics into community care.

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Preamble statement The Plan d’action santé mentale (MSSS, 2005) outlines that there needs to be an increase in the number of discharges of mental health patients from specialized outpatient clinics into the community. Transitioning of patients into community care means that you as a healthcare professional will not be caring for these patients once responsibility of care has shifted to CLSCs and family physicians. Our study will focus on what this experience has been like for you. Whether you have been involved in one or all steps of the discharge planning process including: preparation, planning, decision-making, liaison etc. or have thoughts and ideas about the discharge planning process and the transition of care of mental health patients into the community. Gaining a better understanding of healthcare professionals’ views and experiences may help to facilitate this process for both patients and healthcare professionals.

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Interview Questions 1. Have you been a part of the discharge planning of a mental health patient into the community? If no: skip to 2, if yes: ● Could you tell me about your role or the part you played in that? ● How do you think that went? ● How did it make you feel? 2. Could you explain how discharge planning takes place? If you find it helpful, feel free to draw me a map or picture about this. ● Who are the key players? ● What steps are involved? 3. Which part of the discharge planning process if any that you think could be improved? ● What are your thoughts about how that could happen? 4. What are your thoughts about transferring patients into community care? ● What if any benefits do you see for this? Tell me about that. ● What are your concerns if any? (See probes below) i Could you share your thoughts about the community providing care to this population? ii Could you share with me any concerns you may have about patients’ ability to build trust with new healthcare professionals? 5. Could you share with me any suggestions you may have that could make the transition of care into the community easier? ● For you? For patients? 6. Anything else you would like to add?

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Table 3. Steps of the Discharge Planning Process Steps

HCPs’ Quotes

Description and Important Points - Key players: partnership between the case manager and the patient - Liaison nurse facilitated process: completed referral form, resource, saved time - Important players: community HCPs: RNs, family physicians (GPs), social workers, MH teams, and community psychiatrists.

“...it’s nurse to nurse plus the patient on the sides … like a team all three of us to be able to … transition properly.” (S06)

Making the decision

- Team discussion based on stability criteria, team agreement to be successful - Criteria for stability: no recent medication changes, symptoms under control, no change in social situation or not experiencing major life events

“[stable patient] same medication,… with symptoms but it’s not worse” (S01)

Preparing the patient

- Present the idea to patient/family as a promotion (patient is better, stable). - Preparation essential for a successful transfer: HCPs collaboration with patient, addresses concerns, kept involved and informed as transition progressed

“Supporting [the patient] all the way through the steps…” (S03)

Gathering the information

- Important information to include: psychosocial particulars (family, living arrangement, financial), patient specific triggers, warning signs for relapse, - Determined types of services required - Information often gathered in collaboration with community HCPs - Information presented was patient specific, clear and complete

“… give them as precise information ... about the … diagnoses ... medical issues … to have the best picture possible.” (S01)

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Roles/Key Players

Transferring - By electronic form, fax, phone call, sometimes in the person information - Create a connection with the community HCP: phone call(s), accompany patient to community visit, ensure key players comfortable with transfer - Promoted as good idea, few HCPs had actually accompanied patient to a visit.

“…going to that first meeting, talking about their concerns with the new … [MH] provider. I think that’s really good” (S04)

Following up

“Yeah and follow-up … to make sure it

- Step with most variation and least consistently completed

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- Most commonly a phone call to patient or community HCP post discharge - Remain available: for questions, balance with importance to disengage.

doesn’t fall in the cracks” (S07)

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Table 4. Conditions

Easier

Difficult

Patients

- New patients of P-OPD - Familiar with community HCPs - Organized living arrangements (nursing home, group home) - Good social support network

- Long term patients of P-OPD - Financial issues - Personality disorders - Psychotic disorders - Living in public foster homes - Diagnoses for which community services were not available

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- GPs not accepting MH patients - GPs not comfortable prescribing psychiatric medications - Lack of MH resources (professionals and services) - HCPs lacking interest in MH - Difficulty accessing community HCPs for appointments - Transferring outside hospital’s local health territory

P-OPD

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CE

PT

Community - GP attached to the CLSC - Established services, MH team and community psychiatrists at the CLSC

Not Possible

T

Conditions

- Familiar with community settings & HCPs - Optimistic attitude toward community care

-HCPs disagreement about patient readiness for transfer

- On large doses of medications - On many psychiatric medications - Cognitive disorders - Under curatorship or court order - Community can only follow patients for short time period (ex.6 months) - Lack of MH resources

ACCEPTED MANUSCRIPT TRANSITIONING PATIENTS INTO COMMUNITY CARE

39

Table 5. Implications for Practice

RI P

T

P-OPD HCPs  Using a recovery oriented approach to care by starting the discharge planning process upon patient’s admission to the P-OPD (Maramba et al., 2004).

NU

SC

Administrators P-OPD setting  Establish formal follow-up procedures for all discharged patients to ensure effective transitions.  Involve HCPs in evaluating and improving the process (Clarke et al., 2012).  Perform critical reviews of patients who bounce back to hospital care and ensure HCPs in the P-OPD understand these issues so they can address them if possible.

PT

ED

MA

Educators  Ensuring HCPs’, particularly GPs’, education promotes MH through curricula reform (WHO, 2007).  Create educational opportunities for HCPs to learn from one another, through mentoring, combined setting workshops and continuing education sessions (Kates et al., 2011; McElheran et al., 2004).  Reinforce the professional responsibility of nurses (Desrosiers, 2007) and all HCPs to be competent in MH assessments and care.

AC

CE

Government Policy  Promoting MH specialization and recruit HCPs to work in community MH care.  Ensure sufficient resource allocation.