Transition Care for FEP (TCT FEP)

For individuals experiencing the onset of a psychotic disorder such as schizophrenia, the period of time around their first hospitalization and subsequent stabilization in outpatient care is a critical juncture for establishing the trajectory of their recovery. Engaging early and consistently in care not only yields more rapid stabilization of symptoms, but it is also associated with improved long-term prognosis and better quality of life. In recent years, the field has focused on developing a gold standard outpatient treatment model for individuals experiencing their first episode of psychosis (FEP), called Coordinated Specialty Care (CSC). This model features wraparound services, shared decision making with the young adult experiencing FEP, peer support, and caregiver engagement. It has been consistently shown to improve outcomes for these individuals. Unfortunately, however, many patients who would qualify for enrollment in CSC programs are unable to benefit from this effective treatment. That is, there is a vulnerable period in between the initial diagnosis and stabilization of a psychotic disorder-often occurring on inpatient care units-and successful engagement in the CSC program. In this vulnerable care transition time, many patients are lost to follow-up, thus losing the treatment gains of acute inpatient care and failing to take advantage of progressing further into recovery via CSCs. The barriers to effective transition between these two treatment settings are numerous: poor insight regarding the need for continued care, inadequate caregiver support, insufficient knowledge of the healthcare system, practical/structural constraints such as lack of transportation, long wait times for the initial appointment, and more. In our own preliminary data from one inpatient unit, 76% of qualifying FEP individuals did not successfully attend an outpatient CSC appointment. Accordingly, there is a significant clinical care gap in practice: CSC may be the best outpatient treatment program for individuals with FEP, but many are unable to benefit as a result of being lost to follow-up. In this project, the investigators will pilot an intervention designed to close this gap. The investigators have adapted the concept of transitional care, used in other medical settings, for hospitalized FEP individuals to facilitate engagement in outpatient CSC care. A Transition Care Team (TCT) will engage with FEP patients before and after hospitalization, incorporating CSC elements such as family engagement, peer support, and case management. Importantly, it will also be resourced to provide interim medication management, transportation, etc., which will be offered until the patient engages with CSC for the next stage of their care. This integrates two established care models-transitional care and CSC-for FEP populations. The investigators expect this approach will be successful by addressing targets at the patient, provider, and system levels.

Given the emphasis on transitional care between acute and outpatient settings, this intervention will begin on the inpatient unit itself shortly after the FEP individual begins to stabilize. In preparation for discharge, the TCT will meet individually with the FEP patient and their caregivers to conduct a needs assessment for the transition period. This team will then continue following the patient after discharge, maintaining contact with the individual, their caregivers, and the CSC program they are referred to, for up to 6 weeks or until attendance of the CSC appointment.