Early Intervention in Psychosis Pathways
The interfaces between and within health services are complicated, as are the connections with third sector organisations.
Pathfinder sites worked with service designers and quality improvement advisors to design and develop referral and management pathways, to help plan how service users would access the service, and what they would be offered while within the service.
“It’s a journey of discovery that we go on. We map out potential pitfalls, how we can manage them and keep people safe and how we can start early on to promote the sense of hope and recovery.” Key Worker, Dumfries & Galloway
CONNECT, NHS Tayside developed their referral pathway with Child and Adolescent Mental Health Services to provide joint assessments for young people and pathways to appropriate care, whether accepted onto the Early Intervention in Psychosis service caseload or elsewhere. Other prominent pathways to develop include drug and alcohol and autism assessment services.
Third sector services are also important in supporting the identification of people who are experiencing first episode psychosis. Whilst not all services accept direct referrals from the third sector, they are an important partner in early identification and can help signpost individuals, their families/carers to the appropriate services that can support referral.
Top tip: Revisiting the personas developed in the early stages of establishing the service will aid the development of pathways that meet diverse user needs.
Activity: complete a process mapping excersise to identify areas where things could be improved in your service, for example identifying areas of duplication or bottlenecks.
The TURAS Quality Improvement Zone has resources to support process mapping exercises.
Referral Criteria and Pathway Resources
Data and measurement plan
Gathering data is essential when setting up a new service and to evidence service impact. Data can also be used to pinpoint and assess areas for improvement, review progress of the service over time, and to provide evidence for assurance on the outcomes and performance of the service. Data can also be used to baseline and later evaluate the impact of the new service.
What data should be collected and how this will be done should be considered prior to the launch of the service. Data and measurement plans should contain access, quality and outcomes of the service.
Access measures
Access measures help the services understand how well people with a first episode psychosis can access Early Intervention in Psychosis standard care and treatment. There are three access measures that should be gathered:
- Number of days from referral to Early Intervention in Psychosis treatment for people with first episode psychosis: the measure helps understand whether the service is meeting the Scottish Government target of 14 days from referral to treatment (quality indicator T5)
- Estimated duration of untreated psychosis: this is defined as the time in days or weeks between the first occurrence of psychotic symptoms (based on information provided by the person directly, their family or supporters) and the beginning of systematic treatment with antipsychotic medications or other evidence-based treatment for example, cognitive behavioural therapy, behavioural family therapy
- Engagement of people who have first episode psychosis within Early Intervention in Psychosis service following initial contact: this measure will help establish if people are supported to engage with the Early Intervention in Psychosis services, either directly or indirectly (through family and carer contact if appropriate)
Quality measures
Quality measures help the service understand how well the service is delivering the key components of an Early Intervention in Psychosis service for bespoke and hub and spoke service design.
- Fidelity tool - this is a 17-point measure that covers various operational, process and structural aspects of an Early Intervention in Psychosis service
Outcome measures
Outcome measures help understand the impact of Early Intervention in Psychosis services.
Clinical outcomes
- Brief Psychiatric Rating Scale – data will be collected at key times
Patient reported outcomes
- Questionnaire about the Process of Recovery – data will be collected at a year of being with the service
- EQ-5D – data will be collected at key times
Quality of life measures
- Employment, education, and training – data will be collected at baseline and monthly
Mental Health Inpatient bed days – data can be collected as needed, to determine whether there is a decrease in inpatient bed days. Baseline data will be needed for comparison.
Equality access data – data will be collected once, at admission to services
Similar measures are currently collected within the standalone specialist Early Intervention in Psychosis service in NHS Greater Glasgow and Clyde (ESTEEM) and Early Intervention in Psychosis services in other countries.
Activity: consult the Early Intervention in Psychosis measurement plan and consider how you will gather data in your service
You can also download and become familiar with the Early Intervention in Psychosis Measurement Toolkit from the resources.
Top tip: At this point, the team will need to identify someone within the team with the additional role of ‘data manager’ to coordinate and oversee the collection of data. Within the pathfinder sites this was an assistant psychologist or the team lead, supported by the administrator.
Learning shared from the pathfinders has highlighted that it is useful to have more than one person involved in data collection. This could be facilitated with an additional team member supporting the ‘data manager’, ensuring that knowledge of collection, interpretation and use of data is shared within the team.
The measurement tools provided within the resources section were tested and developed throughout phase 2.
Prompt questions
- What measures are already gathered within the Health and Social Care Partnership that might be relevant for the Early Intervention in Psychosis?
- Is there someone in the team who would be interested in the role of ‘data manager’?
Data and Measurement Resources
Data collection system
Data collection in an Early Intervention in Psychosis service is critical, as the Early Intervention in Psychosis model requires the use of real-time clinical and patient reported outcome measures as part of clinical interaction and supervision. Therefore, it is important to consider a data collection system that ensures the data collected is robust.
Ready-made data management systems are available, such as CORE Net. Pathfinder sites explored this but did not use it due to the time limited nature of the programme. Each pathfinder site developed their own system to gather data and linked this to a bespoke Early Intervention in Psychosis data toolkit created to track programme outcomes.
NHS Dumfries & Galloway designed a clinical outcomes tracker to identify when a measure was due for each person on the caseload. NHS Tayside designed a caseload tracker which identified the source and destination of each referral. This information was helpful when developing pathways into and out of the service. These trackers are contained in the resources.
Early Intervention in Psychosis toolkit
The Early Intervention in Psychosis toolkit and access data spreadsheet support the gathering of data for quality improvement and assurance purposes. These were developed to meet the data requirements for Early Intervention in Psychosis and support the capture of all required outcome measures at agreed time points. Definitions provided within the toolkit ensure comparable collection of data.
The access spreadsheet will assist in capturing all the relevant data concerning the people referred to your Early Intervention in Psychosis service, such as:
- age at time of referral,
- date of referral,
- location of referral,
- prescribed medication,
- date of first contact with Early Intervention in Psychosis service, and
- duration of untreated psychosis.
The information captured in the access spreadsheet will then facilitate completion of the Early Intervention in Psychosis toolkit. The Early Intervention in Psychosis toolkit has been designed to facilitate calculating referral to treatment times, duration of untreated psychosis, engagement as well as quality of life outcomes. This will enable capture of continuous data about the impact that your service is having on people experiencing psychosis.
Prompt questions
- What measures and systems are currently in use in your organisation?
- How might the measures above be gathered alongside other data you might gather for clinical management?
- Who might take on the role of ‘data lead’ within the Early Intervention in Psychosis team?
Top tip: Pathfinders have found that displaying feedback on their website, alongside what has been done because of the feedback, can be an effective way of providing assurance to service users and families that the service has been helpful to others, and that their experiences matter to the service. As well as a great motivator for the team!
Prompt questions
- What feedback mechanisms or groups are there within your organisation for service users and families?
- What would be the most appropriate and inclusive method(s) of gathering feedback for people using your service?
- How effectively is feedback shared and used to inform developments of services within your organisation?
- How would a service user and their family hear about direct efforts to improve their experience and know that their experience matters?
Data, Measurement and Fidelity to the Early Intervention in Psychosis Model Resources
Service launch
At the point of service launch, the primary activity for the team is to visit services identified within the stakeholder mapping activity, both within and beyond the NHS. The purpose of this is to both raise awareness of the new service and to strengthen working relationships that have been established through stakeholder engagement.
This was considered a helpful two-way process by pathfinders as it also identified what other services could offer someone with psychosis and how they might work with the Early Intervention in Psychosis. Engagement with third sector organisations often led to further connections with other existing services and resources, increasing awareness of available support and helping to promote Early Intervention in Psychosis across the wider third sector.
Top tip: Time invested in connecting with stakeholders helps to facilitate the delivery of timely, person-centred care.
Pathfinder sites initially only accepted referrals from services within secondary mental health services, In one pathfinder, referrals were accepted from Community Mental Health Teams, whilst in another, they were accepted from Community Mental Health Teams, crisis teams and inpatient wards. Information on how to refer was selectively given to these services in the first few months of the service opening.
The development of a communications plan identified what materials were needed to advertise the service, and when to make these available.
Activity: consider how you would promote your service, using your communications plan
You can also seek advice and support from your local communications department for promoting your service.
Prompt questions
- Which stakeholders have the most interest in the new service?
- Which stakeholders have the most influence in the success of the service?
- What role might stakeholders have in the future service?
Establishing baseline data on fidelity to the model is valuable to track progress over time.
Early Intervention in Psychosis Service Launch Resources
Timely access to Early Intervention in Psychosis
The length of time someone has experienced psychosis has been shown to be a key factor in the recovery of an individual. Timely referral and access to treatment are therefore crucial in facilitating the best possible outcomes for a service user, and a key feature of an Early Intervention in Psychosis service.
Referral pathways into the pathfinders was different for each site. The resources contain a case study on Early Intervention in Psychosis assessments and gives further detail of how these were operationalised within the pathfinder sites.
The duration of untreated psychosis and referral to treatment time were gathered as primary outcome measures for the Early Intervention in Psychosis pathfinders. Further detail on outcome data is available in the phase 2 report.
The referral criteria and assessment proformas used by the pathfinder sites are available in the resources section.
Early Intervention in Psychosis Referral and Assessment Resources
Integrated care pathways
An integrated care pathway is a care model that defines what treatment a person should be offered, within a set timescale. The pathfinder sites structured the delivery of care around the integrated care pathway created by ESTEEM. This was based on those within England and underpinned by existing evidence-based guidelines for psychosis. Within the integrated care pathway, interventions are mapped out across the 2 years a person may be expected to be seen within an Early Intervention in Psychosis service.
Early Intervention in Psychosis Integrated Care Pathway Resources
- Read more about the ESTEEM Integrated Care Pathway
- Read more about NHS Tayside CONNECT Early Intervention in Psychosis Integrated Care Pathway
Fidelity to the Early Intervention in Psychosis model
Assessing the team’s fidelity to the Early Intervention in Psychosis model is an effective, systematic way of assessing the quality of Early Intervention in Psychosis services being delivered. A fidelity tool can support the gathering of information on the operational and point of care aspects of Early Intervention in Psychosis and can include both audit data and qualitative data.
Scottish Fidelity Tool
The Early Intervention in Psychosis programme team, together with ESTEEM, created and tested an Early Intervention in Psychosis Fidelity Tool created specifically for a Scottish context. This was done in light of other fidelity tools created both within and outside of the UK. The tool assesses which components of the Early Intervention in Psychosis model are available within an Early Intervention in Psychosis team and allows teams to identify areas to develop, for example the input of psychiatry and physical health.
Pathfinder sites participating in the Early Intervention in Psychosis programme used the fidelity tool on a quarterly basis to self-assess implementation of the model. This supported ongoing monitoring of progress and service development. By the conclusion of Phase 2, sites had achieved a high level of fidelity to the Scottish Early Intervention in Psychosis model.
Activity: Establish baseline data for your service
Establish baseline data on fidelity to the model so that you can track progress over time. We recommend you reassess fidelity at quarterly intervals.
Scottish Fidelity Tool Resources
Read more about the Scottish Fidelity Tool and the components used to assess fidelity to the Early Intervention in Psychosis model.
Discharge planning
Whilst Early Intervention in Psychosis services offer support for two years, discharge planning is not something that should be considered near the end of a person’s time with the service, Instead this should be an ongoing conversation, to ensure that there are clear expectations of the service and what will happen when it is time for the person to move on in their journey.
It is expected that services will design and implement their own discharge transition plans based on the needs of their service users, and the local support available. Other services that can offer support after Early Intervention in Psychosis include primary and secondary care mental health services, as well as support available in the community and third sector.
Discharge plans should be person centred and tailored to fit individual circumstances. By the time someone has reached two years with Early Intervention in Psychosis services, there should be a clear discharge plan in place, that details what their ongoing care and support needs are. However, timelines around discharge should not be rigidly applied and should consider what is in the best interest of the person.
Having clear discharge plans in place, as well as understanding what support is available in the wider mental health and community system, can help ensure that people continue with their recovery journey after leaving Early Intervention in Psychosis.
Discharge pathways
How your discharge pathway works in practice will be dependent on the wider mental health system, third sector and community support within your local area.
NHS Tayside and NHS Dumfries & Galloway refined their discharge pathways using the support of a senior service designer. These discharge pathways visualise the discharge processes for services within urban and remote and rural areas. The resources within this section can support your work designing discharge pathways.
Whilst every person’s journey leaving the service will be based on their individual circumstances, there should be a timeline in place to guide this process. To do this, it will be important to understand the landscape of statutory and non-statutory services in your local area. Much of this information may have already been gathered during stakeholder mapping or understanding systems exercises carried out as part of designing an Early Intervention in Psychosis service.
There are two main discharge destinations that people may transition to after leaving Early Intervention in Psychosis.
- Primary care: if the person is doing well in their recovery, they can be discharged to their GP under primary care, who can support them with their physical health needs, provide medication support and monitoring (for some antipsychotics) and can signpost to other support services as and when needed.
- Mental health services: if the person requires further mental health support following discharge from Early Intervention in Psychosis, they will likely be supported by their community mental health team. If the person requires more intensive mental health input following Early Intervention in Psychosis, they may be supported by assertive rehabilitation teams or inpatient mental health services, depending on what is available in their area.
Medications: guidance advises that people should continue taking antipsychotic medication for up to 12 months after their symptoms reduce. If a person is taking oral medication, this could be supported and monitored through their GP. If someone is taking depot injections, this will need to be supported through community mental health team.
What is needed leading up to discharge:
- discharge letters to be produced, directed towards where the person will be discharged to and signed by responsible person
- information supplied to the person and if appropriate their family/carer
- patient referred on to the appropriate service
- involvement of the person throughout in the decisions that impact their care, and
- discharge or service transition letters that highlight the progress that a person has made during their time with Early Intervention in Psychosis, as well as the areas where the person will need further support to continue their recovery journey.
Top tips: When planning your discharge pathways from your Early Intervention in Psychosis service, your team should consider who needs to be involved in the planning process. Early Intervention in Psychosis services take a multidisciplinary team approach to interventions and support; the same approach should be used for discharge planning. It will also be useful to involve people who are external to the service, such as third sector, advocacy groups or people with lived experience of psychosis to sense check the process and ensure that the pathway includes a range of support for the person transitioning from services.
Activity: Discharge planning
Using the pathway visualisations from the resources, consider how discharge would operate within your local area.