Coordinating Mental Health Services for People with Serious Mental Illness: A Scoping Review of Transitions from Psychiatric Hospital to Community

Abstract

Effective coordination as people with serious mental illness (SMI) move between care settings is essential. We aimed to review challenges to care coordination for people with SMI and identify approaches for improving it. Sixteen articles were identified. Two main challenges emerged: people with SMI facing adjustment challenges during transitions and services struggling to provide continuity of care. Effective approaches addressed coordination challenges and resulted in better improvements in service utilization, social functioning and quality of life. Future interventions may benefit from shared decision-making, support for caregivers, and addressing the challenges associated with complicated medication regimes and accessing medications.

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Administration and Policy in Mental Health and Mental Health Services Research
https://doi.org/10.1007/s10488-018-00918-7
ORIGINAL ARTICLE
Coordinating Mental Health Services forPeople withSerious Mental
Illness: AScoping Review ofTransitions fromPsychiatric Hospital
toCommunity
MarianneStorm1,2· AnneMarieLundeHusebø1,5· ElizabethC.Thomas3· GlynElwyn4· YaaraZisman‑Ilani3
© Springer Science+Business Media, LLC, part of Springer Nature 2019
Abstract
Effective coordination as people with serious mental illness (SMI) move between care settings is essential. We aimed to
review challenges to care coordination for people with SMI and identify approaches for improving it. Sixteen articles were
identified. Two main challenges emerged: people with SMI facing adjustment challenges during transitions and services
struggling to provide continuity of care. Effective approaches addressed coordination challenges and resulted in better
improvements in service utilization, social functioning and quality of life. Future interventions may benefit from shared
decision-making, support for caregivers, and addressing the challenges associated with complicated medication regimes
and accessing medications.
Keywords Care coordination· Continuity of care· Care transitions· Serious mental illness· Scoping review
Introduction
The coordination of mental health services to meet a per-
son’s needs across service providers and sites of care is an
essential feature of quality of care for people with serious
mental illness (SMI) (Burns etal. 2009; Fontanella etal.
2014; Jones etal. 2009). Coordination includes the organ-
izing processes, measures and networks at the interfaces of
the mental health hospital, primary care delivery and com-
munity health systems (Banfield etal. 2012). Coordination
commonly occurs during and in response to care transitions
as an individual’s care needs change (e.g., across settings,
within care teams, among care participants, between encoun-
ters or care episodes) (McDonald etal. 2014; Viggiano etal.
2012). It involves bridging activities among health profes-
sionals; establishing shared accountability for patient care;
communicating with stakeholders; exchanging information
and transferring care responsibility; facilitating care tran-
sitions; performing clinical assessments of care needs and
goals; monitoring care and responding to change; and sup-
porting self-management and providing links to community
resources (McDonald etal. 2014).
Coordination can be hampered by mental health systems
that are fragmented and not integrated and/or difficulties that
people with SMI have in obtaining mental health services.
Either factor can lead to treatment nonadherence or service
disengagement (Bao etal. 2013; Bartels 2003; Horvitz-Len-
non etal. 2006). People with SMI can be challenged by poor
interpersonal communication skills, inadequate access to
information about available mental and health care services,
difficulties navigating the mental health care system, and a
lack of opportunities to engage in shared decision-making
(Morden etal. 2009). Organizational and structural barriers
also exist, such as a lack of resources, limited availability of
inpatient beds, and a lack of continuity and community care
follow-up services (Wright etal. 2016).
Two reviews on care transition models and interventions
involving the transition from inpatient to outpatient care
* Marianne Storm
Marianne.storm@uis.no
1 Department ofPublic Health, Faculty ofHealth Sciences,
University ofStavanger, Stavanger, Norway
2 Faculty ofHealth Sciences, Center forResilience
inHealthcare, University ofStavanger, Stavanger, Norway
3 Department ofRehabilitation Sciences, College ofPublic
Health, Temple University, Philadelphia, PA19122, USA
4 Dartmouth College, Institute ofHealth Policy andClinical
Practice, Lebanon, NH03766, USA
5 Department ofGastroenterological Surgery, Stavanger
University Hospital, Stavanger, Norway

Administration and Policy in Mental Health and Mental Health Services Research
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(Viggiano etal. 2012; Vigod etal. 2013) identified compo-
nents that are relevant to the mental health setting and peo-
ple with SMI. The components identified by Viggiano etal.
(2012) can be divided into patient, provider, and system
levels. Patient-level components include prospective mod-
eling to identify individuals at risk of deteriorating health
and patient and family engagement in treatment and transi-
tion planning. Provider-level components include guidelines
and instructions for what to do and when and the provision
of properly tailored information. Systems-level compo-
nents include the use of quality metrics and feedback and
the establishment of accountability mechanisms between
providers to ensure shared responsibility for patient care.
However, the ways in which these components are operation-
alized in the coordination of services in psychiatric hospital
and community settings for people with SMI have not been
extensively explored. Vigod etal. (2013) identified seven
successful interventions that reduced hospital readmissions.
Elements that contributed to the success of interventions
included predischarge components (i.e., psychoeducation,
structured needs assessments, medication reconciliation),
post discharge components (i.e., telephone follow-ups, nurse
home visits, timely follow-up with outpatient care provid-
ers, family education and communication, peer support),
and bridging components (i.e., transition managers, timely
inpatient-outpatient provider communication, and patient
meetings with outpatient staff before discharge). However,
the systematic review emphasized only the evaluation of the
effectiveness of interventions and did not include descriptive
studies that reported the experiences that people with SMI
had with care transitions.
However, there is a need to investigate the perspectives
of people with SMI toward the coordination of services.
Because those with SMI, their families and caregivers are
involved in care transitions, they may be highly relevant to
the success or failure of coordination. The purposes of the
present study are to map the research literature and provide
an overview of the key challenges in coordinating services
for people with SMI, their family members and caregivers
and to identify approaches that can improve coordination
and the ability of people with SMI to manage their lives in
the community.
Methods
Scoping Review Design
A scoping review is an approach to gaining a comprehen-
sive overview of the literature to map key concepts, iden-
tify knowledge gaps and convey the breadth and depth of
the field (Arksey and O’Malley 2005; Tricco etal. 2016).
Our scoping review design followed Arksey and O’Malley’s
(2005) five-stage framework, as follows: stage (1) identify
the research question; stage (2) identify relevant studies in
a literature search; stage (3) select relevant studies; stage
(4) chart the data; and finally, stage (5) collate and summa-
rize the results, including the assessment of methodological
quality.
Stage 1: Research Questions
This scoping review sought to answer two research
questions:
1. What are the perceived challenges influencing coordina-
tion in care transitions from hospital to the community
for people with SMI, including the challenges identified
by people with SMI, their family members and caregiv-
ers?
2. What types of approaches can be identified in the
research literature to improve the coordination of hos-
pital-to-community transitions for people with SMI?
Step 2: Search Strategy andIdentification ofStudies
To ensure that the literature and research questions were
adequately illuminated, the authors (MS and YZI) collabo-
rated with an experienced biomedical librarian to define and
refine the search strategies, search terms and inclusion and
exclusion criteria. The search was conducted by the librar-
ian on May 30, 2017, and included studies published in
English between 1990 and May 30, 2017. The following
scientific electronic databases were systematically searched:
CINAHL, Cochrane trials and Cochrane reviews, Medline,
PsycInfo, Web of Science (WOS), and Google Scholar.
The following search terms were included to represent care
coordination in mental health (Medical Subject Headings
(MeSH) terms used for searches in Medline are marked with
an *): ‘continuity of patient care*’, ‘patient transfer*’, ‘care
plan’, ‘patient discharge*’, ‘patient readmission*’, ‘care tran-
sition’, ‘continuity of care’, ‘care coordination’, ‘discharge
planning’. The search terms were combined with ‘severe
mental illness’ ‘severe mental disorder’, ‘depressive disor-
der*’, ‘major depression’, ‘schizophrenia*’, ‘schizophrenic
psychology*’, ‘schizoaffective disorder’, ‘bipolar disorder*’,
‘stress disorder*’, ‘posttraumatic*’, ‘mental health services’.
Stage 3 Study Selection andEligibility Criteria/
Exclusion Criteria
Stage 3 entails the study selection process and is illustrated
in Fig.1—the Prisma flow diagram (Moher etal. 2009). A
total of 2479 records were identified by the librarian con-
ducting the systematic literature search and were imported
into reference management software. After the removal of

Administration and Policy in Mental Health and Mental Health Services Research
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66 duplicate records, 2413 remaining titles were screened
in three steps: (1) the titles were divided alphabetically
into groups of 100 titles. Two authors (MS and YZI)
reviewed the same first (in alphabetic order) ten titles and
ten abstracts from each group. Disagreements regarding
inclusion or exclusion were resolved through discussion. A
total of 2205 records were excluded in this phase. (2) The
two authors reviewed the abstracts of the remaining 208
records independently and assessed eligibility, and 155
records were excluded based on their abstracts. (3) Four
authors (MS, ECT, AMLH, and YZI) read the full text of
the remaining 53 records and assessed their eligibility. The
reference lists of the selected full-text articles were also
screened. This phase led to the exclusion of 37 records
and yielded the final sample of 16 articles to be included
and analyzed in this review. The four authors conducted
meetings to discuss their assessments of the abstracts and
full-text articles and the inclusion and exclusion criteria to
reach agreement on the studies to be included.
Inclusion andExclusion Criteria
To be eligible for inclusion, the study population needed
to include individuals with SMI over age 18years. Our
definition of SMI corresponds to criteria identified by
The Substance Abuse and Mental Health Administra-
tion (SAMHSA) (2016) and included mental disorders
such as schizophrenia, schizoaffective disorder, psychotic
disorders, major depressive disorders, bipolar disorders,
and borderline personality disorder, along with persistent
functional impairment. To meet the overall purpose of the
scoping review, the included studies focused on transi-
tions from psychiatric hospitals to the community. Eligible
studies reporting on approaches to improve care coordi-
nation needed to include a description of a program or
intervention that aimed to improve hospital-to-community
transitions for people with SMI. We limited the search to
1990–2017 to allow a broad scoping search of the pub-
lished research.
Fig. 1 The Prisma flow diagram

Administration and Policy in Mental Health and Mental Health Services Research
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Titles, abstracts and full-text articles were excluded
when there was no author and when the abstract could not
be accessed. Additionally, we excluded editorials and dis-
cussion papers, research protocols, scale development and
validation papers, systematic reviews/reviews/overviews,
and articles that could not be accessed in full text in English.
The exclusion criteria were tied to the study population (e.g.,
children, adolescents and youth under age 18years, older
adults, immigrants, the homeless), patient diagnostic groups
that were not in accordance with the SAMHSA (2016) SMI
criteria (e.g., dementia, intellectual disability, eating disor-
ders, posttraumatic stress disorder), comorbid mental and
medical health condition, and study setting (e.g., prison and
forensic settings, behavioral and primary care). Studies that
focused on medication adherence and post discharge follow-
up only (i.e., they included no intervention or program) and
studies that did not evaluate hospital-to-community transi-
tions were excluded. A complete overview of the inclusion
and exclusion criteria is presented in Table1.
Stage 4 Charting theData
We extracted and coded each included article according to
the following descriptive data: authors, country of origin,
aims, data collection and measurements, study sample and
results. For the articles that presented approaches in terms
of interventions or improvement programs, we extracted the
intervention and program description. The extraction and
charting of the data were conducted by MS with input from
the coauthors (ECT, AMLH and YZI) (Table2).
Stage 5 Collating andSummarizing theResults
(Including Quality Assessment)
To achieve a thematic presentation of the results and avoid
bias, all the authors read and reviewed the included full-text
articles. The results of each of the included articles were
summarized in separate text description paragraphs by the
lead author (MS). Four of the authors (MS, ECT, AMLH
and YZI) read the text descriptions and suggested edits when
necessary. These summaries were used to identify challenges
and themes related to the coordination of transitions from
psychiatric hospital settings to the community across the
studies. For the intervention or program studies, the authors
read the text summaries to identify how the challenges of
coordination were addressed and the outcomes of the inter-
ventions or programs. The authors then discussed the inter-
pretations of the study results and the challenges, themes and
approaches identified.
We used the Critical Appraisal Skills Program (CASP)
(2018) to assess the methodological quality of the qualita-
tive studies. The tool contains ten questions and assesses
quality in three domains: validity, presentation and impact
of study results. We used the Cochrane Collaboration Risk
of Bias Tool (CCRBT) (Higgins etal. 2011) to evaluate the
methodological quality of the studies that included quantita-
tive results. The CCRBT is a six-domain tool with a total of
seven items that assess selection (two items), performance
(one item), detection (one item), attrition (one item), report-
ing (one item), and other sources of bias (one item). The
risk of bias was evaluated independently by all the authors
who extracted the data (MS, ECT, AMLH and YZI); all
discrepancies were resolved by discussions until a consensus
was reached.
Results
Characteristics oftheIncluded Studies
Sixteen articles were included in the review. There were six
descriptive articles and ten articles that presented approaches
for improving care coordination.
Table 1 Inclusion and exclusion criteria
Inclusion criteria Exclusion criteria
Target group: individual with seri-
ous mental illness > 18years old
Children, adolescent, youth under age 18, older adults over 75, prisoning, immigrants, homeless, not hav-
ing SMI
Patients with dementia, intellectual disability, eating disorders, post-traumatic stress syndrome, comorbid
mental and medical condition
Medication/adherence and post-discharge follow-up only, behavioral and primary care, psychiatric hospital
to community transition not evaluated
Study design: all designs Editorials/comments, systematic reviews/reviews/overviews, research protocols, scale development/valida-
tion papers
Published in peer-reviewed journals Gray literature, no abstract, no author
Language: English Non-English
Dissertations
Published before 1990

Administration and Policy in Mental Health and Mental Health Services Research
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Table 2 Characteristics of descriptive studies
Authors and country of origin Aims Study design Data collection and measure-
ments
Study sample Results
Gerson and Rose (2012) USA To explore individual’s and
family members’ percep-
tions of illness-related
needs, functioning, coping
and social support follow-
ing transitioning to the
community after in- hospital
treatment
Descriptive interview study to
follow up newly discharge
patients with SMI
Exploratory interviews with
individuals and family
members 48h after hospital
discharge and after four
weeks. The interviews
covered the mental illness,
health concerns, and contact
with providers and percep-
tions of functioning, support
and coping
Ten individuals with SMI
were enrolled
Five had a psychotic disorder
three bi-polar disorder
and two major depressive
disorder. Six men and four
women
Age range 23–81. All were
African American
Number of times Hospitalized
between 1 and 17
Family members included
six parents, one fried, three
adult children
Study participants had residual
symptoms and unmet care
needs after hospital discharge
interfering with functioning
despite availability of follow-
up services. Individuals were
satisfied with care and the
support they received from
their families
Family members were con-
cerned about the perceived
lack of improvement in men-
tal health. Both individuals
and family members lacked
a clear understanding of the
goals for follow-up care
Jones etal. (2009) UK To capture the experiences
and views of individuals
and caregivers focusing on
the meaning associated with
dis-continuities and transi-
tional episodes
Descriptive study conducted
as part of a large longitudi-
nal study of continuity of
care in mental health
Qualitative interviews to
explore experiences of rela-
tionships with services, care
continuity and transitions
from the individuals’ and
caregivers’ perspectives
A sample of 20 individuals
with psychotic disorder and
10 of their family members
and caregivers
11 males, mean age 42 (range
27–72). Carers were six
mothers, three wives and
one community psychiatric
nurse
11 user with a non-psychotic
disorder, mean age 49
(range 29–59) and four of
their carers (one mother,
husband, partner and friend)
Five key themes emerged from
the data analysis: discontinui-
ties in relationships, deperson-
alized transitions, invisibility
and crisis, communicative
gaps and social vulnerability
Niimura etal. (2016) Japan To elucidate the challenges
faced by individuals after
discharge from acute psychi-
atric inpatient treatment
Qualitative descriptive design Qualitative interviews with
individuals who had experi-
enced involuntary admis-
sions
Eighteen individuals with
a schizophrenia spectrum
disorder eight male and ten
female, median age 45.5
years, eight were married,
17 were living with family
members
Participants faces post hospital
challenges related to problems
with seeking outpatient care,
lack of knowledge of their
long waiting times, trouble to
contact nurses in outpatient
care, inability to coordinate
matters required for their
post-discharge life

Administration and Policy in Mental Health and Mental Health Services Research
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Table 2 (continued)
Authors and country of origin Aims Study design Data collection and measure-
ments
Study sample Results
Rose etal. (2007) USA To assess the applicability and
acceptability of a nurse-
based in home transitional
care intervention for people
with serious mental illness
Qualitative study presenting
nurses’ experiences with
delivering the in-home
transitional care intervention
The intervention included;
comprehensive discharge
planning, home visits 48h
after hospital discharge,
six additional home visits
over a six week period and
telephone contact
Narrative logs by nurses’
during home visits docu-
menting the person’s home
environment, functioning,
family interaction, and the
nurses’ experiences with
delivering the intervention
and challenges encountered
Ten persons with serious
mental illness (schizophre-
nia, bipolar disorder, major
depression)
All were African American,
five male and five female,
age range 30–62. None were
employed, two had more
than 12th grade education
All received supplemental
security income or disability
insurance
Factors identified as important
to community adjustment
were; caregiver concerns
and physical health status,
structure
/involvement of the individual’s
daily activities, structural and
functional factors affecting
adherence to medications
and symptom presence at
discharge
Perreault etal. (2005) Canada To assess the preferences and
satisfaction of psychiatric
inpatients and their relatives
with family involvement in
discharge planning
Prospective study quantitative
study
Two interviews incl. a ques-
tionnaire with individuals
and relatives during hospi-
talization and 3months after
Ninety-eight individuals
and forty of their relatives
participated in the first
interviews and completed a
preference questionnaire
At the second interview, there
were sixty-five individuals
and thirty-seven relatives
Mean age 45
52% women (n = 51), 50%
diagnosed with schizoaffec-
tive, 24.4% schizophrenia
Preferences incl. information
about health status, preventing
hospitalization, services for
relatives. More relatives that
individuals with SMI reported
that post discharge residence
and activities were important
areas to be involved. Most
individuals were satisfied that
their relatives were involved.
89% of individuals and 84%
of relatives reported no com-
munication between clinical
staff and relatives regarding
discharge, also reducing
satisfaction
Velligan etal. (2016) USA To investigate views of
individuals in transition
from hospital to commu-
nity service on their role in
treatment decisions and the
match with their desired role
Qualitative study Focus group interviews with
individuals with severe
mental illness and family
caregivers
Ten individuals with severe
mental illness, five male,
five Hispanic, three non-
Hispanic and two Afri-
can—American, five had
schizophrenia, five affective
disorder
Eight caregivers participated
in two separate focus group
interviews (three mother,
two siblings and three
spouses)
Individuals with SMI wanted
longer visits and easier access
to services and providers,
to receive more and simple
information about options,
to hear from peers and their
experience and a bigger say in
treatment decisions in transi-
tional care
Family members desired more
involvement. Both individu-
als and family members were
positive about available
programs

Administration and Policy in Mental Health and Mental Health Services Research
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Six articles reported experiences with and perspectives
on the coordination of services in care transitions. These
articles were published in the period 2006–2016 and car-
ried out in four countries: the USA (Gerson and Rose 2012;
Rose etal. 2007; Velligan etal. 2016), the UK (Jones etal.
2009), Japan (Niimura etal. 2016), and Canada (Perreault
etal. 2005). Individuals with SMI and their family members
or caregivers were the study participants in four articles,
including two interview studies (Gerson and Rose 2012;
Jones etal. 2009), one focus group study (Velligan etal.
2016), and a cross-sectional survey study (Perreault etal.
2005). A study by Nimura etal. (2016) included interviews
with individuals with SMI only. One study (Rose etal. 2007)
used narrative logs written by nurses during home visits to
document the home environment, functioning, and family
situation. The studies are presented in Table2.
There were ten articles presenting interventions or pro-
grams that focused on improving care coordination and the
care transition from the psychiatric hospital to community
settings. The articles were published from 2000 to 2013.
Half of the studies (n = 5) took place in the USA (Batscha
etal. 2011; Bauer etal. 2006; Dixon etal. 2009; Price 2007;
Sledge etal. 2011). The rest of the studies took place in
Belgium (Desplenter etal. 2010), Canada (Forchuck etal.
2005), Finland (Reynolds etal. 2004), Israel (Karniel-Lauer
etal. 2000) and Iran (Khaleghparast etal. 2014).
Five studies employed a randomized control group design
(Bauer etal. 2006; Dixon etal. 2009; Forchuk etal. 2005;
Reynolds etal. 2004; Sledge etal. 2011). The remaining five
studies employed a variety of designs, including a one-group
prospective interview study (Batscha etal. 2011), a descrip-
tive analysis of the profiles of patients receiving discharge
management (Desplenter etal. 2010), a longitudinal clinical
trial (Khaleghparast etal. 2014), an intervention and control
group design (Karniel-Lauer etal. 2000), and a posttest-only
experimental design (Price 2007). The measures included
were attendance of the first outpatient visit (Batscha etal.
2011; Dixon etal. 2009; Price 2007), rehospitalization and
emergency room use (Dixon etal. 2009; Karniel-Lauer
etal. 2000; Price 2007; Reynolds etal. 2004; Sledge etal.
2011) and the utilization of health and social services (Dixon
etal. 2009; Forchuk etal. 2005; Karniel-Lauer etal. 2000).
Symptom ratings and social functioning (Bauer etal. 2006;
Desplenter etal. 2010; Reynolds etal. 2004), quality of life
(Bauer etal. 2006; Forchuk etal. 2005; Reynolds etal. 2004)
and medication adherence (Bauer etal. 2006; Price 2007)
were also measured. Two studies included self-reports of
knowledge of illness and social resources (Karniel-Lauer
etal. 2000; Khaleghparast etal. 2014).
An overview of the characteristics of the programs and
intervention studies, including the study aims, descriptions
of the programs/interventions, methods for data collection
and measurements and study results, is presented in Table3.
Methodological Quality oftheIncluded Articles
The quality appraisal of the articles that employed qualita-
tive methods indicated that three articles met nine out of the
ten criteria suggested by the CASP (Gerson and Rose 2012;
Jones etal. 2009; Niimura etal. 2016), and two articles met
eight of the criteria (Rose etal. 2007; Velligan etal. 2016).
The quality appraisal of the articles that included quanti-
tative research methods indicated that all the studies had
a high risk of bias in at least one measured domain. The
“blinding of participants and personnel” item received the
highest percentage of high-risk ratings, and the “incomplete
outcome data” and “selective reporting” items received the
lowest percentage of high-risk ratings. “Other bias” was
noted in 25% of the articles for reasons that included imple-
mentation problems, contamination between conditions,
and small sample size. The quality appraisal is presented as
Tables4 and 5 in the Appendix.
Coordination Challenges inHospital‑to‑Community
Transitions forPeople withSMI
There were two major themes in the descriptive articles
related to the challenges of coordinating the transition from
hospital to community: (1) challenges influencing commu-
nity adjustment and (2) challenges influencing continuity of
care. Community adjustment challenges pertained to indi-
viduals’ reported difficulties with managing community life
after hospital discharge, while continuity of care challenges
referred specifically to difficulties with accessing and receiv-
ing consistent mental health treatment post discharge.
Coordination Challenges Influencing Community
Adjustment
Symptoms andWorries
The transition from an inpatient psychiatric setting to the
community is a vulnerable phase for people with SMI (Ger-
son and Rose 2012; Jones etal. 2009). Many of the study
participants reported ongoing psychotic symptoms at the
time of hospital discharge (e.g., hallucinations, paranoia,
agitation and hearing voices); some had suicidal thoughts,
and many experienced side effects of medications [fatigue,
insomnia, weight gain, and akathisia (Gerson and Rose
2012; Jones etal. 2009; Rose etal. 2007)]. These symp-
toms and issues may lead to hospital readmissions. People
with SMI have reported that they were nervous about going
home, concerned about not being able to manage their symp-
toms and family roles, felt helpless and isolated and feared
not being able to integrate into the community (Gerson and
Rose 2012; Jones etal. 2009; Niimura etal. 2016; Rose
etal. 2007).

Administration and Policy in Mental Health and Mental Health Services Research
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Table 3 Characteristics of the programs and intervention studies
Authors and country of
origin
Aims Study design Program/intervention
description
Data collection and
measurements
Study sample Results
Batscha etal. (2011)
USA
To explore feasibility of
a transition intervention
on first post-discharge
appointment attendance
One-group prospective
interview study
Inpatient transition inter-
vention
Interview study
Attendance first out-
patient visit
Fifteen individuals hospi-
talized with psychosis
Twelve participants
attended the post-dis-
charge appointment. Two
were unable to attend
because of readmission
Bauer etal. (2006) USA To examine improve-
ment in outcomes for
bipolar disorder from
a collaborative chronic
care model
RCT Group psycho-education,
medication-therapy and
nurse care coordinator
Clinical variables Semi-
structured interviews
Weekly symptom rating
for mania and depres-
sion
Social functioning/
adjustment scale, Qual-
ity of life, Treatment
satisfaction
Intensity of bi-polar
pharmacotherapy
Individuals with sus-
pected bipolar disorder
admitted to acute psy-
chiatric wards
Significant reduction by
14% in weeks of affective
episode, increased social
functioning, mental qual-
ity of life and treatment
satisfaction from receiv-
ing the intervention. No
significant reduction in
mental health symptoms
Desplenter etal. (2010)
Belgium
To present profiles of
individuals receiving
discharge management
in ten Belgian psychiat-
ric hospitals
Descriptive analysis Governmental discharge
program implemented
in hospitals incl. sys-
tematic screening and
discharge management
for high-risk individu-
als
Family-, and living situ-
ation before and after
hospitalization
GAF-scores
Three-hundred and fifty-
one hospitalized indi-
viduals in ten hospitals
received discharge
management
In general, individuals
(54% were male), were
about 45years old,
had 55days of length
of hospital stay. 173
individuals (49.6%) were
single, 62 (17.8%) had a
primary care giver, and
69 (19.8%) had a profes-
sional aid. 131 (37.5%)
lived in own home after
discharge
92% of inpatients were
screened, 50.8% had
positive screening and
discharge management
were started for 57%.
20% of these individuals
had a GAF score rang-
ing 41–60, and 10.9%
ranging 61–80. 13.5%
of those that received
discharge management
were institutionalized

Administration and Policy in Mental Health and Mental Health Services Research
1 3
Table 3 (continued)
Authors and country of
origin
Aims Study design Program/intervention
description
Data collection and
measurements
Study sample Results
Dixon etal. (2009) USA To test the effectiveness
of a brief critical time
intervention (B-CTI)
for veterans with seri-
ous illness in outpatient
care
RCT Pre-discharge transition
program rooted within
community-based ser-
vices and social support
Out-patient visits
Hospitalizations
Emergency room use
Nature of help received
135 veterans diagnosed
with a psychiatric
disorder (N = 64 inter-
vention) and (N = 71
control group), living
within 50 miles of an
inpatient facility
B-CTI participants had
shorter time between
discharge and first out-
patient visit, more total
visits within 30–180days
post-discharge and
greater continuity of care.
No significant differences
between groups in hospi-
talization and emergency
room visits, and overall
treatment satisfaction.
Of quality of life factors,
satisfaction with legal
and safety issues and
social contact frequency
showed a significant dif-
ference
Forchuk, etal. (2005)
Canada
To assist hospitalized
individuals with a
severe mental illness in
successful community
living, and to determine
the cost and effective-
ness of a transitional
care discharge model
RCT clustered-rand-
omized design
Transitional discharge
model including
overlap of in-patient
and community staff
and peer support for a
minimum of 1year
Quality of life
Utilization of Health and
Social Services
Six open ended questions
about discharge and
issues that hindered or
facilitated the process
390 clients were enrolled
Intervention (n = 201)
Control (n = 189)
Female 87
Male 102
Mean age 39.5
Mean Age onset of ill-
ness 20.8
Length of admission
(days) 333.5
Schizophrenia (n = 98)
Mood disorder (n = 64)
The intervention group
did not have a significant
improvement in quality
of life compared to the
controls
The intervention group
consumed less hospital
and emergency room
visits than controls, but
this was not significant
(p = 0.0.09)
Peer support was only done
22% of the time on inter-
vention wards compared
to 17% of the time on
control wards
Participants in intervention
ward were discharged
116 days earlier that
controls

Administration and Policy in Mental Health and Mental Health Services Research
1 3
Table 3 (continued)
Authors and country of
origin
Aims Study design Program/intervention
description
Data collection and
measurements
Study sample Results
Karniel-Lauer etal.
(2000) Israel
To report the effective-
ness of a short-term
“re-entry group”
compared to traditional
discharge processes for
individuals with severe
mental illness
Intervention and control
group
The “Re-entry Group”—
a transitional thera-
peutic program carried
out with hospitalized
individuals with mental
illness
Absorption of individu-
als into the clinic
Continued therapy, Com-
pliance with treatment
Re-hospitalization
Knowledge of Illness and
Resources Inventory
Seventy-five individuals
with a severe mental
illness [schizophrenia
divided into an experi-
mental group (n = 42)
and control group
(n = 33)]
Participants who continued
treatment after three
months were higher in
the experimental group
(85.7%) than in the
control (51.5%) and con-
tinued after 1year. There
was a higher percentage
of re-hospitalization in
the control group
A significant interaction
effect was reported for:
motivation for therapy
(p < 0.05), knowledge
of the mental illness
(p < 0.01), knowledge
of medical treatment
(p < 0.05) and knowl-
edge of rehabilitation
(p < 0.05)
Khaleghparast etal.
(2014) Iran
To investigate the effec-
tiveness of discharge
planning on the knowl-
edge, clinical symptoms
and frequency of hos-
pitalization of persons
with schizophrenia
Longitudinal clinical trial Program included an
intervention during
hospitalization and after
discharge
Discharge list including
20 items measuring
positive and negative
symptoms
Knowledge measurement
questionnaire including
19 items
46 hospitalized individu-
als randomized to inter-
vention or control
The intervention group
demonstrated improve-
ment in clinical
symptoms and greater
knowledge at discharge
and three months after
discharge
Re-hospitalization were
significantly lower in
intervention group
Price (2007) USA To facilitate the transition
of individuals with
schizophrenia from
inpatient to community
care by implementing
an evidence-based com-
munity care interven-
tion
Post-test only experimen-
tal design
An advanced practiced
psychiatric nurse inter-
viewed hospitalized
individuals, contacted
outpatient clinics,
communicated via
phone with clients after
discharge
Attending to outpatient
appointment
Medication adherence
Number of hospital re-
admission days
Thirteen English-speak-
ing individuals with
schizoaffective disor-
der, diagnosed within
the last 60 months,
scheduled for discharge
to community
Seven received the inter-
vention and six were in
the control group
No statistically signifi-
cant results between the
groups

Administration and Policy in Mental Health and Mental Health Services Research
1 3
Lack ofDaily Activities
An absence of meaningful daily activities, a lack of places to
go and unemployment were difficulties reported by people
with SMI in several articles (Gerson and Rose 2012; Jones
etal. 2009; Niimura etal. 2016; Rose etal. 2007). The lack
of social opportunities affected the study participants’ abil-
ity to adhere to treatment and affected their quality of life.
Individuals with SMI often did not leave the house, they
were unable to handle a job, and they had impaired decision-
making capacity and poor judgement. Several had unhealthy
lifestyles (e.g., poor diets, excessive smoking) and disturbed
sleep patterns (Rose etal. 2007), sometimes related to the
side effects of medication (Niimura etal. 2016). Family
members reported behaviors that negatively affected family
relations (Gerson and Rose 2012; Rose etal. 2007). People
with SMI could be threatening, angry and loud toward their
family members and caregivers.
Coordination Challenges Influencing Continuity
ofCare
Difficulties withInformation, Decision‑Making andSupport
Family members wanted more advice and information about
discharge (Gerson and Rose 2012; Perreault etal. 2005;
Velligan etal. 2016). They wanted information about the
development of the person’s health status, warning signs of
deteriorating health, preventing rehospitalization, and the
availability of services. Some individuals with SMI wanted
to hear from peers about their experiences and to have a big-
ger say in treatment decisions during transitional care. Some
were better able to cope, depending on the ability to incor-
porate the transition into their daily life (Jones etal. 2009).
Individuals also talked about not being listened to or being
considered in decision-making and not receiving enough
information to participate in decision-making (Jones etal.
2009; Niimura etal. 2016; Perreault etal. 2005; Velligan
etal. 2016). Although family conflicts were reported in some
studies as negatively affecting the transition, family mem-
bers were mostly a source of emotional support; they visited
during hospitalization and served as someone to whom the
person with SMI could talk about their illness (Gerson and
Rose 2012; Niimura etal. 2016; Rose etal. 2007).
Complicated Medication Regimens
Individuals with SMI and their family members were con-
cerned about communication gaps that commonly occurred
around hospital discharge, most often in relation to medi-
cation regimens (Gerson and Rose 2012; Jones etal. 2009;
Niimura etal. 2016; Perreault etal. 2005; Rose etal. 2007).
They wanted to receive more and simpler information about
Table 3 (continued)
Authors and country of
origin
Aims Study design Program/intervention
description
Data collection and
measurements
Study sample Results
Reynolds etal. (2004)
Finland
To test the discharge
model designed to
assist individuals
discharged from acute
psychiatric to commu-
nity living
Pilot
RCT
Transitional discharge
model including peer
support, and overlap of
inpatient and commu-
nity staff (transitional
nurse)
Quality of life—brief
version to measure the
life experiences of peo-
ple with mental illness
Level of functioning and
severity of illness and
hospital readmissions
Twenty-five individuals
from three admission
wards assigned to
experimental (n = 11)
and treatment as usual
conditions (n = 14)
Participants showed a
general improvement,
reported fewer symp-
toms, better functioning,
better quality of life, and
were less likely to be
readmitted after partici-
pating in the intervention
Sledge etal. (2011) USA To examine the feasibil-
ity and effectiveness of
using peer support to
reduce recurrent psychi-
atric hospitalization
RCT with a follow-up
9months after dis-
charge from a psychiat-
ric hospital
The intervention included
an adopted version of
the peer companion
model
Outcome measures
were the number of
hospitalizations and
hospital days during the
9months study period
Seventy-four individu-
als were recruited and
randomly assigned to
usual care (n = 36) and
peer-mentor and usual
care (n = 38)
Participants who had a peer
mentor had significantly
fewer re-hospitalizations
and fewer hospital days.
Sub-group analysis
showed no significant
association between
number of mentor con-
tacts and hospitalization
outcomes

Administration and Policy in Mental Health and Mental Health Services Research
1 3
medications, their side effects, and options (Jones etal. 2009;
Velligan etal. 2016). Individuals with SMI reported that trou-
ble accessing medications at the pharmacy influenced medi-
cation adherence; there could be lengthy waiting times, and
at times, the pharmacies did not carry the prescribed drugs
(Gerson and Rose 2012; Rose etal. 2007). Family members
had concerns about medications; they assisted with filling pre-
scriptions, and at times, they were unsure about their role in
medication administration (Jones etal. 2009). Several individu-
als with SMI seemed to consider the purpose of follow-up vis-
its as medication management only (Gerson and Rose 2012).
Poor access toServices andInstability ofKey Workers
The importance of personalizing the transition and situating it
within the daily life of the person transitioning were empha-
sized by Jones etal. (2009). Most individuals with SMI were
able to make follow-up arrangements after hospital discharge
but seemed unsure or unhappy about it. In several studies, the
individual and family members called for more information
and support regarding how to access the service system (Ger-
son and Rose 2012; Jones etal. 2009; Niimura etal. 2016;
Perreault etal. 2005; Rose etal. 2007; Velligan etal. 2016).
Some reported problems with seeking outpatient care arose
from long waiting times, and many individuals were unable to
utilize available support resources in outpatient services (Ger-
son and Rose 2012; Niimura etal. 2016; Rose etal. 2007).
Individuals and family members talked about being unable to
reach providers and centers and being turned away because
of a lack of insurance, discontinuation of programs or non-
acceptance of new clients (Velligan etal. 2016). There were
difficulties with calling a nurse voluntarily as many individu-
als did not know the nurses; this complication emphasizes
the need for continuity among key workers and the particular
challenges arising from frequent physician changes (Niimura
etal. 2016). Changing relationships sometimes led to the
person feeling helpless and isolated as it took time to build
relationships (Jones etal. 2009; Niimura etal. 2016).
Interventions andPrograms toImprove Care
Coordination
The interventions targeted several of the aforementioned
challenges that are in play in hospital-to-community care
transitions for people with SMI. One of the most commonly
targeted challenges was difficulties with information, deci-
sion-making, and social support. Forchuk etal. (2005) evalu-
ated a transitional discharge model in which inpatient staff
continued their relationships with individuals after discharge
and peer support was available to the person for provide
emotional support and community living skills training.
Similarly, Reynolds etal. (2004) evaluated a transitional
discharge model that included peer support and the overlap
of inpatient and community staff. Sledge etal. (2011) tested
an intervention that included support from peers and from
a recovery mentor. Karniel-Lauer etal. (2000) tested the
effectiveness of a re-entry group, which provided psychoe-
ducation regarding mental illness and treatment.
Several interventions comprised multifaceted approaches
that addressed more than one care coordination challenge.
Batscha etal. (2011) addressed barriers to attending outpa-
tient appointments, such as the instability of key workers
and unfamiliarity with the treatment setting, by helping the
individual to plan for the first postdischarge appointment,
providing appointment reminders, and having a familiar
clinician meet with the individual at the first appointment.
Bauer etal. (2006) targeted information needs through group
psychoeducation regarding illness management and access
needs through the availability of a nurse care coordinator
and psychiatrist during the hospital-to-community transi-
tion. Support for outpatient providers was also a focus of
the intervention as the nurse care coordinator facilitated
the flow of information among the outpatient team and pro-
vided education regarding evidence-based pharmacotherapy
guidelines. Similarly, Price (2007) targeted access by provid-
ing individuals with SMI with prepaid cellular phones that
were active for 3months after hospitalization; additionally,
the patients had 24/7 access to and home visits from a transi-
tional nurse. The transitional nurse also communicated with
the consumers’ case managers to enhance continuity of care.
Other interventions also targeted the challenges that influ-
enced community adjustment, such as symptoms, worries,
and a lack of daily activities. Dixon etal. (2009) evaluated
the effectiveness of a brief critical time intervention (B-CTI)
model designed to enhance both continuity of care and com-
munity adjustment. The intervention placed a heavy empha-
sis on personalized care planning and social support through
routine contact between clients and familiar clinicians.
Desplenter etal. (2010) utilized a discharge management
program that emphasized care planning in accordance with
individuals’ social environment. An intervention evaluated
by Khaleghparast etal. (2014) included patient training ses-
sions that focused on daily living tasks, such as leisure activ-
ities, financial resources, independence, self-management
of health and well-being, working, and daily living skills. A
component of Reynolds etal.’s (2004) transitional discharge
model was peer support related to community integration,
skills development, and recreational activities.
Some of the interventions and programs that aimed to
improve coordination of care demonstrated improvements in
service utilization, such as attendance of the first outpatient
visit, reduced hospitalization, and improved medication and
treatment adherence. They were also associated with improve-
ments in the participants’ social functioning, quality of life,
treatment satisfaction and knowledge regarding the illness and
available resources. Dixon etal. (2009) reported that B-CTI

Administration and Policy in Mental Health and Mental Health Services Research
1 3
participants had significantly fewer days between hospital dis-
charge and the first outpatient service visit, received more help
with mental and medical appointments and with making fam-
ily and community connections; furthermore, they received
more information about medications than those in the compar-
ison condition. Sledge etal. (2011) demonstrated that partici-
pants who were assigned a peer mentor had significantly fewer
rehospitalizations and hospital days than controls. Bauer etal.
(2006) demonstrated that the collaborative care intervention
contributed to improvements in social functioning, quality of
life and treatment satisfaction. Two articles also reported sig-
nificant improvements in program participants’ knowledge of
their illness and the available social resources (Karniel-Lauer
etal. 2000; Khaleghparast etal. 2014).
Discussion
This scoping review study mapped the research literature
and identified 16 research articles that focused on care coor-
dination for people with SMI in hospital-to-community tran-
sitions. The literature review the identified symptoms, wor-
ries and lack of daily activities as coordination challenges
influencing community adjustment. Difficulties with access-
ing information, lack of involvement in decision-making and
support, complicated medication regimes, poor access to
services and instability of key workers were coordination
challenges influencing continuity of care. The approaches
to improving care coordination were multifaceted programs
or interventions that commonly addressed information,
decision-making and support. Several interventions targeted
several of the identified challenges to care coordination.
The individuals with SMI and their family members and
caregivers in several of the included articles faced coordina-
tion challenges to community adjustment. These challenges
influenced the consumer’s quality of life, lifestyle behaviors,
and the ability to live a meaningful life in the community
(Davidson etal. 2005). The study results show that the tran-
sition from hospital to community is a vulnerable period,
particularly when psychotic symptoms or suicidal thoughts
are not sufficiently controlled. Research has documented that
the period immediately following discharge is a high-risk
period for suicide (Cutcliffe etal. 2012; Meehan etal. 2006),
rehospitalization, homelessness and violent behavior (Vig-
giano etal. 2012). Needs assessments and systems for iden-
tifying people at risk of deteriorating health provide a way
forward (Desplenter etal. 2010) by requiring that available
measures and support are put in place across the hospital or
community setting (Chung etal. 2016; Viggiano etal. 2012).
Qualitative studies of care coordination challenges high-
light the desires that individuals with SMI and their family
members have for more information and involvement in deci-
sion-making, the complicated medication regimens that affect
adherence, numerous difficulties with accessing services, com-
munication gaps and a lack of continuity in relationships with
providers. These challenges reflect the current limitations in
the ability of mental health service systems in many countries
to coordinate and bridge across care settings, and measures of
these challenges are needed at the patient, provider and system
levels (Chung etal. 2016; Samal etal. 2016).
Our scoping review identified ten programs and interven-
tion approaches that addressed the coordination challenges,
including several recommended measures for successful
care coordination and the integration of general medical
and behavioral healthcare (Chung etal. 2016; McDonald
etal. 2014; Vigod etal. 2013). However, the included care
coordination interventions focused less on improving shared
decision-making, medication-related difficulties, and lack of
support for family members, which we have identified as
challenges. Shared decision-making can be a particularly
relevant tool to support the involvement of the consumer and
family members in decision-making regarding medications
and psychosocial matters, such as work, housing, psycho-
therapy and other services (Deegan and Drake 2006; Deegan
etal. 2008). Shared decision-making can also help to pro-
vide information about the available services and programs
in the community and help to enhance the knowledge of
those with SMI and their caregivers regarding the transition
process (Zisman-Ilani etal. 2018). Through these means,
shared decision-making may ease the individual’s concerns
before discharge from the psychiatric hospital about the
unknown factors waiting for them in the community.
Health care professionals’ competencies regarding the ser-
vice system and the involved providers’ complementary job
tasks and functions are important for quality of care transi-
tions and care coordination (Storm 2017; Storm etal. 2014).
Provider competencies were not addressed as a coordination
challenge in the included qualitative studies, although two of
the interventions focused on clinicians’ and providers’ capac-
ity for and competencies regarding care coordination (Dixon
etal. 2009; Reynolds etal. 2004). Future intervention studies
to improve care coordination could benefit from addressing
the provider competencies necessary for successful coordina-
tion and community adjustment for people with SMI.
The methodological characteristics of the included articles
suggest a need for additional controlled studies of care coor-
dination for people with SMI. Many of the intervention and
program studies were characterized by small study samples,
no randomization and a lack of control group, which increases
the risk of bias and the ability to draw conclusions about out-
comes (Higgins etal. 2011). Five of the studies employed a
randomized control group design (Bauer etal. 2006; Dixon
etal. 2009; Forchuk etal. 2005; Reynolds etal. 2004; Sledge
etal. 2011). The randomized controlled trials examined inter-
ventions that included multiple components and demonstrated
improvements in service utilization and the individuals’ social

Administration and Policy in Mental Health and Mental Health Services Research
1 3
functioning, quality of life and knowledge about their illness
and available resources. These findings need to be replicated
and extended in future studies to clarify precisely which
approaches are associated with the greatest improvements in
care coordination outcomes among people with SMI.
Our findings are subject to certain limitations. First, despite
a comprehensive literature search of multiple databases that
used broad search terms, the search may have missed relevant
studies. We searched the reference lists of included articles
and the full-text articles that were excluded with reason.
However, these searches did not result in the inclusion of
additional studies. Arksey and O’Malley (2005) recommend
consulting experts in the field as a separate but optional stage
in the search strategy. However, expert consultation was not
feasible in this study. Second, discussions among the authors
on the depth and breadth of the review during the study selec-
tion stage may have resulted in a reduction of the scope. For
example, a broader scope would have been to include studies
that addressed the coordination of other types of transitions
in the community setting. Third, assessments of the methodo-
logical quality of the studies is debated within the scoping
review tradition (Pham etal. 2014). In the present review, the
quality assessment was performed to identify the strength of
the evidence base and was not used as a tool for the exclusion
of studies. This resonates with the design and recommended
use of the CASP checklist as a pedagogical tool.
Conclusion
Overcoming the challenges to coordinating community
adjustment and continuity of care is essential for people
with SMI. This scoping review identified several interven-
tions with multiple components that address the identified
coordination challenges. These interventions have demon-
strated improvements in individuals’ social functioning,
quality of life and knowledge about their illness and the
available resources. These findings need to be replicated
in future studies to clarify which approaches are associ-
ated with the greatest improvements in care coordination
outcomes among people with SMI. Future interventions
or programs can also benefit from engaging individuals
with SMI in shared decision-making, providing support
for family members and caregivers, and addressing the
challenges related to complicated medication regimes and
accessing medications. Improving provider competencies
regarding care coordination will also be important.
Acknowledgements The authors express gratitude to Thomas L. Mead,
retired Reference Librarian, Dartmouth Institute for Health Policy and
Clinical Practice for performing the systematic literature searches.
Funding First author 2017–2018 Harkness fellow Marianne Storm
received support for this research by the Norwegian Research Coun-
cil Grant Agreement No. 276638 and The Commonwealth Fund. The
views presented here are those of the authors and should not be attrib-
uted to The Commonwealth Fund or its directors, officers, or staff.
Compliance with Ethical Standards
Conflict of interest The authors declare that they have no conflict of
interest.
Research Involving Human and Animal Participants This scoping
review article does not contain any studies with human participants
performed by any of the authors.
Appendix
See Tables4, 5.
Table 4 Quality assessment
qualitative research designs
Assessment questions: (1) Was there a clear statement of the research; (2) Is a qualitative methodol-
ogy appropriate; (3) Was the research design appropriate to address the aims of the research; (4) Was
the recruitment strategy appropriate to the aims of the research; (5) Was the data collected in a way that
addressed the research issue; (6) Has the relationship between researcher and participants been adequately
considered; (7) Have ethical issues been taken into consideration; (8) Was the data analysis sufficiently rig-
orous; (9) Is there a clear statement of findings; (10) How valuable is the research?
Yes: score of 1
No: score of 0
Can’t tell: score of 0
CASP Assessment questions* 1 2 3 4 5 6 7 8 9 10 SUM
Study
Gerson and Rose (2012)Yes Yes Yes Ye s Yes No No Yes Yes Yes 8 yes
Jones etal. (2009)Yes Ye s Yes Ye s Yes Can’t tell Ye s Yes Yes Ye s 9 yes
Nimura etal. (2016)Yes Ye s Yes Ye s Yes Can’t tell Ye s Yes Yes Ye s 9 yes
Rose etal. (2007)Yes Yes Yes Ye s Yes No No Yes Ye s Yes 8 yes
Velligan etal. (2016)Yes Ye s Yes Ye s Yes Can’t tell No Yes Ye s Yes 8 yes

Administration and Policy in Mental Health and Mental Health Services Research
1 3
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Table 5 Quality assessment
quantitative research designs
Assessment question*: (1) Random sequence generation; (2) Allocation concealment; (3) Blinding of par-
ticipants and personnel; (4) Blinding of outcome assessment; (5) Incomplete outcome data; (6) Selective
reporting; (7) Other bias
0: Low risk of bias
1: High risk of bias
99: Unclear risk of bias
Assessment question* 1 2 3 4 5 6 7
Study
Batscha etal. (2011) 1 1 1 0 0 0 99
Bauer etal. (2006) 0 0 1 0 0 0 99
Desplenter etal. (2010) 1 1 1 1 0 0 99
Dixon etal. (2009) 1 1 1 1 0 0 99
Forchuk etal. (2005) 0111 001
Karniel-Lauer etal. (2000) 1 1 1 0 0 0 99
Khaleghparast etal. (2014) 1 1 1 1 0 99 99
Price (2007) 1 1 1 1 0 0 99
Reynolds etal. (2004) 0 0 1 1 0 0 99
Sledge etal. (2011) 0000 001
Perreault etal. (2005) 1 1 1 1 99 0 99

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