|Intervention category||No of papers||Authors name and years||Description of intervention|
|Critical Time Intervention||5||Tomita (2014), Kasprow (2014), Herman (2011), Shaffer (2015), Chen (2014)||• Focused on homelessness|
• Delivered by CTI workers
• Develop therapeutic relationship
• Time limited (gradually reduced contact), Small caseloads, Community based
• Phase 1: Transition: Provide support & begin to connect client to people and agencies that will assume the primary role of support
• Phase 2: Try-Out: Monitor and strengthen support network and client’s skills.
• Phase 3: Transfer of Care: Terminate CTI services with support network safely in place.
• Also includes Brief CTI (shorter time)
|Transitional Discharge Model (TDM)||3||Forchuk (2005), (2012), Reynolds (2004)||• Ward nurses work with SU until a therapeutic relationship is established with the community worker|
• Then peer support introduced
• AKA/similar to Transitional relationship model (TRM)
|Transitional care model||2||Hanrahan (2014), Rose (2007)||• Nurse based in home transitional care intervention, to increase CoC|
• A) comprehensive discharge planning
• B) home visits and telephone contacts with a nurse (assessments, care, psychoeducation)
• Aimed at most challenging patients with long history of readmission
• Immediately providing intensive support and identifying problems early before readmission
• Increase QoL through symptom management, medication adherence and enhanced family support
|Peer Support||3||Lawn (2005), Scanlon (2017), Simpson (2014)||• Scanlan: Peer-delivered support programme: peers delivering providing individualised practical and emotional support to individuals for 6–8 weeks following discharge|
• Simpson: Peer support workers to provide peer support for 4 weeks to discharged service users, initial contact begins on ward
• Lawn: Peer support workers trained alongside other health professionals. Service users matched to peers experience and skills, 8–12 h, 1–2 week period. Also hospital avoidance packages for those who are thought to need them.
|Contact based interventions||6||Bennewith (2014), Bauer (2012), D’Souza (2002), Exbrayat (2017), De Leo (2007), Botha (2018)||• Bennewith: Letters sent to follow up recently discharged service users at home|
• Bauer: SMS sent to recently discharged service users about maintaining treatment
• D’Souza: MDT videoconferencing with rural patients post-discharge
• Exbrayat: Nurse telephone follow up 8, 30 and 60 days post suicide attempt
• De Leo: Intensive case management – Weekly face-to-face contact with community case manager and telephone calls from counsellors
• Botha: 90 Day Transitional care intervention – 4 phone calls, 1 home visit focusing on maintaining adherence, appointment reminders and psychoeducation
|Role-based Interventions||6||Walker (2000), Virgolesi (2017), Hengartner (2016,17), Jenson (2010), Bonsack (2016), Hampson (2000)||• Walker: Discharge co-ordinators – educational role with service users and family, develop relationships, 6–8 weeks post-discharge, Dr. routinely telephoning GP practice regarding impending discharge and arrange an appointment with GP within 7 days of discharge, posting discharge summary to practice|
• Virgolesi: Nursing discharge programme- information interventions provided by nursing staff, direct hospital medication, distribution and follow-up telephone calls. Nurses attend a 1-h class organised into 5 modules: introduction to medication adherence, conceptual framework of medication adherence, medication adherence, intervention programmes, structure of medication adherence interview, and case studies.
• Hengartner: Post-discharge network co-ordinator – delivered by social workers, support service users to build and maintain social network and link to community care system – goes to ward on 1st week, develops plan before discharge, home visit 3 days post discharge
• Jenson: Community based discharge planning – in reach, community nurse visits ward daily
• Bonsack: Transitional case management –- a nurse, or a social worker was added to the treatment as usual procedure. Their role was not to replace the other care providers but to coordinate care provision and to represent the patient’s viewpoint.
• Hampson: Community link team - to facilitate early discharge team-based service offering intensive support during the day.
|Pharmacist Interventions||2||Abraham (2017), Shaw (2000)||• Abraham: Pharmacist consult intervention- psychiatrist has to order a pharmacist consult in the EHR for all LAI orders, hard copy of form sent to inpatient pharmacy and clinical pharmacist. Pharmacist has to approve LAI prescription before administered. Day of discharge injection clinic. Pharmacist led transitions in care program and medication delivery available prior to discharge. Following discharge continued treatment in outpatient clinic.|
• Shaw: Pharmacy discharge planning- baseline pharma needs assessment, information about medicines and then plan sent to community pharmacist
|Intervention to prevent homelessness||2||Forchuk 2008, 2013||• Immediate assistance in accessing housing, assistance paying first month rent|
|(Psycho) educational||5||Kariel-Lauer (2000), Zheng (2005), Sato (2012), Khaleghparast (2013), Hegadus (2018)||• Kariel-Lauer: Re-entry group – short term group meetings, psychoeducational approach|
• Zheng: Family education- 8 h with service users, 36h with family in hospital, 2 h per month for 3 m post-discharge. Nurse with > 10 yr experience provided intervention. Purpose is to educate families about schizophrenia, treatment, teach skills to help families cope
• Sato: Community re-entry program- discharge preparation programme – psychosocial preparation for long-term service users
• Khaleghparast: Self-care training programme, delivered by nurses- 6 1 h sessions pre-discharge, 1 a fortnight post-discharge
• Hegedus: Short transitional intervention in psychiatry – aims primarily to prepare patients for specific situations that could arise during the days immediately following discharge- cards with potential scenarios on
|Needs-oriented discharge planning||2||Puschner (2011), Lin (2018)||• Puschner: Manualised needs led discharge planning and monitoring intervention with 2 intertwined sessions, 1 at discharge 1 3 months after. The intervention aimed at improving this communication (between primary and secondary) by means of information (needs assessment)-based standardised recommendations for outpatient treatment and monitoring of compliance with these recommendations.|
• Lin: Needs-orientated discharge planning for caregivers- nurses served as care coordinators and provided 6-step hospital discharge planning services to caregivers. Integrated therapeutic partnership, mental health education, and needs oriented services.
|Whole Care Pathway Initiatives||2||Attfield (2017), Juven-Wetzler (2012)||• Attfield: Integrated care pathways- reducing unnecessary tests interventions and duplications- (ICPs), is a ‘multidisciplinary plan of care that provides detailed guidance for each stage in the care of a patient with a specific condition, over a given period of time’|
• Juven-Wetzler: Continuation of care model– continuation of care by the same staff from the ward rather than outpatient referral
|Multi-component interventions||3||Kidd (2016), Smelson (2010), Ghadiri Vasfi (2015),||• Kidd: Welcome Basket- 6 weeks- peer support- contact on wards prior to discharge and post, basket of items, environmental support|
• Smelson: Brief treatment engagement- 5 h per week of services in community- assertive community treatment using BCTI, peer support, dual recovery therapy
• Ghadiri: Aftercare Services- 3 components, follow-up care (home visits or telephone), family psychoeducation, social skills training for patients
|Discharge Checklist||1||Khanbahi (2018)||• Doctor's checklist as an aid memoir|
|Motivational Aftercare Planning||1||Kisely (2017)||• Motivational interviewing with advanced directives|
|Brief Care Management-||1||Taylor (2014)||• A brief interview that addresses goals and barriers to treatment which was administered by care managers of a managed behavioural health organization prior to the individuals’ discharge|