Table 3 General issues and factors

Organizational issues/

Systems and procedures should be developed to ensure clear responsibilities and transparency at each stage of the pathways of care

Intervention on patient, provider and system levels stimulate transitions. (Viggiano et al. 2012)

Seven successful components; facilitated pre discharge, post discharge and transition processes, and promoted timely communication of inpatient staff with outpatient care or community service providers after discharge. (Vigod et al. 2013)

First contact is important. (Amaral et al. 2018)

Information technology supported care pathways. (Neame et al. 2019)

Care pathway in use led to significant better scores on the overall CPSET scale and subscale, ‘coordination of care’ and ‘follow-up care’ with primary care. (Seys et al. 2017)

Specialist health service should improve the systematic follow-up of care pathways as well as the collaboration with primary care. (Biringer et al. 2017)

Use of on-line evidence-based care pathways across primary and secondary care increased over time

(Akehurst et al.2018)

The care pathway led to more focused interventions being offered and the working in it were a positive change. (Khandaker et al. 2013)

Systems and procedures should be developed to ensure clear responsibilities and transparency at each stage of the pathways of care. Around the clock care, designing one responsible health person in each system for each patient, and involvement of patient and their families. (Sather et al.2018)

First contact was a physician, but referral source was emergency services. Ethnic determinants not in focus in CP. (Anderson et al. 2010)

Patients emphasized the non-linear nature of the transition process. (Hasson-Ohayon et al.2016)

Lack of integration between emergency, hospital, and community. (Amaral et al. 2018)

Continuity challenges during transitions. (Storm et al. 2019)

Resources and Outcomes/

Use of CP and information technology in improving objectively patient outcome

Positively impact on length of stay and hospital costs with CP. (Allen et al. 2009)

More cost-effective care pathways and allows for active case management and clear clinical leadership. The care pathway led to more focused interventions being offered and working in it were a positive change. (Khandaker et al. 2013)

Transitional intervention components are feasible and likely to be cost-effective. (Vigod et al. 2013)

Care pathways showing promising results in increasing the quality and efficiency of care for patients diagnosed with schizophrenia. (Chen et al. 2015)

Effective approaches addressed coordination challenges and resulted in better improvements in service utilization (Storm et al. 2019)

Use of information technology improved objectively patient outcome. (Neame et al. 2019) (Akehurst et al. 2018)

Information and Documentation/

Providing patients with enough information and structured, documented plans at the appropriate time

Care Pathways improve documentation. (Allen et al. 2009) (Rotter 2010)

Found variation in the quality of written communication and information transfer between primary care and specialist mental health providers, and patient-centered care was among the least investigated topics. (Durbin et al. 2012)

Structures had a positive effect on exchanging information, formulating, and exchanging information. (Van Houdt et al. 2013)

Main barriers were communication errors. Adequate direct communication and proper documentation system between health personnel, patient participation in plans and working hour of ambulant teams were success factors. (Sather et al. 2016)

Care pathways are useful for securing key objectives. Success with opportunities for information sharing, implementation of systematic plans, and use of e-messages. (Sather et al. 2016, 2018)

Care processes with a written clinical procedure were better organized than processes without such standardization. (Biringer et al.2017)

Themes developed with on-line care pathways showed how pathways were used: in leadership, relationships, support decision-making and referral, and available resources (Akehurst et al. 2018)

Lack of information can result in increased perceived stigma (Gronholm et al.2017)

Stigma and lack of awareness about where treatment is available were barriers to seeking appropriate care. (Teshager et al. 2020)

Former patients reported shared decision making more precisely as informed shared decision, and that shared information between all parties is key. (Sather et al. 2019)

Patient and Family’s Participation/

Continuous collaborative decision-making

Patients with two different wards reported less treatment satisfaction with clinical care pathways for schizophrenia after the implementation. (Steinacher et al. 2012)

Due to the lack of resources (inpatient beds and community care follow-up), the role of service user could play was diminished. (Wright 2015)

Patients revealed oscillation between feelings of strength and vitality to vulnerability and despair in transition phase. Patient emphasize the importance of supportive relationships and work. (Hasson-Ohayon et al. 2016)

Families perceived care planning to be uncoordinated. Lived experienced were not appreciated. Collaborative decision-making not regularly experienced. Family involvement was found to be an important factor related to pathways to care communications constraints. (Doody et al. 2017)

Care Pathways affected patient safety, supported autonomy and activities in community. (Mutchler et al. 2019)

Improved information sharing in/between all care systems is imperative to strengthen patients` participation in decision making, ownership of the care plan and improve adherence to treatment. Patient participation in care plans a success factor. (Sather 2016, 2018,2019)

Shared decision-making support for caregivers with complicated regimes (medication). (Storm 2019)

Family involvement was found to be an important factor related to pathways to care. (Allan et al. 2020)

There is a significant delay in seeking modern psychiatric treatment. Religious healers were first source of help for mental illness (Teshager et al. 2020)

Clinical Care Issues and Teamwork/

Collaboration between mental health and other professionals to guarantee that planned activities meet patients’ needs

Care Pathways gave more interpersonal aspects, changing professional attitude positively. (Allen et al.2009)

Patient-centered found that care was among the least investigated topics between CPs and mental health specialists. (Durbin et al. 2012)

Support interprofessional teams in enhancing teamwork. (Deneckere et al. 2012)

Practitioners being held account over clear standard of care. (Khandaker et al. 2013)

Patients reported the formal professional support as important to their recovery process in general and in their transition to the community in particular. (Hasson-Ohayon et al. 2016)

Shared decision-making support for caregivers with complicated regimes (medication). (Storm 2019)

Patients participation in plans and working hours of ambulant teams were success factors. Key person handling all information and communication between levels of care. (Sæther et al. 2018)

Regular meetings sharing key information; avoidance of delays extending inpatient status and block satisfactory transition to the community setting. (Sather et al. 2018)

Mental health professionals, and general practitioners played a key role in help seeking. (Allan et al. 2020)

Ethical Issues/

Respectful communication and patient-centered care to avoid humiliating the patients

Stigma and discrimination limited factors in delivery of care. (Volpe et al. 2015)

Clinical staff used language which dehumanized the individuals. (Wright et al. 2015)

Dilemma when patient and health personnel have different options on treatment. Respectful communication to avoid humiliating the patients. (Sæther et al. 2016)

The complexity of welfare systems negatively affected patient dignity. (Sather et al. 2018)

Poverty, interpersonal difficulties, and stigma were barriers. (2019 Mutchler) (Gronholm 2017)

Stigma and lack of awareness where treatment is available were barriers to seeking appropriate care for patients with various diagnosis of mental illness. (Teshager et al. 2020)