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Comparison of hospital admission cared for by psychiatric multidisciplinary outreach teams with and without peer specialist: a retrospective cohort study of Japan Outreach Model Project 2011-2014

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Journal:

Manuscript ID

Research

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Article Type:

bmjopen-2017-019090

Date Submitted by the Author:

Kido, Yoshifumi; Mie Prefectural College of Nursing, Psychiatric and mental health nursing Kawakami, Norito; The University of Tokyo, Department of Mental Health Kayama, Mami; St. Luke's International University, Psychiatric and mental health nursing

Primary Subject Heading:

Mental health

Secondary Subject Heading:

Mental health

Peer specialist, Psychiatric multidisciplinary outreach program, Retrospective cohort study

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Keywords:

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Complete List of Authors:

28-Aug-2017

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Title

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Comparison of hospital admission cared for by psychiatric multidisciplinary outreach teams

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with and without peer specialist: a retrospective cohort study of Japan Outreach Model

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Project 2011-2014

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Authors

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Yoshifumi Kido, RN, PHN, DHSc1

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Norito Kawakami, MD, DMSc2

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Mami Kayama, RN, PhD3

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Author institution affiliations

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1. Department of Psychiatric Nursing, Mie Prefectural College of Nursing, Mie, Japan

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2. Department of Mental Health, Graduate School of Medicine, The University of Tokyo,

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Tokyo, Japan

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3. Department of Psychiatric and Mental Health Nursing, Graduate School of Nursing, St.

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Luke’s International University, Tokyo, Japan

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The postal and e-mail address of the corresponding author

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Corresponded address: Yoshifumi Kido, Mie Prefectural College of Nursing, 1-1-1

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For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml

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Yumegaoka, Tsu-city, Mie 514-0116, Japan.

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Phone & Fax: +81(JPN)-59-233-5635.

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Email: [email protected]

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Key words

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Peer specialist, Psychiatric multidisciplinary outreach program, Retrospective cohort study

Number of Figure: 2

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Number of Tables: 4

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Number of Words: 3759

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Manuscript information

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Abstract

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Objective: This study examined whether having peer specialists (PS) in psychiatric

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multidisciplinary outreach teams was associated with a lower risk of hospitalization,

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improved social functioning and problem behaviors.

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Design and Setting: This study was a retrospective cohort study based on medical records.

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This study was conducted as a part of the Japan Outreach Model Project (JOMP) 2011-2014,

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provides services for persons diagnosed mainly as ICD-10 F0, F2, and F3, who have a high

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possibility of hospital admission/readmission if they applied to typical services provided thru

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regular Japanese outpatient care.

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Participants: A total of 292 participants (clients) from 31 multidisciplinary outreach teams

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fulfilled the inclusion criteria and were subjected to the analysis.

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Outcome measures: The primary outcome measure was hospitalization during follow-up.

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The difference in hospitalization during the follow-up between teams with and without PS

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was analyzed by Kaplan-Meier survival curves and a Cox proportional hazards model. The

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secondary outcome measures were social functioning (Global Assessment of Functioning,

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GAF) and problem behaviors (Social Behavior Schedule, SBS) of clients were assessed at

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baseline and at 6-month follow-ups. Changes in social functioning and problem behavior

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were compared between clients cared for by the two types of team. Amount and content of

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the service were also compared between the two groups.

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Results: Average follow-up periods were 405 and 397 days for clients cared for by teams

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with and without PS (n=108 and 184), respectively. The clients cared by teams with PS had a

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significantly decreased probability of hospitalization (HR=0.53; 95%CI, 0.31 to 0.89 in Cox

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proportional hazards models adjusting for baseline characteristics). A six-month change in

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GAF or SBS was not significantly different between the two groups.

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Conclusion: Psychiatric multidisciplinary outreach teams with PS showed a lower rate of

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hospitalization during the follow-up. Having PS in such outreach teams may decrease

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hospitalization among clients.

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Strengths and limitations of this study:

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This is the first epidemiological study about psychiatric multidisciplinary outreach

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program with peer specialists in Asian countries including Japan.

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This study contributed to international accumulation of evidence whether having peer

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specialists (PS) in psychiatric multidisciplinary outreach teams is associated with a lower

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risk of hospitalization.

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The main limitation of this study is that there is a possibility of existing unmeasured confounding variables, especially for team characteristics, structure, and experiences.

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Introduction

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Among those with mental illness who live in the community, many are not connected to

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services due to various factors despite the need to receive appropriate psychiatric services.

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This has become a worldwide problem and also exists in Japan1-4. For example with

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schizophrenia, not having treatment during the first 2-5 years after onset determines a poor

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long-term prognosis5. Thus shortening the duration of untreated psychosis is considered

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important for improving prognosis6,7. Furthermore, relapse is often seen among people who

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quit medication after the initial contact for treatment8. Critically, psychiatric symptoms and

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social impairment become chronic as a result of repeated relapses, with less probability of

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remission9. As such, providing psychiatric services with appropriate timing for untreated

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patients of mental illness and patients that have suspended treatment is important in order for

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people to continue their lives in the community while having a mental illness.

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In Western countries, as the care for people with mental illness transitioned to

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community-based approaches, various community care programs were developed and

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provided according to each country’s resources and system10. Multidisciplinary outreach

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programs such as Assertive Community Treatment (ACT)11-15 and Assertive Outreach

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(AO)13,16-20 were effective approaches that reduced hospital admission, the costs of hospital

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care, and improved outcomes and patient satisfaction12 in various countries, including Japan. 5


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The Dartmouth Assertive Community Treatment Scale (DACTS) which assesses treatment

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reliability to ACT clearly designate “Peer Specialist (PS)” as necessary to secure the quality

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of program21 and also many teams of ACT and AO also employ them17.

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Peer supporters, persons providing peer support to others, are referred to by various names

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depending on the form of their activity. When such persons are employed as workers, not

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volunteers,

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specialist”, ”Consumer Provider” etc. There are studies regarding the effect of PS in a

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psychiatric multidisciplinary team that have been deployed since the 1990s22. Two

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randomized controlled trials and one quasi-experimental study reported that participation of

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clients with severe mental illness in multidisciplinary outreach teams showed a significant

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decrease in hospital admission and/or shorter hospital days23-26. In comparison, six other

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studies did not find a significant decrease in these hospital-related outcomes22,27-31. Among

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five other studies, three found that the participation of PS increased engagement in services

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and social relationships among clients27,28,32, but two studies failed to find significant

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differences22,25. One study indicated a significantly positive association on a client’s personal

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recovery31, but many other studies found no statistically significant improvement of social

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functions27-29 and psychiatric symptoms29,33. Thus, it is still not fully clear if the participation

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of PS in psychiatric outreach programs will decrease hospital admissions.

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“Peer

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Additionally, in Japan, there is no study and unclear whether the participation of PS in a 6


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psychiatric multidisciplinary outreach team targeting clients with difficulties maintaining the

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contact with psychiatric services is associated with a decrease in hospitalization. The purpose

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and hypothesis of this retrospective cohort study was to examine whether psychiatric

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multidisciplinary outreach teams with PS were associated with a lower risk of hospital

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admission/readmission.

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Study design and setting

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Methods

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This study was a retrospective cohort study conducted in the Japanese Outreach Model

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Project (JOMP) led by the Ministry of Health, Labour and Welfare from October 2011 to the

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end of January 201434,35. The goal of the JOMP was to prevent hospitalization of persons with

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severe mental illness who had a high possibility of hospital admission/readmission if they

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applied to typical services under regular Japanese outpatient care funded by public insurance.

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Thirty two multidisciplinary outreach teams within the 21 prefectures agreed to participate

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this study.

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Peer Specialist (PS) in this study Of the 32 teams that participated in this study, 10 teams added PS as team members and a 7


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total of 17 PS were members of a multidisciplinary outreach team. In this model project, the

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government did not set written criteria for PS. The majority of PS were males in their 40s

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diagnosed with: schizophrenia, schizotypal, delusional, or other non-mood psychotic

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disorders (coded ICD-10 F2). Team psychiatrists or directors recruited PS based on a lengthy

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stable condition, experience with peer support activities, and interest in working with a

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multidisciplinary team as a PS. This meant that PS had dual roles as peer supporter and client.

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At the time, they were not able to receive structured training as PS because the certified

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training program was not available in Japan. However, the average amount of prior

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experience as a peer supporter was 34 months. Each team through the project budget

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officially employed the PS. Whether or not PS express ‘I am a PS’ to clients was up to the PS.

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More details of PS of this study are given in a separate article36.

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Target populations and participant (client) criteria

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JOMP provides services for persons diagnosed mainly as ICD-10 F0, F2, and F3, who have

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a high possibility of hospital admission/readmission if they applied to typical services

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provided thru regular Japanese outpatient care. Clients were classified according to treatment

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condition: ‘treatment suspended’, ‘untreated’, ‘Hikikomori (social withdrawal)’, and

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‘discharged after long-term admission or repeated admission in the short term’.

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Consults and service requests for teams were received mainly from a health center, medical 8


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institutions, welfare service providers, police, and educational institutions. After teams

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received consultations, the Management Committee assessed the necessity of JOMP services

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in accordance with inclusion criteria. Management Committee members were composed of

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administrative officers of health centers and the local community, commissioned welfare

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volunteers, members of patient and family advocacy groups, other service providers and

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academic experts.

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Data collection

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Clients were recruited from October 2011 to July 2013 and followed up until January 2014.

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Hospital admission and other survey data were measured during the follow-up based on

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medical records. At the baseline, client characteristics that were assessed included clinical

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condition, socio-demographic data, social functioning and problematic behavior. Client

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treatment condition and outcomes including social functioning and problematic behavior

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were assessed at baseline and 6 months follow-up from medical records. Each team staff

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anonymized participant data and entered the data into a computer database.

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Measures

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Socio-demographic data were assessed by age, marital status, and living status. Age was

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assessed using 8 categories (from ‘10s’ to ‘80s+’) and used as a continuous variable. Marital 9


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status was assessed using 5 categories (‘Currently married’, ‘Never married’, ‘Separated’,

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‘Widowed’, and ‘Divorced’) and dichotomized (‘Married’ or not). Living status was assessed

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using categories (living with father, mother, brother/sister, spouse, son/daughter, uncle/aunt,

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friend, other, and living alone) and dichotomized (‘Living alone’ or not).

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Psychiatric diagnosis was assessed by a team psychiatrist using the ICD-10 classification

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of mental and behavioral disorders, diagnostic criteria for research37. Treatment status at

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baseline was composed of persons who were in ‘suspended treatment’, ‘untreated’,

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‘Hikikomori (social withdrawal)’, ‘discharged after long-term admission or repeated

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admission in the short term’. ‘Hikikomori’ cases were only included when a psychiatric

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diagnosis was given by a team psychiatrist, and treatment status was ‘suspended treatment or

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untreated’.

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Social functioning was measured by the Global Assessment of Functioning (GAF)38. GAF

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was developed for the overall assessment of psychological, social, and occupational

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functioning on a hypothetical continuum of mental health/illness rating 1 (persistently and

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serious impaired) to 100 (no symptoms, superior functioning). Problem behaviors were

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measured by the Social Behavior Schedule (SBS)39,40. The SBS is scored using a Likert scale

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from 0 (no problem) to 4 (serious problem). It includes items relating to positive psychotic

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symptoms as well as negative behavioral items. A high score (max 78) on the scale indicates

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increased behavioral difficulty.

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Client treatment condition and outcome were measured with service-start date, service-end

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date and current state/the reason for service-end. Client reason for terminating service use

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was recorded using the following categories: still using the service, terminating the service

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because he/she switched to regular outpatient care, terminating the service because he/she

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became an inpatient, terminating the service due to moving outside the service area, and

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service terminated because of death.

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Team staff activity logs were recorded for each visit during the service period in order to

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assess the amount and content of care provided. Data included: date of visit, travel-time for

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visit, service time (minutes), care categories, client ID and staff ID. If multiple team members

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dealt with a same case at the same time, they recorded the IDs of all participating members.

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The total amount of service was assessed for each client ID. Care categories were created for

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the content of a psychiatric home visit following classifications in previous studies41,42. The

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care categories were composed of 12 types of services: “Case management with clients”,

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“Case management without clients”, “Assistance with daily living task”, “Develop and

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maintain personal relationships”, “Family support”, “Medical support for psychiatric

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symptoms”, “Support for physical health”, ”Social life and financial support”, “Housing

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services”, “Vocational and educational support”, “Empowerment”, and “Conference”. Each

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team recorded all their data in a computer database. Activity logs were analyzed in order to

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describe service content and amount. Care content and amount (minutes) of provided services

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to clients were integrated by a month from service-start to end of service-end, separated by

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groups cared for by teams with/without PS. Additionally, a t-test was performed in order to

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test for significance between groups cared for by teams with/without PS. (see online

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supplementary table 1, 2)

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The collected data had a two-level hierarchal structure, i.e., ‘client personal’ (Level 1) and

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‘teams providing services’ (Level 2). Clients of this study received services from a particular

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team in charge of their area of residence. Before analysis, a team ID was given to each team.

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In addition, a client ID was given to each client. Clients belonged to either a team with or

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without PS (‘care by team with PS or ‘care by team without PS, respectively).

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Client length of stay in a community was calculated based on service-start date and

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service-end date. Person-time was calculated from service-start date until service-end

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including hospital admission or end of follow-up (January 31, 2014). The Kaplan-Meier

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survival curve was calculated in order to examine the effect of receiving services provided by

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a team with PS on hospital admission. Univariable (Model 1) and multivariable (Model 2)

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Cox proportional hazard regression models were also conducted, estimating hazard ratios and

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95% confidence intervals, with number of days since a service start as the time scale. The

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multivariable models (Model 2) were adjusted for age category in increments of 10 years, sex,

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diagnosis, marital status, living status, problem behavior (SBS score), and social functioning

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(GAF score) at baseline. These univariable and multivariable Cox proportional hazard models

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were also conducted by treatment condition (clients with a status of ‘suspended treatment or

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untreated’ or ‘discharged after long-term admission or repeated admission in the short term’)

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at baseline.

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A paired t-test was performed in order to test for significant changes in social functioning

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and problem behaviour over time. Additionally, two-sample t-tests were conducted to test for

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any significant differences after 6 months from baseline between clients having care provided

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by teams with/without PS.

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Data were analyzed with the use of ‘ttest’, ‘stcox’, and procedures in STATA software,

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version 14.1. Statistical tests were two-sided, with a significance level at 5 %.

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Ethical considerations

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This study was conducted in accordance with international standards for epidemiological

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studies, as established in the International Guideline for Ethical Review of Epidemiological

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Studies. The Research Ethics Committee of St. Luke’s College of Nursing approved this

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study (11–032).

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Results

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Among 541 possible participants who were assessed by the Management Committee, 126

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were excluded because they did not meet JOMP inclusion criteria. Additionally, 47 clients

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who received services for less than 6 months at the end of September 2014 were excluded

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from the analysis because their 6-month evaluations were not conducted. Finally, 76 persons

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who had missing values necessary for multivariate analysis were excluded. A total of 292

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participants (clients) from 31 teams fulfilled the inclusion criteria and were subjected to the

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analysis (Figure 1).

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Clients’ characteristics of socio-demographic and clinical condition at baseline

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The largest number in terms of treatment condition for clients in the group cared for by PS

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at baseline was ‘suspected treatment’ (68.5%). The proportion of ‘suspected treatment’ was

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significantly greater than for clients in the group cared for by teams without PS (53.3%).

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Other variables were not significantly different with clients of groups cared for by teams

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without PS (Table 1). The average SBS scores in the group cared for by teams with PS (25.3,

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SD 11.9) at baseline was significantly higher than in the group cared for by teams without PS 14


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(22.1, SD 11.2).

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-Insert Table 1 about here-

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Association between receiving services provided by a multidisciplinary outreach team

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with PS and hospital admission

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Average follow-up period of clients was 404.9 days (SD 201.8) and 396.7 days (SD 237.4)

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for the groups provided the service with and without PS (n=108 and 184), respectively. A

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total of 20 (27.0%) and 54 (75.0%) clients were admitted to hospital for teams with and

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without PS, respectively, during the follow-up. The survival curves that groups cared for by

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teams with PS had a lower rate of hospital admission (Figure 2), and was statistically

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significant (p=0.04) (Table 2). This pattern was observed only among clients who were in

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suspended treatment and untreated at baseline (p=0.04).

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Cox proportional hazards regression with crude analysis (Model 1) indicated that the group

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cared for by teams with PS had a decreased risk of hospital admission in the total sample 15


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(HR=0.59; 95%CI, 0.35 to 0.99) and among clients who were in suspended treatment or

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untreated at baseline (HR=0.56; 95%CI, 0.32 to 0.98). In multivariable analyses adjusted for

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the level 1 variables (Model 2), the groups cared for by teams with PS had a decreased risk of

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hospital admission in the total sample (HR=0.53; 95% CI, 0.31 to 0.89) and among clients

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who were suspended treatment or untreated at baseline (HR=0.48; 95% CI, 0.27 to 0.86).

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(Table 3)

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Change in social functioning and problematic behaviour

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A decrease in average SBS scores between baseline and 6 months follow-up was

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significantly greater for the group cared for by teams with CPs than the groups cared for by

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teams without CPs in clients who were discharged after long-term admission or repeated

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admission in the short term. No significant difference was found in the decrease in SBS

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scores between the two groups in the total sample or in the suspended treatment and untreated

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clients cared for by teams with and without CPs (p>0.05). There was no significant difference

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in improvement of average GAF scores between baseline and 6 months follow-up between

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the two groups in the total sample or each of the subgroups (Table 4).

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Discussion

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The group cared for by teams with PS had a statistically significantly decreased probability

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of hospitalization compared to the group cared for by teams without PS in the Kaplan-Meier

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analysis. Cox proportional hazards models showed a similar pattern even after adjusting for

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client characteristics, with a 50% reduction in the risk of hospitalization. This pattern was

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similar among clients who were in suspended treatment or untreated at baseline, while it was

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not among clients with long stay/repeated status at baseline. A decrease in average SBS

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scores between baseline and 6-month follow-up was significantly greater for the group cared

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for by teams with PS than the groups cared for by teams without PS in clients who were

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discharged after long-term admission or repeated admission in the short term at baseline.

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There are several possible reasons why clients cared for by teams with PS had a decreased

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risk of hospital admission. Firstly, PS can empower their clients by emotional support based

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on shared experiences32,43. PS in this study provided a large amount of “Empowerment”

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category services (see online supplementary table 2). This category includes “enhancement of

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self-efficacy and control” and “positive feedback”41,42. These services are similar to

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emotional support based on shared experiences. PS might build a relationship of trust

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smoothly with clients to use these techniques. Secondly, PS can provide supports to client

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families as a recovered role model. In this study, entire teams with PS and sole PS provided a

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large amount of “Family support” category services (see online supplementary table 1 and 2).

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This category includes “Family support about the instruction with a client” and

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“Empowerment to family”41,42. Previous studies indicated that high negative expressed

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emotion affects the relapse rate in schizophrenia in client families44. PS might reduce the risk

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of relapse by demonstrating appreciation to families about the hardships they have endured

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and by conveying effective tips regarding instruction with a client. Additionally, having PS

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participate in team conferences might have a spillover effect on team members and other

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attendants. In this study, teams with PS provided a large amount of “Conference” category

11

services (see online supplementary table 1). A previous study indicating that peer support

12

activities improve the quality of services45, and PS experiences and perspectives might

13

promote staff understanding toward clients and develop more effective care procedures. The

14

promotion of quality of service with respect for client experiences might earn client trust and

15

decrease the risk of hospital admission.

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There was significantly more improvement in problem behavior at 6-month follow-ups

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among clients cared for by teams with PS than those without PS only in clients who were

18

discharged after long-term admission or repeated admission in the short term at baseline. This

19

result is not consistent with any other previous study27-29,33. The average SBS score at 18


Page 19 of 40

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baseline in the group cared for by teams with PS was statistically higher than that in the

2

group without PS, especially among clients who were discharged after long-term admission

3

or repeated admission in the short term. The hospital long-stay clients who had chronic

4

psychiatric symptoms and lack of daily living skills might have experienced a greater

5

difficulty due to an environment change after the discharge from a hospital. Teams with PS

6

provided services related to communication and coordination, case management and

7

conference more than teams without PS (see online supplementary table 1), thus the service

8

provided by the former teams may have filled the gaps in life between hospital and

9

community, which may in turn have resulted in a reduction of problem behavior. While the

10

difference between the groups cared by teams with and without PS was not statistically

11

significant, the group cared for by teams with PS showed slightly better improvement in

12

social functioning (GAF) and problem behavior (SBS) at 6-month follow-up in the total

13

sample. However, the group difference was small. The present study may have not enough

14

power to detect the effect of teams with PS on these outcomes. The effect should be

15

investigated in a future larger-scale study.

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Limitations

18

In addition to the above discussion, the present study has several limitations. First, there is

19

a possibility of existing unmeasured confounding variables, especially for team 19


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characteristics, structure, and experiences. A multivariate analysis can adjust for some of

2

these factors, but there were many potential unexamined related factors. In order to generalize

3

these findings, it is necessary to conduct a multilevel Cox hazard analysis or a randomized

4

control trial. Second, PS in this study may have had a diverse level of knowledge and skills,

5

which may have resulted in an underestimation of the true association and also could lead to

6

difficulty in generalization of the findings. Third, GAF and SBS evaluators varied by

7

occupation in some teams. Variations of team evaluation may also lead to an underestimation

8

of the findings because of possibly decreased inter-rater reliability of the measures.

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Conclusion

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This study came to a conclusion that by receiving service from multidisciplinary outreach

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teams with PS, the risk of hospitalization for clients who suspended treatment or had

14

untreated decreased by approximately half when compared to teams without PS. This study

15

contributed to international accumulation of evidence about PS and multidisciplinary

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outreach programs.

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Page 20 of 40

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Page 21 of 40

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Contributor ship statement

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YK contributed whole process of this study. NK contributed acquisition and analysis of data,

3

and drafting the manuscript. MK contributed conception and design of the study and drafting

4

the manuscript.

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Competing interests

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The authors declare no conflict of interest.

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Funding

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This study was part of a project supported by a grant from Comprehensive Research on

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Disability Health and Welfare of Health and Labor Sciences Research Grants of Japan

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(2011-2013).

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Data sharing statement

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All available data can be obtained by contacting the corresponding author.

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541 candidates assessed for eligibility in the Management Committee 126 ineligible 415 clients of the model project 47 clients received services for less than 6 months 368 clients of this study

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76 had missing value

292 clients were used for analyses

Figure 1. Flow chart of study participant selection.

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Table 1. Socio-demographic characteristics and clinical Clients condition of clients cared for by at baseline (n=292) Clients cared for by teams without PS teams with PS (n=108) (n=184) n % n % χ2 p Treatment condition 14.59