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Evidence to Improve Care

Schizophrenia

Care for Adults in Hospitals

Click below to see a list of brief quality statements and scroll down for more information.


Quality standards are sets of concise statements designed to help health care professionals easily and quickly know what care to provide, based on the best evidence.

See below for the quality statements and click for more detail.


Quality Statement 1: Comprehensive Interprofessional Assessment
Adults who are admitted to an inpatient setting with a primary diagnosis of schizophrenia undergo a comprehensive interprofessional assessment that informs their care plan.


Quality Statement 2: Screening for Substance Use
Adults who present to an emergency department or in an inpatient setting with a primary diagnosis of schizophrenia are assessed for substance use and, if appropriate, offered treatment for concurrent disorders.


Quality Statement 3: Physical Health Assessment
Adults who are admitted to an inpatient setting with a primary diagnosis of schizophrenia undergo a physical health assessment focusing on conditions common in people with schizophrenia. This assessment informs their care plan.


Quality Statement 4: Promoting Physical Activity and Healthy Eating
Adults who are admitted to an inpatient setting with a primary diagnosis of schizophrenia are offered interventions that promote both physical activity and healthy eating.


Quality Statement 5: Promoting Smoking Cessation
Adults who are admitted to an inpatient setting with a primary diagnosis of schizophrenia are offered behavioural and pharmacological interventions to alleviate nicotine-withdrawal symptoms and to help them reduce or stop smoking tobacco.


Quality Statement 6: Treatment With Clozapine
Adults who are admitted to an inpatient setting with a primary diagnosis of schizophrenia who have failed to respond to previous adequate trials of treatment with two antipsychotic medications are offered clozapine.


Quality Statement 7: Treatment With Long-Acting Injectable Antipsychotic Medication
Adults who are admitted to an inpatient setting with a primary diagnosis of schizophrenia are offered the option of a long-acting injectable antipsychotic medication.


Quality Statement 8: Cognitive Behavioural Therapy
Adults who are admitted to an inpatient setting with a primary diagnosis of schizophrenia are offered individual cognitive behavioural therapy for psychosis either in the inpatient setting or as part of a post-discharge care plan.


Quality Statement 9: Family Intervention
Adults who are admitted to an inpatient setting with a primary diagnosis of schizophrenia are offered family intervention.


Quality Statement 10: Follow-Up Appointment After Discharge
Adults with a primary diagnosis of schizophrenia who are discharged from an inpatient setting have a follow-up appointment within 7 days.


Quality Statement 11: Transitions in Care
Adults with a primary diagnosis of schizophrenia who are discharged from an inpatient setting have a team or provider who is accountable for communication and the coordination and delivery of a care plan that is tailored to their needs.

Summary

This quality standard addresses care for people aged 18 years and older who have schizophrenia. The quality standard focuses on care for people who are in an emergency department or admitted to a hospital. It also provides guidance on care that takes place when a person is between settings, such as when discharged from a hospital.


This quality standard applies to the care of adults aged 18 years and older with a primary diagnosis of schizophrenia (including related disorders such as schizoaffective disorder) who are seen in an emergency department or admitted to an inpatient setting. This quality standard also includes guidance for the care of people who are transitioning from the inpatient setting to the community. While focused on hospital care, some of the interventions described are likely to take place outside of the hospital, following their initiation or a referral in hospital. All patients should have a follow-up visit after initiating any new treatment.

Schizophrenia is a severe and chronic mental disorder that usually begins when a person is in late adolescence or early adulthood. It is associated with “positive” symptoms such as hallucinations and delusions and “negative” symptoms such as social withdrawal and a loss of interest.

In Canada, about 1% of the population has schizophrenia. The disorder ranks in the top five conditions that have the highest impact on the life and health of people in Ontario. Schizophrenia is more common in men and in certain ethnic subgroups.

People with schizophrenia live about 15 to 20 years less than the general population, with the majority of deaths resulting from cardiovascular or chronic respiratory diseases. People with schizophrenia also have an increased risk of substance use, homelessness, unemployment, and suicide.

There are significant gaps in the quality of care that people with schizophrenia receive in Ontario: only 25% of people discharged from a schizophrenia- or psychosis-related hospitalization receive the recommended follow-up visit with a physician within 7 days; people hospitalized for schizophrenia have a high rate (12.5%) of readmission within 30 days of discharge; and rates of emergency department visits for schizophrenia vary widely across the province.

People with schizophrenia often also encounter stigma or beliefs and attitudes that lead to negative stereotyping of them and their illness. Stigma, or the perception of stigma, can negatively affect their ability to tell friends and family about their illness, and to seek help. Stigma may also impact their ability to access health care services.

These issues suggest the need for a quality standard for schizophrenia care in Ontario.

This quality standard is underpinned by the principles of respect and recovery, as described in the Mental Health Strategy for Canada.

People with schizophrenia and their families, caregivers, and personal supports should receive services that are respectful of their rights and dignity and that promote self-determination. They should be engaged in informed shared decision-making with their care providers around their treatment options. Each person is unique and has the right to determine their path toward mental health and well-being.

People with schizophrenia have a right to services provided in an environment that promotes hope, empowerment, and optimism, and that are embedded in the values and practices associated with recovery-oriented care. There are “many intersecting factors (biological, psychological, social, economic, cultural, and spiritual)” that may have an impact on mental health and well-being.

Beyond the hospital-based clinical care that this quality standard focuses on, people with schizophrenia can benefit from a wide range of community and social services, including:

  • Employment
  • Housing
  • Education
  • Peer support
  • Family-centred care and support for family members and caregivers

Care for people with schizophrenia should also recognize the specific needs of marginalized, underserved, or other subgroups (e.g., lesbian, gay, bisexual, transgender, and queer or questioning [LGBTQ] populations, Indigenous populations, specific cultural groups, survivors of sexual abuse or violence).

Care for people with schizophrenia should also incorporate what is referred to as recovery. As described in the Mental Health Strategy for Canada, “recovery—a process in which people living with mental health problems and mental illnesses are actively engaged in their own journey of wellbeing—is possible for everyone. Recovery journeys build on individual, family, cultural, and community strengths and can be supported by many types of services, supports, and treatments.”

Early in the development of each quality standard, a small number of health outcomes are chosen as the most important measures of success of the entire standard. The outcomes are mapped to indicators that reflect the goals of the standard. These outcomes and the associated indicators guide the development of the quality standard so that every statement within the standard aids in achieving the chosen outcomes. Each statement is accompanied by process, structure, and/or outcome indicators that measure the successful implementation of the statement.

The following set of outcome indicators has been selected to measure the impact of the schizophrenia quality standard as a whole:

  • Number of deaths by inpatient suicide among people with a primary diagnosis of schizophrenia
  • Percentage of people admitted to hospital with a primary diagnosis of schizophrenia who die by suicide within 30 days of discharge
  • Percentage of people admitted to hospital with a primary diagnosis of schizophrenia who experience an improvement in behavioural symptoms between their admission and discharge, stratified by their length of stay
  • Percentage of people admitted to hospital with a primary diagnosis of schizophrenia who experience an improvement in positive symptoms between admission and discharge, stratified by their length of stay
  • Rates of readmission to any facility within 7 days and 30 days of discharge, stratified by the reason for readmission:
    • Any reason
    • A reason related to mental health and addictions
    • Schizophrenia
  • Rates of unscheduled emergency department visits after hospital inpatient discharge within 7 days and 30 days, stratified by the reason for the visit:
    • Any reason
    • A reason related to mental health and addictions
    • Schizophrenia
    • Self-harm

We look forward to including patient-reported outcome measures in this list when validated indicators become available.

Schizophrenia affects approximately 1% of the Canadian population2. Between 2007/08 and 2010/11, the number of Ontarians with this condition increased from 98,413 to 119,5713. Data suggests that between 2006 and 2014 no improvement has been achieved in the quality of care received by people living with Schizophrenia in Ontario. For example, in 2014, 13% of patients were readmitted to hospital for a mental health or addictions condition within 30 days of a previous hospital discharge for schizophrenia; this proportion has not changed from the years 2006 to 20144 (Figure 1).

Figure 1

graph


To learn more about why this standard is needed, please review the Information and Data Brief for this standard.


2A Report on Mental Illness in Canada (2002) – Chapter 3, Schizophrenia, Public Health Agency of Canada.

3Ontario Brain Institute – ICES (2015) - Brain Disorders in Ontario: Prevalence, Incidence and Costs from Health Administrative (p.107)

4Quality Standards, Schizophrenia Care for Adults in Hospitals (Slide 7) - Data sources: Discharge Abstract Database, Ontario Mental Health Reporting System, Registered Persons Database, provided by the Institute for Clinical Evaluative Sciences. Crude rates.

"[Before joining this committee…] “I don’t think I ever had an opportunity to have a really constructive discussion about the mental health system. Those questions [addressed by the quality standard] were never able to be formulated because you just come into the system, you talk to a psychiatrist and you get re-directed, you get re-directed…and you follow a path that is set out by other people. A lot of experiences of clients and a lot of feelings and thoughts and viewpoints of clients are really not taken into consideration. If we can get the proper support and real, accurate, professional information and knowledge, we will not be so dependent on our mental health system. We can go on and live our lives. That would be good for so many aspects including self-respect and self-esteem. We will not be overly reliant on a mental health professional. [What underlies the standards is] self-determination, a person being able to find their own path, not feeling uncomfortable to speak, being able to feel comfortable to ask questions, to ask for what they need […] that is where I hope the conversations will start with this quality standard."

- Participant, expert panel

"Implementing the schizophrenia quality standard represents an opportunity to advance quality in a way that we have never had before and that no other province in Canada has had. Implementing the quality standard will represent a paradigm change. It will bring a better service user experience and a different lens that will be more aligned with recovery and better clinical outcomes for the patient. For example, we have historically assumed that people with schizophrenia just need medication and time. The new notion that a patient with schizophrenia gets a psychological treatment or at very least should be offered a psychological treatment is a really significant change. If patients and family members have these statements in front of them they will be more informed about the best evidence-based treatments and they will ask the right questions to make sure they get the best evidence-based treatments."

- Dr. Phil Klassen, expert panel member

This quality standard was completed in October 2016.

Updated: February 2017

For more information, contact QualityStandards@HQOntario.ca.

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