Exploring sustainable care pathways - a scoping review

Care pathways are used increasingly worldwide to organize patient care. However, there are different views about their effectiveness, outcomes, and impacts [1, 2]. There is a growing interest in extending care pathways in both primary and mental health care to improve the quality of service through enhanced care coordination [3]. Vanhaecht et al. [1, 2] defined the term ‘care pathway’ as follows: ‘A care pathway is a complex intervention for the mutual decision making and organization of care processes for a well-defined group of patients during a well-defined period’.

It seems to be consensus on the importance of early intervention in the treatment of mentally ill patients [1, 2]. Rutman et al. [4], find that the evidence between the relationship between care pathways and care coordination are sparse.

Care pathways are a way to improve care coordination and operationalise the patient-focused care concept [5]. The aim of care pathways is to improve outcomes by providing a mechanism to coordinate care and reduce fragmentation and, ultimately, costs [6]. However, several studies have revealed that care pathways improve the components of care coordination [7‐9].

Care pathways are not simple or straightforward but rather complex interventions; they comprise separate elements that seem to be essential to the proper functioning of the intervention; they target multiple outcomes and involve multiple interventions, and the ‘active component’ is difficult to specify [10, 11]. Consistent with this definition, the characteristics of care pathways include ‘an explicit statement of the goals and key elements based on evidence, best practice, and patients’ expectations and their characteristics’. This includes a range of elements: facilitation of communication among team members, patients, and families; coordination of the care process by coordinating the roles and activities of interprofessional care teams, patients, and their relatives; documentation, monitoring, and evaluation of variance and outcomes; and identification of the appropriate resources [10].

Care pathways are popular tools to improve the quality of the diagnostics, treatment, and follow-up of hospital patients [10, 12]. Mental healthcare delivery systems and policies have shifted the focus from more extensive psychiatric inpatient settings to community services [3, 13, 14]. Yet mental health in-patient facilities continue to discharge patients too early, without clear discharge planning, and the post discharge follow-ups do not function properly [15].

People with mental illness often experience stigma and social rejection when returning to their communities [16]. Research reports engagement in 6–12 months community rehabilitation compared to shorter inpatient rehabilitation [17]. Transition of care is particularly important for patients with mental health problems who experience numerous transitions into and out of hospital. This transition comprises hospital discharge, post-discharge support at the next level/location of care and the engagement of the patient and caregiver in these processes [18].

Patients as high-frequency users of psychiatric services in hospital, remaining well for only short periods of time [19]. These patients have diverse preferences for care and face a variety of barriers associated with mental health treatment [19, 20].

Many persons with mental health problems will have need of services from different levels at the same time and this context suggest need for easy access to a range of treatment and providers [3, 21‐23]. Essential elements in this care process are open communication and well-organized, delegated coordinating roles for interprofessional care teams [24, 25]. With care pathways, high-performance teams can be built [4]. Chew-Grahee [26] pointed out that, depending on its quality, communication could function as both a promoting factor and a barrier to success. Starfield et al. [27], identified the following key elements in the integrative functions of primary care: first contact, continuous, comprehensive care and coordinated care. These four elements are implicitly incorporated into the health care system to improve outcomes [28]. Vickers et al. [29], noted that expanding integrated mental health care in the primary care setting/services resulted in increased staff and provider satisfaction.

Thus, the aim of a care pathway is to enhance the quality of care across the continuum by improving risk-adjusted patient outcomes, promoting patient safety, increasing patient satisfaction, and optimizing the use of resources [11, 30, 31].

The extent to which these discourses have impacted on individual clinical practice and care experiences remains unclear. Crucially, the involvement of patients at points of transfer of care from the community to inpatient settings and back to the community has been underreported. Tveiten et al. [32], advised giving patients in mental health contexts a voice to express their concerns and have them addressed. A study about patients’ knowledge and the power imbalance in the doctor–patient relationship supports our assertions that patients need knowledge and power to participate in shared decision-making processes [33].

The study offered several recommendations for enhancing patients’ participation by simplifying the trialled pathway and the accompanying guidelines and strategies to improve communication between nurses and general practitioners. Pelto-Piro et al. [34], found that paternalism still clearly appears to be the dominant perspective among staff caring for patients in psychiatric inpatient care settings. Grim et al. [35], described obstacles to legitimizing patient knowledge, including relational issues that patients highlighted: being independent, often being dismissed and unable to edit their testimonies. Health providers typically described workflow issues, patients’ insufficient decision-making competence and patients’ vulnerability to stress factors.

Care Pathways are developed and implemented across the international health care arena, evidence to support their use has been equivocal, and the understanding of their ‘active ingredients’ is poor. Care pathways are ‘complex interventions’ and are increasingly being implemented for a variety of purposes in a range of organizational contexts [1, 2, 36]. The development and implementation of care pathways are based on interprofessional teamwork, an understanding of the practical organization of care and the integration of a set of evidence-based key interventions [1, 2]. A recent study evaluating the implementation of a transitional discharge model, an intervention for community integration of clients with mental health illness, concluded that this implementation provides cost-effective supports to help keep clients in the community and out of hospital [37]. And as reported previously [22] the establishment of relationships among patients, inpatient staff, and community staff is of utmost importance in the transition process between inpatient and community mental health care.

In mental health care pathways involve a significant change work which should give the patients more holistic and coherent services but are hampered by professionals experiencing large workload, frustration and stress associated with registration, and administration systems [38]. A bottom-up implementation strategy for implementing care pathways is recommended [39]. Ruben von Zelm [40] concluded that the implementation and normalization of a care pathway depends on the following: involved professionals, including physicians, to achieve the desired outcomes; understanding and appreciation of the content, goals; and related standardization of the care pathway and play an active role in the improvement team. Implementing the pathway requires: resources, including a care pathway facilitator and a clinical data system; the improvement team’s experience, collaboration, and clinical leadership; and individual experience and expertise [12].

The purpose of the study is to provide an overview of studies assessing clinical care pathways for people with mental health problem in the transitional process from hospital to the community.

Grant and Booth [41] described scoping review as ‘a preliminary assessment of potential size and scope of available research literature.’ We followed Arksey and O’Malley’s approach [42], and used Levac [43] as a guide, for how to operationalize each step.’

Arksey and O`Malley`s [42] five-stage methodological framework including:

1) identify the research question; 2) identify relevant studies/articles in a literature search; 3) select relevant studies/articles based on inclusion and exclusion criteria; 4) chart the data extraction in a standardized form; and finally, 5) collate, and summarize the results, including the assessment of methodological quality.

A scoping review method was chosen to gain a comprehensive overview of the literature to map key concepts, identify knowledge gaps and convey the breadth and depth of the field [44‐46]. At the abstract screening stage, we keep the references that meet the inclusion criteria for review and those that we are unsure about. We dismissed the rest. The references we kept was moved to the next stage in the selection process: Arksey and O`Malley [42] full-text screening.

Among 28 selected studies: was 19 quantitative synthesis and nine qualitative syntheses.

The literature review identified themes and issues relating to: Organization; Resources and Outcomes; Information and Documentation; Patient and Family’s Participation; Clinical Care and Teamwork; and Ethics. Articles supporting the included studies are indicated with reference number in italics. Issue concerting the first of our themes, organization, seem to embrace our findings concerning improving pathways of care, and system and procedures should be developed to ensure clear responsibilities and transparency at each stage of the pathways of care. Effective transitional interventions at patient, provider and system levels were found to be feasible and likely to be cost-effective. To address transitions in the health mental population more effectively care pathways need special procedural guidelines, instructions and links to national guidelines provided in the prehospital, hospital, outpatient, and home phase [51]. A study of Sather [70] concluded that to achieve sustainable integrated care, pathways of care should also describe content of the transitional phase in and out of hospitals and community services.

Facilitated pre-discharge, post-discharge, and transition processes, and promoted timely communication of inpatient staff with outpatient care or community service providers after discharge were successful components [52]. First contact is important in pathways of mental health care, and there is lack of integration between emergency departments, hospitals, and community [55]. Care pathways led to better coordination of care and follow up with primary care [62]. The first contact for patients was a physician, but the referral source was emergency services. Ethnic determinants of the pathway, or the impact of the pathway to care on treatment delay was not found [54]. Earlier research has stated that the context of care pathways implemented in complex organizations must be considered in both external and internal contexts and have better descriptions of implementations and the contextual factors [12, 71]. An understanding of the development changes and implementation process of a particular context is critical to support multidisciplinary teams in their search for excellence; and it is recommended that clinicians and managers should evaluate each of their individual projects to ensure that patient and organizational outcomes are improved [72, 73]. Information technology supported care pathways and improved objectively measured patient outcomes and resources [13, 60]. It supports decision-making and referral, and available resources; made more cost-effective care pathways and allows for active case management and clear leadership, relationships, support decision-making and referral, and available resources [13, 59, 63]. It was found that care pathways may lead to better clinical outcomes, ensure more focused interventions and be valued by workforce [48, 52, 65]. This is in line with Mater et al. [74], who emphasized that development and implementation of care pathways are knowledge-based systems, care pathways optimize medical behaviour, and as clinical decision support systems, care pathways play a role in improving healthcare quality [74]. Our review revealed that pathways are a solution to safety problems and can improve extended care episodes as part of preventing unnecessary hospitalization [3, 59, 66]. Development and implementation of care pathways is labour-intensive; thus, resources should be optimally used.

Opportunities for information sharing, implementation of systematic plans, use of e-messages were identified for successful patient transition, and the absence and systematic plans and delay in information sharing were barriers found to impede the patients’ transition between levels of care [20, 22, 23]. Care pathways were found to reduce in-hospital complications and improved documentation without negative impact on the length of stay and hospital cost [50]. This is in line with research in somatic health care [75, 76] that has shown that the implementation of a care pathway leads to increased or clearer documentation of care, and better interprofessional teamwork and better organized care [77, 78].

Continuous collaborative decision-making and patient and family’s participation was found to be an important factor related to pathways to care. Care pathways affected patient safety, supported autonomy and activities in community [59]. It was found that patients revealed oscillation between feelings of strength and vitality to vulnerability and despair in transition phase and emphasized supportive relationships and work [67]. Continuous collaborative decision making was emphasized, but this was not regularly experienced. Families perceived that care planning was uncoordinated and that their lived experiences were not always appreciated [57]. It was also found that improved information sharing in/between all care systems is imperative to strengthen patients’ participation in decision making, ownership of care plans and improve adherence to treatment. Additional, patient participation in care plans were success factor [20, 22, 23] as well as shared decision-making support for caregivers. Power and trust seem to be important factors that may increase as well as decrease patients’ dependency, particularly as information overload may increase uncertainty [79].

Clinical care and teamwork were found to be important in pathways of care; collaboration between mental health and other professionals was a guarantee that planned activities meet patients’ needs, and pathways gave more interprofessional aspects, changing professional attitude positively [48]. Regular meetings sharing key information and avoidance of delays that extend inpatient status and block satisfactory transition to the community setting are key [22]. It was revealed that care pathways have the potential to support interprofessional teams in enhancing teamwork. The most frequent positive effects were on staff knowledge, interprofessional documentation, team communication and team relations ⁵⁶. Open communication, well organized and delegated coordinating roles for interprofessional care team delivery are essential elements so that the service is consistent with agreements reached with patients and relatives [24, 25].

Mental health professionals support is key in help seeking for patients and important to their recovery process in general alongside transition to the community [67]. Patient-centred care was among the least investigated topics between mental health specialists [14]. Research indicated that creating reliable treatment and care processes, a stimulating social climate in wards, and better staff-patient communication enhances patient perceptions of safety during inpatient care [79]. The review showed considerable variations in the ethics relating to mental health care pathways. The role of general practitioners could either decrease or increase the referral time, and stigma and discrimination towards patients with mental illness are limiting factors for the equal delivery of mental healthcare [53]. The results highlighted the disconnect that occurs for patients as they transition from hospitals back to their communities, indicating the need for effective, ethical transitional interventions that target these challenges [59]. Lack of information could result in increased perceived stigma and devaluation of people with mental health challenges. Stigma and lack of awareness where treatment is available were barriers to seeking appropriate care for patients with various diagnoses of mental illness. The complexity of welfare systems negatively affected patient dignity, with patients and health personnel viewing treatment options differently. Respectful communication to avoid humiliating the patients was emphasized [20, 66]. Without ownership in decision making, patients in psychiatric inpatient care settings may prove less treatment compliant [34]. A recent study suggested that greater epistemic justice might be achieved by shared decision-making processes in which patients are engaged as a full, collaborative partner in their care [35]. Many of the studies were characterized by small study samples, no randomization and lack of control group, which increases the risk of bias and the ability to draw conclusions about outcomes [47]. Despite a comprehensive literature search of multiple databases that used broad search terms, the search may have missed relevant studies. These searches did not result in the inclusion of additional studies. It is recommended to consult experts in the fields as a separate but optional stage in the search strategy [42, 45]. However, expert consultation was not feasible in this study. Discussions among the authors on the depth and breadth of the review during the study selection stage may have resulted in a reduction of the scope. An assessment of methodological quality of the studies is debated within the scoping review tradition (Pham et al.; [80]). 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.

In pathways of care, systems and procedures can ensure clear responsibilities and transparency. Information technology could support decision-making and referral to improve objectively patient outcomes in care pathways. Collaboration between mental health and other professionals can guarantee that planned activities meet patients’ needs through regular meetings sharing key information. Around-the-clock ambulant teams in the community are important alongside informed shared decision making, information and documentation between all parties to support patient participation. Respectful communication can avoid patient humiliation that could undermine treatment compliance. The combination of professional and patient perspectives best promotes positive outcomes from sustainable care pathways.