The CRA service
The study took place in a community residential aftercare (CRA) service in Trondheim, a city in Central Norway with 190,000 inhabitants. In September 2009, the municipality established the short-stay CRA for patients with SMI discharged from the mental health department at the local university hospital. One aim of the CRA was to reduce the time the patients, who normally would be in need of public community services after discharge, spent in the mental health hospital after they are been declared ready for discharge. This is done by supporting self-care and facilitating community health and social services, as described below.
For the patients to be eligible for discharge to the CRA, the hospital must have assessed and document that the patients are ready for discharge, such as deciding on the main diagnosis and starting a treatment plan. The patients are usually transferred on the same or following day after the hospital have contacted the CRA. The stay at the CRA is voluntary, meaning that the patients can leave any time they want to. The tentative length of stay in the CRA is up to 4 weeks, based on experiences with the time it takes to organize public community services that the patients’ needs once, when living at home. The length of stay is usually longer for homeless patients’ due to the practicalities of making housing arrangement. In 2016, the average of length of stay at the CRA was 37 days (69 patients), 64 days for homeless (14 patients) and 29 days for those with a residence (55 patients).
The CRA has 14 single rooms with their own TV and bathroom, 10 reserved for discharge-ready hospitalized patients (step-down), and for patients living in the community who are homeless or need another residence (step-up), two rooms reserved for self-referral patients who have previously been at the CRA, and two rooms reserved for sub-acute admission directly from patients’ residence (step-up). There are also three single rooms not in use. Patients using beds as part of step-up were not part of this study. There are common rooms and kitchen where the patients can make their own food, whenever they want.
The CRA operates 24/7 and is staffed with psychiatric nurses, general nurses and nursing assistants. All except one have experiences from community services to ensure their understanding of the need a patient can have in the community. Four employees are present during the day, two at the evening shift and one nurse during night shift. In addition, a team leader is present at daytime on weekdays. The nurse on the night shift can alarm for assistance from nearby services. The staff has training in recovery-oriented strategies, such as self-management and self-responsibility to manage daily activities. A general practitioner (GP) is present in the CRA 1 day a week and offers a consultation to all patients who have recently been admitted, and those in need of medical follow-up at the CRA. The GP cooperates with the patients’ regular GP and requests the patients to make regular appointment with these.
To prepare patients for independent supported living the patients are directed to activities in the community. The philosophy of the CRA is to purposively not offering any in-house activities. Instead, the patients are informed about activities in their neighborhood and in the community. Thus, there are no organized activities at the CRA like common meals, therapy options or equipment for exercise. Consequently, there is a strong emphasis on and practical training to support self-care; how to structure daily routines including sleep patterns, strategies to cope with difficult symptoms, personal hygiene, appointments with other agencies, self-care and independent living like use of public transport, shopping, meal planning and social and leisure activities outside the CRA. The patients also have overnight stays in their own home during the stay at the CRA.
The CRA also is central in facilitating the process of establishing community health and social services to support the transition from the hospital to independent supported living. When patients arrive, they get a dedicated contact person whose main responsibility is to support the patient during the whole stay. The contact person also observes and assesses the patient following a checklist presented in Table
1, always with a focus on preparation for the discharge process from the CRA. During the stay, the result of the individual assessment is discussed with the patient and communicated to the community Health and Welfare agency services to help them agreeing on the level of services to be provided after discharge, e.g. housing for homeless, relocation (move away from a substance abuse neighborhood), home nursing services and home care services. This is done in meetings, coordinated by the CRA, between the patient and the agencies that offer the different types of services that are judged to be appropriate. The process is started as early as possible to establish relationship between the patient and the service providers offering the follow-up services after discharge.
Table 1
Checklist for observation and assessment of patients used by the staff during the CRA stay in preparation for the discharge planning process and to help decide on the type of services to be offered afterwards
Self-care | Hygiene, food preparation, diet, cleaning, washing, shopping, exercise/activities, and mastering substance abuse problems |
Medicating | Self-medicating, misuse of medicines, need of support with medicating |
Economy | Assess needs of any support to manage finances, e.g. pay bills |
Social network | Assess the social network, relationships, and participation in any social activities |
Housing | Visit the residence together with the patients – assessment of the facilities in the residence, such as cooking and cleaning |
Primary care services | Assess present follow-up services and other tailored services |
Leisure time | Assess patients’ hobbies and interests |
Facility | Assess patients’ technical aid needs |
Mobility | Assess the need for assistance to take the bus, visit public offices, cultural and leisure activities |
Job/education | Assess present education and job – arrange job/education or activities together with the patients |
Before discharge | The contact person organizes a meeting with the patient and community agencies for assessment and approval of tailored services. The follow-up services must be up and running at home at the expected date of discharge. The general practitioner has received discharge summary from the CRA. |
Before discharge from the CRA, patients receive information about the possibility of later self-referral to a short (maximum of 3 days) inpatient stay at the CRA.
Sample and recruitment
The aim was to recruit patients with SMI currently staying at the CRA or who had been discharged from the CRA within the last 4 months. Participants were selected to ensure variation in age, gender, and time from admission to the CRA or time since discharge from the CRA.
To recruit participants for the individual interviews, the team leader in the CRA introduced the study to eligible participants at the CRA both orally and by handing out invitation letters. Eligible participants who had been discharge were contacted by phone. The CRA staff passed on contact information for those who wanted to participate to the first author (ER). Then, the first author contacted the participants by phone and repeated and gave more information about the study. Patients were given the choice to be interviewed in their own apartment, in a public office, or in the CRA.
To recruit patients for the group interview, the team leader in the CRA handed out invitation letters to eligible participants at the CRA and scheduled the interview. The group interview was conducted in a common room at the CRA.
Data collection
The individual interviews were conducted by the first author, and the group interview by the first (ER) and the fourth author (AS). The staff in the CRA did not take part in any of the interviews, but a contact person was present at one individual interview at the patient’s request. The interviews were audiotaped and transcribed verbatim. The average time of the individual interviews was 27 min (range approx. 15–45 min), and the group interview lasted 1 h and 47 min.
An interview guide (Additional file
1) was used in all interviews to ensure that all participants were given the opportunity to comment on the same topics. The main question was “Can you tell me/us about your experience with your stay at the CRA?” The follow-up questions addressed what the participants were most and least satisfied with, their daily activities during the stay, and how they perceived the organization of services they would need after discharge. Those who had used the self-referral inpatient care were asked about their experience with this particular service.
Analysis
The data were analyzed following systematic text condensation, which is a method suited for thematic cross-case analysis inspired by Giorgi’s psychological phenomenology approach [
27,
28]. The analysis started after the first four interviews were done and continued simultaneously with the recruitment and interview process. The recruitment continued until no new themes emerged from the analysis and the material was considered saturated.
The analysis itself was also iterative, meaning that the four distinct steps of systematic text condensation were repeated during the process. The first step was to read the transcribed interviews with an open mind to obtain a general impression and to identify preliminary themes. The first author read all interviews and selected, based on richness, two individual interviews that all authors read. In the second step, the transcripts were systematically reviewed line by line to identify meaning units, which were classified and sorted into the preliminary themes. Particularly at this step, the authors had several meetings to discuss and refine the subthemes and themes. In the third step, the meaning units within each subtheme, established in the second step of analysis, were reduced into a condensate, an artificial quotation maintaining, as far as possible, the original terminology applied by the participants. This facilitated further sorting between the subthemes. In the fourth and last step, the condensates of each subtheme were rewritten in general descriptions, and the final sorting of subthemes into the main themes was finalized.
The main part of the analysis was performed by the first author and discussed with the co-authors. The analysis was further validated by a thorough review of the original transcript of each interview to ensure all points of significance were reflected in the results. The quotations that best illustrated the themes were chosen to support the results. The description of the chapter “The CRA service” was validated by the manager and the team leader of the CRA to ensure that the authors had understood the purpose and the philosophy behind the CRA.