Implementation of Early Psychosis Intervention Program ... - EENet

73Table 32: Client referrals as part of discharge planning (Q 133)Where are clients referred post discharge % programs referring clients often to …Case management 31PC providers only 29Outpatient psychiatry 25College or university MH services 8Other community MH agency 8Other comm. addictions agency 6ACT team 4Main challenges to client graduation within 3 years noted by programs (Table 33):o Programs noted lack of appropriate alternatives (67% of sites), clients not being ready toleave (65%) and staff not ready to let go (12%).o Specific challenges noted:o Difficulty transferring clients to new services due differences in care, inconsistent followupor loss of contact with client.o Clients who do not meet eligibility criteria for other services or the referral process isunclear, complex or lengthy.o Long wait times for other services, especially community services, case management, andpsychiatry.o Also noted were concerns about relapse.Table 33: Reasons clients stay longer than 3 years (Q 132)Reasons clients stay > 3 yrs. % yesLack of appropriate alternatives 67Clients not ready to leave 65Staff not ready to let go 12Strategies suggested by programs for client graduation:o Planning ahead with clients and their families, which can be done using a discharge protocoland providing written materials to support the protocolo Beginning referrals in advance of discharge.o Alumni program activities, either through a graduation celebration for clients and peersupport opportunities or by using a shared-care model with PC physicianso Programs provide consultation support (some for more than a year) to providers who areworking with discharged clients, and 1/4 offer an alumni program, although no sites in smallcatchment area sizes offer this option.What would help programs with client graduation:o Almost all programs (87%) said that more services for graduating clients would help theirdelivery of EPI.o Access to information about community resources, for example a centralized access registryof community providers accepting graduated clients.o Peer support workers who can help clients with the transition process.