TRA ITI R p R M HI Rl R T RIM RY h ryl Du ault c , riti h UN IV -< R ITY lumbi a In titut f cc hn 1 gy, 2 F N RTHERN BRlTI H March 2015 © h ry1 Du ault, 2015 L MBI R .. 11 b tra t n u F r adult with e cr m ntal illn .' there ar are man type with 1 r lransiti n. f ca rc. h r [ tran iti n that pati nt. e p ri nee th at can ncga ti el affc t c nti nu ity f ar . he tran iti n ca n al pr ~ n ti 1 su c ITIJ und r ati cnt' illn c . h [! cu ithin the limit [ thi re ctting tran iti on fr m ac ute t primm ca re. he p int of di scharge fr m acut p hiatri ar t primar ca re i a ritica l tim e in th care c ntinuum, and it h uld be treat d ith th utm e id n ba ed prac tic and c ntinuity f car t imp rtanc he 1 urp c f thi int grati vc rc 1cw 1 t e am me and pr ce e m rd r t id ntif way t fa ilitatc ca ml cs tran iti n [! r m ntall y ill adult care. Further, t offer reco mm endati n di harged fr m acute p yc hia tric care to primary [! r Famil y ur e Practiti ncr practi cing in prim ary care exampl are pre nted al ng with an o er 1ew f primary ca re. A c mprehen ive earch trategy identifi d 17 relevant tudi e . Four key findin g underline the imp Jiance of co nfid enti ality, linkage between acute and primary care, c mmuni cati n, and therap uti c relati on hip . The recommendations offered are directed to the P in primary care, but are rele ant to many healthcare provider . They may al o be helpful in oth r etting , uch a acute p ychi atric care or community mental health . K ~yword : tran ition of care, c ntinuity of care, evere m ntal illn e , famil y, primary care, famil y nur e practi tioner, primary care pro ider 111 T BLE OF ONTENT .. b tra t .............. ..... ... ........... ... .. ...................................... ... .. ... ........................................... ............ u Li t fTab l ................................................................................................................................. JV Lit fFi gur ..................................................................................................... ............................. v Dedi cati n ................................................................................................ ...................................... vi .. ck.no l dge1ncnt ....................................................................................................................... v u hapter 1 Introdu ction ............................................................................... .............................. . 1 R earch u ti n and im .................................................................. ... ............ 7 Chapter 2 Backroviding a patient's care. They serve as the entry point for patients' m edical and healthcare teeds, and are charged with coordinating the use of the entire healthcare y tern to benefit the >atient (Aggarwal & Hutchison, 2012). Patients with SMI and their famili es eek general nedical care, advocacy, and support from the primary care provider (Le ter, Tritter, & orohan, 7 2005 · Ru 11 t al. , 200 pr vid r workl ad b ca u . hi mp n nt f car add f th chr nic and mpl ub tanti all y l a pnmary car nature f e r m ntal illn s ( est r et al.) . The intr ducti n f thi paper ha id entifi d th unp Iian f thi t p1c a it i unding a y un g adult' ca r tran iti n during an acute e emplifi ed by th v nt p ychi atri admi n and di harg . Th int nti n f th rc earch and utT rall purp e f th paper foll w . Re ea rch Qu e tion and Thi proj ect will meth dica lly and criti all y r 1m iew evid enc to an wcr the re earch qu e ti n: What are evid nc ba ed pra tice and pr ce e that help to achieve eaml e s tran iti on and continuity of care fo r mentall y ill adult di ~ charged from acute p ychiatri c care to primary care? A critical an aly i and ynthesi of the findin g w ill be the ba i of prac tice ba ed recommendation for Famil y N ur e Practitioner in primary care in anada, in an effort to improve tran itions of care for adult di charged from acute p ychiatri c care. The practice ba ed reconm1endations will also be useful to other healthcare providers in both acute and prim ary care setting . While policy and systems level change is important it is beyond the focu , scope and limited ize of thi paper. This chapter has hi ghli ghted the significance of a compl ex and unpredi ctable illne course for individuals with SMI. Chapter Two provides an overvi w of concept and bac kgrou nd information on severe mental illnes and care transitions. Chapter Three offer an the methods for thi s proj ect, including the search trategy and analysis. An anal y is of th med findin gs is pre en ted in erv iew of lection of relevant literature for hapt r Four. A di cu ion of pra ti e and proces e that h lp achieve eamJ ess tran ition and continuity of care i presented in 8 hapt r Fi . Th pap r c nclude with a ummary c nclu i n, and r c mmend ati n D cu mg n the practice lev l f F P car and implicati n [! r future r ar h. H P R2 Ba k ro und Th dia gn f Ml me with tra rdina1 health, health are, burd n . In rd er t appr ciat th magnitud [ MI, and th are [! r thi p pul ati n r 1 ant c nce1 t and ont ci tal, and financial ignifica n e f aD tran iti n of tual c n iderati n will be pre ented. S evere Mental /lin es gen eti c urobi 1 gica l pl an ati n .D r m ntal illne n ironmental, ng nita! and de el pm nta l, and ma ny th at rema in unkn w n (Kaa , Lee, & Peitzman, 2003). The t 1m e ere mental illne include a myriad of ca u e , including M I, i an umbrell a tenn u ed to de crib m ntal di ea e that are di abling and persi tent (G ld Kilb em , & Valen tein, 200 8). evere, eri ou di ord er and/or per i tent mental illne uch as chizophrenia are term u ed interchangeabl y to de cr1b e chi z affecti e, bipolar di ord er (BD ), maj r depr s ive disord ers (MDD), ob e ive compul ive di order ( CD), panic di ord er, po t-traum ati c stre s di order (PTSD), and bord erline per onali ty di sord er (BPD) (Kilbourne Keyser, & Pincu , 20 l 0; N ational Alliance on M ental Illness [NAMI] , 2014 ). A detailed description of th e definiti on of the disorder listed and other k ey term and concepts in this paper are located in th glo ary. For the purposes of this paper SMI will refer to these di sord er . Individuals with the e di sord ers can exhibit challenging ymptoms requiring considerable amounts of care and upport (Vella & Pai, 201 3). They are likely to have concomitant medical problems and suffer excess morbidity and mortality, compared with the general population (Kaufman, M cDonell, ri t falo, & Ri es, 20 12). They di e at an average of 25 years earli r than the gen ra l popu lation, w hich also refl ect an increa ed occunen of ui id am ng th m ( arley et al. , 20 13; Knapik & Gra r, 201 ). The co n equ en e of thee di orders 10 n t nly ad er el affect th indi idual with th illn and their familie , but al n ga ti ly impact the c n my a a wh 1 . The h alth probl m and burd n Thee timat f MI ar pre alent thr ugh ut th d vel p d world. f th in id n e f m ntal illne inc mmunitie ar ne in fi e pe ple e peri ncing a ignificant m ntal illn (Millik n, 2007). F r m any, th illn at wi ll b gin in y uth r y un g adulth od. he di abilitie uch a diab t m llitu cardi n wi th MI uffer m re a cu lar di ea e, b tru ctive pulmonary di ea e, and be ity, c mpared t the general p pulati n (Kna pik & The everity of the illne (Knapik & ryw h r with me p int thr ugh ut life can b pro! nged and the effect can la t a li~ tim (Milliken) . Per from clu· ni phy ica l illn imilar ra r , 20 13 ). t nd to be greater than th at e perienced by the general popul ation ram} Peopl e with MI are more prone to infection and injurie and frequently take ri ks in their life tyle , such a making and ub tance abu e (Farley et a!. , 20 13; Knapik & Graor) . For younger adults, the per onal negative impact i related to edu cational achi evem ent, occupational or career opportunities, and ucce e . Severe m ental illne s a! o impacts the formation and nature of personal relation hip where the effect extend throu ghout an individual's life (Public Health Agency of Canada [PHAC] , 2012). In 2001 the World Health Organiza tion (WHO) de cribed m ental di orders a having an impact on the quality of life of individuals, their familie , and society. The economic burd en on the Canadian economy is described in terms of productivity losse and healthcare costs. In 1996/97 , the Publi c Health Agency of Canada (201 2) estimated the cost to the Canadian healthcare system to be $ 14.4 billion. The WHO reported that in 1990 m ental disord ers accounted for ten percent of the world' s total di ab iliti es. By the year 2000 th numb r was 12%, by 2020 it i proj ected to have increased to 15% . 11 An qually imp rt nt and un ettling burd n f MI i th mi und r tanding a r quir ( individual with MI ft en d n t r di criminati n r ult in 1 clinical r ice than for rr ar f h alth ar ( Ke n 200 ; Picard , 20 12). rgam z d bey et 1. , 2011 ). In anada, m ental h alth n mic burden of illne e ten iv h burd en f m ntal illn e and nth ri e. Thi burd n place an incr a ed dem and n h althcar rl y c th y mplex, rga ni za ti on . Within h althcare y t m th ere i increa ing c ncem ab ut th adver fin ancial outc me of fragm nted and p ult, H , 014 . tigm a and ar h fundin g ~ r mental health and p en r1ce ar und rfund ed in r lati n t th ir pre a l nee and the e inflict (Kirb y ). hich re ult in di c1iminati n and tigm a (Kirby, 2 ith m ntal illn iated human and rdinat d care. hi concern i h ightened by quality car indi cator th at re ea l p or patient tran ition , repeat ho pitali za ti n , and preventabl e emergency r om i it (Trachtenberg & R yv ic ker, 2011 ). In readmi i n for mental illne anada, the rate of are hi gh , relati ve to tho e for mo t o ther di ea e ( anadi an Institute for Health Inforn1ation [CIHI] , 20 14) . Readmi ion rates for m ental illness within one year of discharge are 37% compared to 27% for other typ e of illne ses (M adi , Zh ao, & Li, 2007) . Po t-di charge suicides tend to cluster in the fir t few weeks after di charge (CIHI). Tran sitions of Care Every patient admitted to acute care has already exp eri enced one tran ition and unl ess admission results in death, the patient will eventually experi ence a econd tran sition to another setting (Russell, Doggett, Dawa da, & W ells, 2013) . "Tran ition of ca re" refe r to the de livery of service de igned to en ure hea lthca re continuity. It refers to the movement of patients betw een healthcare etting or provid er , or b etw een different level of care wi thin the ame location (National Tran iti n of ar oalition 12 [ T ] 200 ). n arly very typ care in an th r he c p p d cr e ut m f h alth ar tting tting and di u h a pnmar ntinuit a nd e p ciall re ( he J int mm1 ccur fr m c ut care t n, 0 14). f car bet een acute and primary care a f thi pap r ~ u rl y m anag d tran iti n f are during car tran iti n en u pr bl m Je pardizing c ntinuity f care, incr a ing th ri k f ho pi tal r adm i i n and ympt m e acerbati n r del teri u outc me (Pu elmer t al. 20 11 ; w r & R hland, 2004; tcffen K ·· ter ecker, Pu hn r, 2009). When co rdinating th care of pat ient wi th M l car pro id r m u t ackn w ledge that tran ition t the community m ay be m re difficult for the e pa ti nt than ~ r m any oth er ( omez, 200 ). T date re earch n care tran iti n ha larg ly b en focu ed on the gen ral m edical patient populati n and only a m all number have pecifi cally foc u ed on the m entally ill (Viggiano et al. , 201 2). H owever, m an y fac tors have been identifi ed a co ntributing to ineffective care transition , and the e barri er explain wh y care transitions do not always go smoothly. Barriers to Tran sitions of Care Among the common barrier to effective care tran itions are the chall en ges with infonnation sharing and cormnunication betw een healthcare provid ers and care settings. Thi 1 largely du e to inadequate sy terns for delivering information reliably betw een provid er (Chon g, A lani, & hen, 2013 ). Universal electronic health infon11ation ystem with connectiv ity aero settings, such as hospital, clinic, or office, are lacking or nonexi tent in m any ca es ( a leman & Berenson, 2004) . Th ere is also concern about the uboptimal quality and tim line of di charge um.marie and about the y tem for deliverin g tl:ll information reliably betw en care setting or 1 11 tal. 201 ). pro id r (Ru id ning the 111muni ati n gap and narro\ ing th e likelih inall , ambiguit and g neral pra titioner tal. , 201 ). Wh n di and c llaborati e pr ften functi n in i alation, d fa tgm ng re p 11 ibility wh n B r n n) . probl m ari e ( care and th health are er ice ik urr unding th r le f primar car pr 111 p t-di harg are ften imped ider (P P ), u h a F P effectiv care tran iti n (Ru 11 harg planning i d ne v ell it i c n idered a dynamic, compr h 11 ive, initi t d at th tim upp rt that the patient and hi f admi i n t determine the patient' pl an o f r her family may require after di charge Alghzawi , 20 12). For di charg from acut care tting t go w 11 , patient w uld have an ace untable pnmary care pro id er during all p int f care tran iti n, in ce pati nt and h ea lthcare sy tem tend to rely on ptimary care provider to coo rdinate patient care between care etting ( T 2008· Russell et al.). Unfo1iu11at ly, the ran ge of ervice frequently required for th e pati ent with SMI often exceed the coordination capacity of the primary care provider, addin g to the challenges of achieving succe ful care transitions (Pauze, Gagne, &Pautler, 2005). The Family in Care Transition The context of family in care transition is based on the a umption that familie want to play a supportive role in the care and treatment of their ill relative. It is important to recognize that not all individuals with severe mental illness have families that play a po itive role, or any role in in their care. Some individuals do not have familie that are involved with their wellbeing on a day to day basis. For the purposes of this paper, the term fa mil will refer not only to biological relati es but to all people identified by individuals with SMI a important to th ir reco ery or tr atment, such as spou e , friend , romantic pa11ners, and room-mates ( olomon, 20 12). Res arch has 14 h wn that famil m 1 em nt in the car m rbidity and m rtalit (Kaa urc of upJ rt fl r p pl f indi idual tal. 200 · Macfarlan ith MI and ft n pr daily li ing and financial upp rt (Ma farlan ). ad f MI i efG cti e in redu ing 20 11 ). amili are typically a major ide h u ing a i tanc amilie pr ith a ti iti f id cri i interv nti n and cat on b half of their ill relati e , h lping them t na igat th mental health y tem (Macfarlan . Th y m nit r npt m and nc urag treatm nt and m dicati n c mpliance (Macfarlane) . Thirty-fi familie (Ward- riffin, ith MI are li ing with r receiving care from h fi ld, & at w rthy-Pu p ky, 2005). In anada, approximately 50% f adult with chiz plu· nia li e with their familie (Ward- riffin tal.) . aring for a r lati e with Ml can b a life altering experience that few people are prepared for (Rowe 20 12). With a hift fr m acute caret c mmunity-based care, more respon ibility for p ycho ocial care ha been placed on family caregi er (Rowe). Familie are faced with n1ultiple i ues in caring for a r lative with MI. Per onal , interper onal, and sy temic challenges faced by fmnilie include lack of acknowledgement of their care giving role , tigma of mental illne s, and poor relation with the mental health, legal, and welfare ystem (WardGriffin et al., 2005). Banier to providing care to an adult family member with MI stem from poor engagement and communication with healthcare providers, and familie ' own abilitie to cope (Rowe). Poor engagement and communication are comn1only related to matter involving privacy and confidentiality. Privacy and Confidentiality in Care Tran sitions The ri ghts to privacy and confidentiality are fundamental values and right for all members of society, including individual with mental illness and persons with MI wh ha e been involuntarily hospitaliz d (0' Rei ll y, Chaimowitz, Brunet, Looper, & Beck, 201 0) . Federal l and pr m iallaw pr teet an indi idu al' ri ght t pn a health informati n thr u gh a t 201 0). Pr illn red und er the M ntal H alth in iallaw that g H althcare pro id er \ cod nfid ntialit f p r onal and r ed m fIn~ rmati n and Pr t cti n f Pri acy u ha Act ( RNB are c and 111 th car and trea tm nt f pe ple w ith m ental ct ( utl r Phillip , 20 1 ). rking in m ntal h althcare ar b und by law and pr fe i nal f condu ct t a duty f confid ntialit t th ir patie nt (R yal ll ge of P ychi atri t , 2014) . If a h althca r pro id er breache c nfi denti ality they can face di cipl inary m ea ure , including being ued or di mi d (Roya l !l eg of P ychia tri t ). Pri acy and c nfidenti ality f patient h ealth in~ nnati on take n unique m eaning in m ental h althcare b cau e of matter uch a ti gm a a ciated w ith m ntal hea lth illness, or issue of fan1il y dyn amic (Bern te in, 20 14). eve re me nta l illn e sca n a lter an indi vidu a l' I ve l of understanding, rea oning, and j ud gment. become more problematic w ith on equentl y, i ue uch a infonn ed con e nt m ay ri ously mentall y ill pati ents (Am er, 201 3). Therefore, balancing patients' rights and fan1ili es seeking inform ation becom e a challenge for healthcare providers (Betnstein) . At time of crisis relationships can be trained and healthcare provid ers m ay get a fa! e sense ofthe true family dynamic (Royal Coll ege of Psychiatrist , 2014). Mi conception about the family can impede information sharing with them, or considering them as a resource in care. Tllis is compounded if the patient does not consent to information sharing with family m ember . Healthcare provid ers involved in a patient 's care have a duty to follow profe ional codes of practi ce and law regarding confide ntiality (Royal College ofP ychiatri t ). When pati ent entru t their care and personal health information to a healthcare provider, th y e pect that it will be kept confidentia l ( RNB , 201 0) . In a similar vein of expectation , patient e pect their 16 am ng all [their inD 1m a ti n t b u d in a a[! guard c ntinuit Muld neau Th [ th ir car in a c m1 l r 1r id r , in rd r t an, Ru ell , gg, R h althcar n, 200 an dian a param unt and ad i ia ti n ( ur ,2 impl ment p lici that hca lthca r [ n id r an ind i idu a I' ri ght l pn a t en ure pri acy nfidentia lit are n t ab lut and th rc arc itu ti n 111 hi ch nfidcnti alit ma b j u tifiabl brea hed ( ' ReiII ) t al. ..... 0 I ). uch itu ati n may itat a m difi ca ti n fp li e in rd er t pr t t the pati nt r th cr (T in , 2009). Th e rcc mmend th u e f dec i i n-maki ng path ay and pr ce c wh n ethi ca l i ue r lated t pn a ari e. Hea lth arc pr that go ern th ir practi ce, a id er h e~ e a re p n ibility t be famili ar with th e law ell a th p li ithin the rga ni za ti n wh re they practi ce ( RNB ,201 0). De pite thee id ence that inclu ion f family in treatm ent and rec ery f adult with MI improve their outcome confidentiality cone m and mi co ncepti on by hea lthcare provider po e major barrier for fa milie to be ac tively in lved in th eir ca re (Wilkin on & McAndrew, 200 ). Mi conception and la k of clarity regarding what infom1ati n can and hould be hared with family place healthcare provid er in difficult itu ati n when u ing th 1r di cretionary judgment. A lack of knowl edge or confidence on how t addre di ffering need and rights of patient and families around in[! 1111ation baring crea te ethi al conflict for healthcare provider when d ciding to di clo e certain inD tmation when working with famili e (Wilkin on & McAndrew) . lt i imp rtant t balan e and con id er c nfid enti ality on a ca -byca e ba i . amily may ften be the onl y con tant re ource a ailabl to an indi idual \ ith Ml 17 ( inke, 2004) and barrier cr at d b the r th art f~ tiv imped mpl iti e in managing c nfid entiality i u are tran iti n and c ntinuit can f ar ~ r u h indi idual . Eff ective Care Tran ition ffecti e care tran i ti n nt a h alth ar acr car pr onn cted, c id r , 1 co llab rati n acr tran iti n include c rdinat d and appropriat D r th ir need and pr ference f ca r , and 1 ati n . a healthcar ( leman & nd cam l eren n, 2004 ). rdinati n and c ntinuity f c mpr hen ive 1lan well-trained practiti ner -who ha pr fer nee h n th indi idual i abl t e pen nee eparate ur are tr n iti n d p nd on ttribute f effe tive f care canied ut by urr nt informati n abo ut th e patient' treatm nt g al , and lini cal tatu . Education of patient and family, a well a dial gue am ng car pr vider , i unp rtant to ensure appropriate re ource and erv1ce are availabl in the mo t appropriate care etting (Ce ta, 201 2 · NTO C, 2008). Tran itional and di charge pl anning afeguard the arn e mo th movement of the patient through the care continuum (Cesta) . The di charge proces from ac ute care to community care should be considered in the context of the pre-admission, admission, treatment, discharge and po t-discharge continuum (Ru ell et al. , 20 13). The focus of di charge from acute care is on the movement of the patient from the acute care etting to an alternate level of care (Cesta). This process involves an assessm ent of the patient' s needs following di charge and confirmation that neces ary services are organi zed to facilitate continued care for the patient (Cesta). For optimal continuity of care, there is orderly and unintenupted movement of patients among the diverse divi ions of service along the continuum of care ( dair et al. , 2005; WH , 2008) . 18 Predictability and fr m Ml becau ntinuit the illn 1 1 ng t 1111 and a d J nge Wea tein b kk, 20 l ). uch, 1 ngitudinal care pr con iderati n in the ar uf:D ring n id r d imp r1ant D r indi idual f ar ar cia ted ith p r lbj r, Ri r, 2004 · Le ter et al. , 2005 · cial functi ning ( raw fi rd , t rlund ,W ' id r i an imp rtant id cd y prim ary er mental illn f patient with Family N ur e Practitioner and Prim01y Care Primary car focu treatment f illn Health care .D r n wand ongoing n n health pr m ti n, illne i an I anada, 20 12). Furth r, primary car allow Gr 1 atient to receiv d and health pr blem ; primary car i per coordinate and int gra te care pr 20 12). The Family and injury pr v ntion, di agn n-fi cu ed and ided by oth r h althcar pro ider ( ggarwal & Hutchi on, ur e Practition r pl ay an imp rtant ro le in primary care, which i the fir t point of entry to the healthcare y tem in anada ( A 2009). In addition t pnmary care services, FNPs work with individual , communitie , and diverse populatio n nacting the principles of primary h ealthcare, uch a accessibility to h ealth care and community participation (CNA). Family Nurse Practitioners are healthcare provid er who have achieved advanced nursing practice education and skills at the gradu ate level of education (College of R egistered Nur e of British Columbia [CRNBC] , 2014). Family Nurse Practitioners provi de hea lthcare from a holistic nursing perspective, in which they independently dia gnose and treat acute and chronic illnesses. Family Nurse Practitioner practice within a regulated scope of practice (CRNBC, 2014 ), and provide primary care ervices including health as essrn ent , ord ring and interpreting diagnostic tests, dia gnosis of di ea (British and condition , and prescribing m dications and treatment . lurnbia Ministry of Health, 201 2; RNB ). It is tlu· ugh an integrat d approach that p bring th nur ing ~ [ t a hing u tr atm nt ar th pr id R pra ti an b nit n am ng th m tting , pra ti in b th rural and ur an mmuniti , and pr [all ag ( riti h lum bia ur ti \ \' rk in [ fl id h althca r ri ti n mmunity t p ], ciati Prac ti ti nd [ p v ing t juri di ti nal ' ti ti ner er intr du cd t impr ve eli nth alth utc me by in ur mg ·pandin g li ent · h alth are pti n , and fillin g gap that i tin h althca r d li etting , and ur e Pr ib ili t ac n da th r gul ati n nd . In amil nald t al., 20 indi idu al and famili 2014) . nd upp rt t th m di al di gn un ling P ha e a br ad rang with hea lthca rc pr W ng ' Fan·all , 2 1 f pati ent and th ir famili id cr in primary are ithin th ir pra ti ce and will nc unter indi idu al . amil y ur Pra titi ner prac ti cing in prim ary care ar re p n ible fir the longitudinal care fth ir pati ent and will be in lved in th deli ery of their car . Admi ion and di charge pri il ege ary am ng juri di ction aero anada, notwith tanding the F P may b re pon ibl e for co rdinatin g a pati nt' adm i i n t a ute ca r and tran ition back to primary care (Briti h olumbia Mini try of Health, 20 12) . pr vid er , F P may be the fir t point of acce pnm ary ca re for pati nt with MI and are in a po iti n to id entify the need for a higher level f care. Fut1her, Famil y ur e Practition r , a primary car pr vid er , may be re pon ible for the care of patient with MI foil wing di charg fr m an acute p ychiatric ho pitalization. A uch, Famil y ur Practition r an pl ay an int gral r 1 m afeguarding effectiv car tran iti n for indi i lual with ev re mental illne . ln ummary, thi chapter ha id ntifi cd and de crib d the mple and unpredi table nature f MI that pl aces the e indi idual at in reascd ri k for ham1 . Po rl manag ~ d car 20 tran iti n and di admi ntinuity f ca re D r adult up n li ch arge fr m an ac ut p ychiatric ion ha e be n id entifi d a detrimental. Ithough the impo rtance f m aintaining ontinuity fr m tran iti n p int in m ental hea lth are h a been well d cum cntcd , there i a limited am ount f re earch n inter enti n t addre thi problem ( iggian t al. , 20 12 ). a e e am1l and rele ant backgr und inf m1ati n e tab li h th e c ntc t fo r thi proj ect a it relate to adult di charged from a ute p ychi atri c ca re. e pite ef[i rt aimed at improvem ent in mental hea lth outc m e , chall enge remain [! r indi idu a l w ith Ml wh o e healthcare te nd t be fragm ent d and hind red by und r funding fo rm n tal health e1 icc (Briti h M edi cal olumbi a ociati n [8 M ], 2009) . T he p eri d f tran iti n between acute car and primary care is important for afe and eaml continuity of ca re, and th e P, a a prim ary care prov id er, is an integra l part o f th e tran ition of care proce . Th e foll owing ch apter w ill de crib e the ea rch m ethod fo r an integrati ve rev iew o f the literature that will exa mine prac ti ce and proce se to achi eve seamle tran ition and continui ty of care for adults discharged from acute p ychi atri c ca re to prim ary care. 21 H PT R 3 Method The purpo e f thi pr J practi ar und car tran iti n ii r indi idual with MI. Furth r t and pr practic 1mpr t i to obtain am r c mprehen i e und r tandin g f cunent ment that may b made t a hi eaml e tran iti n 111 e ti ga t f care thr ugh e amination of the literature. The m eth d 1 gical trat gy f an integrati e literature revi w ha been u ed becau e the appr ch all w for a br ad pe trum [ re earch meth d that can be applied toward impro em nt in lini cal prac ti e and (Whittemore & Knafl 2005 ). T electronic databa btain di er e and id nee infl nned prac ti ce initiati ve t n IV literature th e earch incorporated el c tronic j oun1al earching, web earchin g reference li t , and guid eline (Whittemore & Knafl). A fund amental component of a credibl e integrati ve r view i a we ll . defined earch trategy (Whittemore & Knafl ) and to thi end, th e search trategy £ r thi pap er will now be outlined . Figure one outline the three stages involved in the search strategy, and the filtering of literature for critical analysis. A detailed description of each tage i provided. 22 1gur 1: arch frat (ad pted fr m hr 20 1 ) Web earc h Jectron ic Datal a e ll • • • Psych! • Pub ed Mental Health omm 1Ss1on of anada -le tron1c earchofKe Psychtatnc and Pnmary are Journal s • anad1an Famd y Ph ys 1c1an • Journal for urse Pract1t1oners • lnternattonal Journal of Psyc hiatry • Psychiatnc Quarterl y • Canad1an Journal of Psychi atry • Journal of oc tal Work • Journal of the Ameri can Psyc hi atn c Assoc1ation can of rele ant art1cl e references for addit10nal potential articles ta ge I : Results fr 111 eac h so urce exam med for potent1al rele\ancy \\ lthm th e title for keywords and 1e H tern1s 380 p te ntia l articl ba eel on titl identified umber exc lud ed 3789 ta ge 2: Potent1all rele\ ant art1cles exam mecl abstracts and body sk1 mm ed further for rele\ancy based on mclus1on and e clu s1on cntena 140 potentia l article after ab tract re\'iew Full tex t pnnt cop1es ret neved for potential so urces umb er exc lud ed 2 2 umb er exc luded tage 3: Each art1cle re-read 111 deta tl for re levancy and appropnateness to the research qu es tiOn . 17 re levant article ide ntified Fu II text print cop1es retne ved for relevant so urces 123 S tage One: Searching E lectronic Databases Stage one of the literature search was con1pleted u ing multiple resources . The earch terms were obtained through key terms and concept de1ived from the research question and topic for this study. The keywords u ed were: mental di sorder primary hea lthcare, patient transfer, care transition, p ychiatric units, confidentiality, and fam.ily . A electronic databases identified th medica l subj ect heading (M arch through the H) t tm n d d including: mentally ill , psychiatiic pati ent, nurse practitioner family nur e pra ti tioner, co ntinuum of care, continuity of patient care, tran fer di charg , p ychiatric ho pi tal , co nfidentiality and privacy, 2 and PubM d. T r trie tho e written in th only th m IN HL P ychiN earch d and pri ileg d otru11um ati n . The l ctr ni databa , articl tr 1 ngli h languag and publi hed b t w re limit d to en Ja nu ry 2002 and ct b r 2014 . tim fram f fi e t t n y ar i u ually placed n the age f w rk t b includ ed ( r nin Rya n & ughl an 200 ). Thi tim frame t -date r arch with ut mi ing ld r, r 1 ant tudi e . a pand ed by tw y ar to ca pture the m t up- r th initi al earch [ the databa ag rang wa limited t tho e between 1 and 44 to m r accurately repre cnt the adult popul ation w ith Ml and t ex lud lit ra tur pe1ia in ing t initial earch, it wa n ted that there a lack f selection. Ther fo r , th age ran g a br ad ned t Appendix II depicts the arch ld er adult or ad le c nt . A fter the n i tency acr the databa e fi r age 1 yea r and ld er fi r ub equent earche . c nducted, and the number of re ult btain ed from each. After pertinent combination of the te1m were earched u ing Boolean L g ic, the duplicates found betw een databa e were rem oved. Electronic journals w ere manually expl ored to add 1i gor to the earc h. Journals earched were the Canadian Famil y Phy ician, Joun1 al for Nur e Practitioner , P ychiatri c Quarterl y, Canadian Journal of Psychiatry Jomnal of Social Work, and Journal ofthe Am erican Psychiatric Nur es Association. The e journal w ere elected to obtain a comprehensive examination of multidisciplinary research in healthcare. The terms used to search within these jomnals were: discharge pl anning, continuity of care, psychi atric patient, primary healthcare and p1i mary care, transition of care, family , and confidentiality. Google Scholar web search engine was al o e plored to confirm s arch te1n1 and key t rms u ed, such as planning, tran iti n f are, ontinuity f care, and continuum of care, and the combination of tho e tenn with psychiatri c acute care, p yc hi atric ho pitals, tran itions, care 24 tran iti n , pati nt tran :D r nd primar healthcare we r r tTi tw articl ed and th other :D r the purp n e f which w rnm ent w b it H alth n f P ychi atric wer , uch a riti h r m thi earcl t .G r thi pap r and mental h alth w re u d lumbia Mini try f H ea lth and M ntal an ada and a n ngo ernment rganizati n web ite the an adi an ciati n. Th title ourc u d :D r the backgr und and c nt f re i w . h t 1111 m ntal illne .G r ear hing g nun1 nfid ntiality and family. f th arti produced fr m the databa , 1 ctr nic j urnal , and in ternet ca!U1ed and ea h article wa e am ined :D r p ten tial rel ancy within th e title, ba ed n keyword and M e H tenn . If the paper did n t conta in the appropri ate term r levant ubj ect, they were elim in ated. The can of article titl r pr du ced from the databa j oUinal , and inte1net ou rce re ult d in the eliminati n of 3789 article at this tage, leaving th e remaining 38 0 article fo r fu rther orting. Stage Two: S creening A bstracts and Hand Searching Stage two of the search trategy invo lved filtering the retrieved articles from the databases by review ing the abstract and skimming the body of th e arti cles. In additi on , the reference lists of the applicable articles were scanned fo r seminal articles and additional literature source to en ure data saturation. The screening process used in tage one and two wa also applied to the articles located from the reference li ts. To eliminate and fur1her refin e the results the inclusion and exclusion criteri a, as hown in T able 1, were appli ed at thi tag e. Articles were included if they were in Engli h, relevant to adult (1 8 years of ag and old er) with m ental illne s, relevant to care tran ition and all other term listed in Ta ble 1 und er inclu ion criteri a. Artie! that discu sed transitions that w r m de becau e of age, such a tran itioning 25 fr m p diatric and ad 1 nt are t adu lt w r e clud d. ta g and 140 re ama Tabl 1: In lu ion and Ex lu ·ion rif ria liminat d in thi d D r the final r ing: tran 1t1 n o f care, di charg di harg planning acut 1 y hi atri c care to ommunity r primar ca re/primary healthcare patient confid ntialit , famil , primary ar I primary h althcare, nur e practitioner w hundred and thi1iy arti le w ere i Publi hcd pri r t i ch arg from l ng t rm facility tudy p pul ati n ampl e limited t childr n d le cent (< 18) r eld erly with e lu i ely rganic m ental di rd er (dem nti a r lz heim er' di ea e) Publi hed in a language th r than nglish Stage Three: Exten ive R eview f or Imp ortan ce and R elevan ce The 140 pot nti all y relevant article id ntified in tage two were exa mined fo r relevance. The ab tract were re- read and who le paper were read in orne detail to a e evidence and relevance to th e re earch qu th e qu ality f the tion . The tex tbook by LoBi nd -W ood, Haber, Cameron, & Singh (20 13 ), the miicle by Cronin et al. (200 8), and the guideline , illu trated in Appendix E and Appendix F, were utilized to guide the criti cal apprai al proces . T hi proce re ulted in the elimination of 123 miicle , and th e selection of a fin al numb er of 17 pertin ent atiicles. Appendix B presents the level of evid ence for each miicle, which is defined in Appendix A . The final 17 miicles were thorou ghly read and w ere used to analyze practi ces and processe that m ay achieve sean1l ess transitions and continuity of care for m entally ill adults disch arged from acute p sychiatric care to pri1nm·y care. All earches w ere conducted betw een 2013 and 2014 . An analysis and summary of the findings from the selected miicle fo llow 26 H PT R4 Finding hi int grati lit ratur re i w e k t amm pr ce e that help t achi e e eaml e tran ition acute p ychiatric ca re t prim r care. rom the anal idence-ba ed 1 racti e and f ar for ad ult with MIdi harg d fr m f the key arii 1 [! ur m aj r theme were identifi ed: c nfid enti ality c mmuni ati n linkage betwe n a ute an I primary ca re, and therap eutic r lati n hip . Baui er t care tran iti n that were iden tified in the backgr und f thi paper ar refl ct d in th maj r theme fr m the lit ratur revi w, h wever, th rapeuti c relation hip emerged a a new th me in the finding . The e theme rga ni ze th e pr entati n f finding and guide th di cussion . Du e to the cope and ize of thi project the finding fr m th e _selected article are examined within the context of th e amily ur e Practition r practi cing in primary care and relevance to adult di charged from acute psychiatric care to primary care. The need for change to healthcare sy tems and poli cies urfaced in the literature. The e findin gs will be discus ed briefly becau e of their impotiance, however, the y tem and policy level i out ide the scope of this proj ect. Confidentiality Confidentiality concerns and misconceptions regarding famil y involvement by hea lthcare professionals serve as batTiers to effective care tran ition and continuity of care ( olamon, 20 12). Healthcare profes ionals vary in their understanding and practice regarding confidentiality and its application with fami ly (Mood Disorder 2008). As previously explored, fami li ssociation of Briti h olumbia, are playing an increa ing role in pro iding care for an adult family member w ith M I. How ev r, the literature id entified that care provider are not 27 ad quat ly rec gnizing and in 1 ing famili in th p ati ent' ar . ntinuity f care £1 r pati ent with Ml ma y b n ga ti ely a f~ c ted by thi lack f r c gniti n . i pr bl m a iat d with pri ac and c nfid enti lity 1 lici r commendati n ~ r impr fi e tudi e are n t p cific t m ent . n ana l i , law , r pra ti e and ffer f the e tudi e [! ll w . an ada, the fi nd ing ar applica bl with in the ue pri acy and c nfid enti a lity ar tudi e identified lth ugh ~ ur f th e anadi an contex t as 11 docum ent d thr ugh ut th br ad r lit rature w ithin anada and int rn ati nall . de cripti antwell 20 12) invo l ry tud y fr m Philadelph ia ( o l m n, M lin ar , Manni n, & d two comp n nt . T he fir t pa11 f th tu dy inv lved a se in g care pro ider ' and admini trator ' know ledge of co nfi dentiall y and in£1 rm ati n haring w ith fa milies of people with MI. The ec nd part of th tud y wa th development of a pilot training program and evaluation which wa ba ed on th e fi nding of the first p m1 of th e tud y . The first pati of the tudy was a su rvey co mposed of a nine- item m easure of beli ef: and knowl edge about fan1ili es. Two o f the que tion on the urvey were directly related to confidentiality and information harin g with famili e . The result showed that 40 - 4 2% of the care providers and administrator urveyed believed that they could not direct familie to upp 011 resources or listen to info1mation from them abo ut their family m ember with MI. T he e result were troubling as famili es may have ignificant information neces ary for the care or afety of the pati ent. Based on these findings, the authors developed the training program a the second pat1 of this study. Twenty- fou r case managers pm1icipated in the training program that was designed to provide infom1ation on confidenti a lity p li i and legislation related to inform ation haring with families . T he program di cussed famil y confidentiality po lici w ithin the ag ncy and t n 2 nan di u were r ated for c rm11ent and di 1 n. h am t t u i n. pre-te twa admini ter d prior to thi a u d D ll ov in g th training t It wa 11 und that th training program initial! impr kn wl dg , h we er, re-t ting ne year later, aluat th pr gram ' ed ca uc mana g r under tandin g and ith the arne t t u ed in the pre and p t-te t, identifi d that participant had 11 t r tain d th in£ rrnati 11 . Recommendati n includ d additi nal educati n £ r healthcar pr nnpr e 11 r m nit ring th education alone do id r in matt r fD cti ene n t c ntribute t im1 r patient , and car pr vid r . Th emen t f pri acy and c nfidenti ality, and [training. The author identifi d that 111 c mmunication betw een familie , ackn wledged that ne r a on taff had p r knowledge retention wa due to th e fact that taff di agr ed with th e inform ation provid ed . The auth r ugge ted that mi communication, in uffi cient di cu ion , or lack f tru tin g relati on hips between taff and mana gers may have weakened the effectiven es of trainin g. They acknowledged that more research wa needed in this area . An important point rai ed by th e authors was that one tin1e education i not enough to su stain a change in pra ctice. Continuing education and establi hed proces e to determine whether the knowl edge i tran lated into practice is important for the involvement of families in the treatment and recovery of family members with evere mental illness. The study participants were from a wide variety of work and educational background , increasing the generalizability of the results . FUiiher, the author piloted the urvey in an effort to identify redundant survey questions. The authors did identify that more research i needed to understand why staff disagreed with the training regarding information sharing. Thi m ay be a critical asp ct to enhancing communication betw en ar provider and familie . However, in the urvey admini tered in the first pmi of the tudy, the author mentioned that ome ur ey 29 que ti n addr if p d are pr id r ' attitud r parenting cau d m ntal illn r garding car pro id r ' attitude t qu alitati e tud y fr m th ult r exan1pl e, f the urvey ard familie and the e re ult may h ld alu ble n car pr baring m ay contribut ith MI. . he auth r did n t includ th r informati n r ga rding why car pro id er ar relu ctant t In r a d c mmunica ti n b tw f pe pl t wa rd famili ami hare inD nnati n with fan1ili id r and fa mili , a w 11 as impro ing information tran i ti n f car fo r pe pl with MI. K ( ray R bin on, r fl e i e t ryt !ling and emi- tructured interview ( prunary car pr vid er , manager , enior 1 ader = dd n Robert , 2008) u d 5) wi th taff m mber erv ice devel per , including cial w rker and g n ral practitioner m m ntal h alth, toe amme c nfi d nti ali ty mi concepti ons th at created banier for familie t obtain info rmation about their fa mil y m ember wi th MI. The interview id entified that participant were uncertain about information they could hare with famili e . They al o indicated that many of the parti cipant did not take the fa milie ' ri ghts to bas ic informati on into account to help the1n care for their mentally ill family member. The tud y found that hea lthcare providers reported frequentl y using confidentiality as a justification to withhold inform ati on from a pati ent' s famil y to avoid intennediating and negoti ating confidentiality bani er and information sharing with families. In thi tudy, ambiguity around poli cy and fa mili es' ro le in patient care led to the identification of a need for care provid er training on confid enti ality and family, including family rights and assessm ent of the fatnily and their need to support th individual with SMI. The author identified that primary care providers w re vital in id entifying and asses ing familie in ord er to meet their needs for relevant infon11ation , and to addr feelings of i olation, guilt, stigma , and failure. In exampl of good practi ce, primary care providers acted as interm diatie between patients and famili e , promoting b tter und er tanding 0 and informati n haring. Thi tudy ~ und that primary ca re pr id r ne d t id entify th family f go d pra tice includ d : the a a part f th pati nf car . The auth r [i und th at e ampl provi ion fin[! rmati n haring abo ut m di ca ti n and id e ffect ; ad anced are pl anning hen th pati nt a w 11, baring· dir cting familie t and a e ing famili th ey an p cify th ir prefer nee ~ r treatm nt an l in[! 1111ation upJ rt gr up and rai ing awarene The tud y repre ent d care pr cmnmunitie . H w which pr m ted p er upp 11 and coping trategie ab ut fa milie . ider [r m ari u etting , in b th rural and urb an er, the author did n t identify h w m any f the 65 participants were ampled fr m ach etting. Th auth r id entifi d that within the attempted to n ure ampl pportuniti mi- tru ctured interv iew , they for re pond nt t identi fy key i ue and t pic , a well a di cus their concern . Thi wa d ne to all w parti cipant t tell their tori e , both go d and bad, and refl ect on the impact for fa mili es and patient with MI. The authors did not id entify their potential bi ase or influence within the qu e tion and how this m ay have been addre ed. They also did not identify if they had encountered any need to change the re earch design to eliminate potential biases. They did provide ound sugge ti ons for fut1her re earch based on their findings. Ov erall, this study offers impm1ant findings to promote coll aboration between famili e and healthcare providers that will fo ster a more eamles transition of care. Of particular impm1ance in this study is the findin g that primary care providers should perform an asse ment of the famil y's needs. The Canadian Parliament Senate Standing Committee on Social Affairs, cience, and Technology (2006) inquired into the i sue of priv acy and confid entiality in their report on tran formin g mental healt h and menta l illness and addi ti n rvices in Can ada. The report contained per onal accounts from pati nts and fami.lie living with m ental illne in an ada . 1 The ace unt w er t rrit ry. H w ll ted 1a nlin er the number face unt ubmi i n and public h anng m ea h pr p cific t pn acy and c nfid n tiality w r n t cl arly tated in the rep rt. The data ugge t d that fa mili c nfid ntial di u w n between hea lthcare pr need d to kno u h thing a the diagn they could ntinu t pr me and did n t n e d inb m1ati n ab ut the ider and their l ed n , h we r, they i , care p lan, mcdica ti n , and aD ty i u ide the b t upp rt. The that mmittee c nclud ed that h althcare ~ r haring in~ rma ti n with pr vider did n t try hard en ugh t btain con cnt fr m patient famil y. Further th y identifi d that erly tric t adherence to pri acy policie ca n be detrimental to a emnl e tran iti on and continu ity f care. Th law per1aining to the ri g ht to pri acy [! r peo pl e wi th mmitte wa no t c nvinc d that ex i ting MI are ineffective. ln tead the c mmittee recommended th at a tran [! 1mati n of th m ental healthcare y tem i needed The opinion pre ented in thi rep or1 m ay be critical to crea tin g eaml e tran ition of care from acute to primary care. The r commend ation th at healthca re profe ional pl ace greater emphasis on obtaining con ent fron1 patient for infon11ation sharing w ith fami Iie i import ant to enhancing care for pati ents with MI. The report upp011ed information harin g w ith fa milie but there w ere conflicting opinions from some m embers of the m ental hea lth care community. For example, a coordinator fron1 a m ental h ealth program in V ancouve r, BC believed that adult w ith SMI should be treated completely ind ependent of the famil y, de pite their invo lvem ent. T he fact that there are still key m e1nbers of the m ental healthcare community that do not recogniz famili es in the care of patients with SMI is con is tent with other literature that ugges t that there are inconsistencies in care provid ers' know ledge and und erstanding in thi area. Thi m ay be critical to und erstanding how to be t addre s mi c nc pti n in an effort to create sean1le s transitions of care. 2 Th fi nal tw tu di e r lat d t p i r the p er p ecti e nfid ntialit utili zed th gr und d th ry appr ach to f famili e and care pr vider related t inii 1mati n baring. trength f thi m th d i the y tematic and ri g rou proce n tab I u ed in btaining rich data and di er e per p cti The fir t, a w 11-de igned tud y fr m famil y m emb r ( = 27 arin g D r an adult t report on the pr bl em fa mili u tralia in olved mi- truc ture l interview of n r daughter wi th M I. T he tud y' puqJo p ri nee a are ult f patient confid entiality (W ynaden & rb, 2005 ). The findin g were con i tent with th in ther litera tu re. T hey indica ted that, in pite of guid line r c mmending famil y inv lve ment in all a pect confu ion around confid entiality i u famili e wa f the trea tm ent proce , imp de coll aborati n between hea lthcare provider , and pati ent . The tudy [! und that when uncertainty occurred, heaJthcare provid er u ually cho e to w ithhold all inf01mati on about the ill fa mil y m ember. W ynaden & rb reported that a close examination of confidentiall y i ue wa required to better pro mote familie in the support of the patient in ord er to create seaml ess transitions of care. T he author conclud ed that increased collaboration between fmnili e , p ati ent , and healthcare providers will furth er the expansion of community mental healthcare. This finding m ay b e an imp011ant factor in attempting to create seamless transitions of care from acute psychiatric care to community care and improve patient outcomes. The authors identified that the main them e from the interviews was " bein g exc luded because of patient confidentiality" (p . 168). The them e was refl ected in the example n arrati ve from the famili es and m et the purpose of the study, which was to identify problem familie encounter on a regular ba is du e t nfid ntiality. The authors r ported that 11 of the 27 participants were called back to clarify and expand on data obtained during their initi al int rv i w an indicat r fa th r ugh appr a h . h auth r did n t ffer infi rmati n nth Jr own p t ntial bia .H w er, the did pl in that th y u ed pen-end d qu e ti n that b came m r fo cu ed throughout the inter 1 w . The nan ati e from fami li m in thi tud und erl in d th imp rta nce f fa mil y m nt and id entifi ed gap in car tran iti n . th family car g1 r r e amrl e, ne nan ative de cribed h w a unaware f th plan fi r di charg of their fami ly memb er with MI. Thi n gati e l affi ct d the pa ti nt ' co ntinu it f ca re. 1 ng w ith ther nanati ve in the stud y, thi ex perience ali gn with th ca e e ampl e f tephen. The e p ri nc upport the id a that fa mil y in Th lvement may be cri ti al to afeguarding tran iti n of care. econd tud y ( hen, 200 ), from th healthcare pro ider in the study further , xp lor d h w cmnmun ity mental hare info nnation with the ir patient ' fami lie . s part of a larger re earch _proj ect, 24 case manager were interviewed about practice and trategies u ed to facilitate collaborati on with famili e . Re ult indicated that case managers would accep t patient re lated infonnation from families to prom ote tabilization of the patient, rather than help fam ilies provide care. The m anager had trouble balancing adherence to confi dentiality gu ideline and the patients' best interes ts, which becam e more compl ex when patient wo uld not con ent to the inclusion of their family. Chen explored that within wes ten1 ociety individuali m i highl y valued and information i a personal possession. The author fu rther explored that confidenti ality laws in the US promote this possessiveness of infonn ation. Chen recommended that it wou ld be helpful to enhance confidentiality laws to improve the exchange of pe11inent patient infom1ation . Chen' s (2008) study method was cl ear and thorou ghl y explained, including a de cription of how stud y participant were 1 ted. Although no exclu ion criteri a wa li ted, detai led infon11ation was given regarding the pa11icipants selected including age, race, gend er, fie ld of 4 rk, and ear f h n did n t id ntif p r p n en f inter i th re ult , h w v r, clear d cription included . The analy i depth d cription f th anal i 111 an meth d and que ti n e amp l f th data wa c mp l ted by indi idu al fr m fr m a ariety f background anal nal bia e that may ha f[! rt t addre 1 nhan ing th and pr alidit h n a ti u trali a, k w were aiwan an I th f th data. Th a1iicl had an inreflected n a umpti n during th p tential bi th r tudie that have identifi d that h n' finding are imilar t me h ea lth care pro ider are n twilling to hare in[! nnati n with familie t help them pro id careD r their family memb er with MI. h auth r' re pro id r to incorporate the relea mm end ti n nh nc d regulati ns D r h althcare f informati n, a well a the r ceipt of informati n, may be an important a pectin cr ating eaml e tran ition f care for people with MI. L inkages between Acute Care and Prima ry Care The role of acute p ychiatric care i now primarily centered on cri is tabilization and rapid di charge (Sharfstein, 2009) . Ho pital now play a more limited role within a con1munitybased system of care (Sharf: tein) . The need for connection between primary care and acute care becomes integral in the patient' s transitions between these services. Linking with primary care is the subj ect of the following five tudies, four from the U A and one from Canada. Each of the article focused on linking patients with MI to either new or existing primary care providers following discharge from acute psychiatric care. The Canadian quantitati ve study by Dewa, Tugg, tergiopoulos, Ghavam-Ra ou l, and deRuiter (2012) exmnined the characteristics of patients with MI without a regular primary care provider, prior to admi sion t acute psychiatric care. Patient were surv yed during their inpatient hospita lization and again after rec iving care by a primary car provid r after di charge 5 fr man acute ychiatric unit. inpati nt unit and a cri i ata fr m parti ipant ( c nt r in a h = 11 2) from a cr pital in dif[i rent in trum nt . The F- 6 Health in trument m a ured ph lc h 1 and th id ntify dru g and al fa ctor a Id ntifi ati n 1 gi tic regre h 1 u e pr bl em cia t d with c ntinuity f care between di auth r found that ympt m a oc iated provider and difficulti e in trument wer u ed t n analy i wa u ed to identify barge and a primary care vi it. The ith Ml, uch a p ith m m ry and btained u ing everal ical and mental health tatu , I IT) and -b d p ychiatric rer in ight, mi tru t of h althcare ecuti e fun ti n were banier t continuity of care after di charge. They further identified that patient admi tted to acu te care p ychi atric ward without a primary car provider t nd d to be young rand in better phy ical health. Thi uggested that they may have had le opp rtunity to becom familiar wit h the hea lth ca re _sy tern. Dew a et al. id entifi ed that th e lack f availability of primary care provid er and th e overwhelming waitli t were a predictor of continuity of care. However, they conclud ed by acknowledging that removing barrier to healthcare sy tern acces i not a guarantee that pati ent will utilize the resource , rather that the illne -related ymptom and the vulnerability of patients with SMI n1ust be addressed. The authors set clear goals, utilized approp1iate m ethodology, had clear inclu ion and exclusion criteria, there was an in-depth description of the analy is, and there wa a clear presentation of the fmdings and ali t of the tudy' limitati ons, including a relati vely mode t sample size. The results of their findings did hi ghlight ome predictors of follow up with primary care providers; however, the most important fmding of thi s tudy, that illne r lated ymptom were a barrier to accessing primary ar , wa minimally di cussed. Th authors made no uggestions on how to manage this, nor did they offer recommend ations for research in thi area. 6 Th tud y ugge ted in etting w here primary car i the fir t p int f ace , illne relat d ymptom int rTupting c ntinuity f ar i particularl y pr bl 1natic. hi m ay b a rucial ar a to e plore in att mpting to creat aml e tran iti n f ca re fr m an a ut ca r admi ion to pnmary care. In a m all pil t tudy, Bat cha, M e fea ibility f u mg an appointment p d anced Pra tic vi tt, W ei den, and an y (20 11 ) e pl red the ur e ( P ) t li nk pa ti nt with MI to their fir t t di charge. P ati nt (n = 15), ag d 19 t 5 re~ rred by the inp ati ent treatment team were intet iew d t d t nn in ban ier to attend ance at the fir t app intment. T he res ult h wed that fa ilitated int rventi n , uch a app intm nt rem inder and the P m eting the patient at their fir t appointment aft r di charge were practica l appr ac he to linking the tran ition from acute care to outpati ent car . In thi they felt were important to di cu tud y, patient identified [! ur releva nt area with outpatient cl inician : m edicati ons, p ro bl m r ymptoms associated w ith hospitalization, patient-prov id er relation hips is ues, and trea tm ent preferences. The intervention of meeting the pati ent prior to discharge showed no effect on attendan ce. It i noteworthy that the three pati ent with no previou ex perience with the clinic were the least likely to attend the first appointment (p = 0.024 ). In additi on , age, gend er, race, were not associated with attendance to the first outpatient appointment. A lack of ex peri nee with the outpatient clinic was found to be an important fac tor in attending the first outpatient appointment. The authors acknowledged that this study is li1nited due to it mall sample size, however, they uggested that it is feasible to conduct in xpensive intervention to help nanow the gap between di charge fr m , n inpatient unit to the fir t outpati ent appo intm nt. One 7 interventi n the auth r t ugg t d i phy ically ac v rcom unfamiliarity ith th Du t th li1nited u ed in the tudy w r p IZ mpanying pati nt t th clinic in an f~ rt n ir nm ent. f the tudy it i difficult t d t nnine wh ther the intervcnti n iti [ attending a fir t outp ti ent app intm nt. Th c nclu ion ab ut the lack of xperi nee w ith the utpati ent clini drawn, d pite a hi gh predicti e alu e a ign d to it, a tw eem t be pr m aturely fthe thr e pati ent who di In t attend th ir fir t D 11 w up app intm nt ere re-ho pitaliz d pri r t th eir pp intment. thi , the con lu i n pr tud y m ay b nt d w ithin th e pite alid and requi re m re re earch t identify wheth er or not inten t nti n , uch a accomp anying patient to outpati ent appointm ent , could increa e attendance at fir t app intm ent po t di charge, helping to fac ilitates aml e tran ition of car e. It i imp rtant to not that th e u e of an ad anced practice nurse to link patient to outpatient clini c may n ot be co t effective or fea ible in the cunent The mixed-method tudy from the anadi an y tem . SA of Griswold et al. (2 008) wa the follo w-up of a preliminary tudy from 2005 . The 200 8 stud y involved a randomi zed controlled tri al (R T) to investigate the effectivenes of care m anager in connecting patient ( = 175) to primary care after a p ychiatric crisis, and a qualitative inquiry to gain patients' in ight abo ut acce to psychiatric or primary care. The researcher hypothesized that, in contrast to care provided at a psychiatric emergency departtnent, case managem ent would result in high er rates of connection to primary care. They were of the opinion that patients emerging frmn a psychi atric crisis face unique challenges connecting with a primary care provid er and require more than simply the name or location of a provider. Furthermore, they suggested that the point of discharg i an opportune time to initiate linkage b tween m di cal and p ychiatric erv ice , afeguarding continuity of care in both ( riswold et al. , 2005) . 8 Participant eekin g car in the p a ign d t an int 1 enti n group problem w re hi atric m rgen y d pa1iment w re rand mly ith car m anag r mparabl in both gr up . ra ntro l gr up . he phy ical health mi- tru ctured inte1 i w fr m 28 participant in each gr up were ondu t d at ba lin and again ne yea r later ( hea lthcar e p ri enc . ualitati e and quantitati qualitati e data wa nt r d into mu ltidi ci1linary t am f fi analy i wa -= 11 2) t a e data wer an al zed parti ipant ' parat ly. T he 2.0 fi r management and analy i an I amin d by a re earcher trai n d in qualitative analy i ; tru tw rthine f the tr ngth n d by the di e r ity f team m mber , ne of wh m wa a nur e practitioner. riswold et al. ' (200 ) tudy h wed that care m anager and ca e ba d int rventi ns had a po itive influence on attend ance at primary care :D !lowing a p ychiatric cri is. uch ~nterv ention included a istance w ith sch eduling and attending appointments, nav iga ting travel mode and route to app ointm ent , and reinfo rcement of inf01ma ti on provided by the primary care prov ider. How ever, the qualifi cations of the care m anager were not m ade clear. Thi stud y identified that establi shed connections with a primary care provid er offering coll aborative and continuous care are important; patients acknowl edged the imp011ance of good corrn11uni cati on and sensitivity andre pect between themselves and their hea lthcare provider . They al o acknow ledged personal challenge in obtaining or accepting care. The qualitati ve an aly is supp011s quantitative findings, that care m anagement is effective for helping patient acces primary care after a psychiatric cri is. The study de cribed patients' nega tive care experi ences that ste1nmed from is ues as a resu lt of a lack of health in uran . Th.i w uld not be app licable in anada' publicly fu nded h althcare system. Thi wa s a well done comprehensive tudy that mploy d the ri gorou r earch meth d f th R T t det nnm th relati n hip b tw en th interventi n by a are mana ger and th ir utc m . Th re earch de ign licited r al-lit c nt under tandin g adding in ight fr m pati nt , nd i u afe tran ition and c ntinuit the f care [! 11 re ult are appli able within the point fa ce Dr p an1 d ut tual ful in id ntifying helpful trategi for ing a p ychiatric cri i . It i imp011ant t n te that anadi an c nte t, her primary are 1 ften the main p 1 with MI. l-Ma11 akh et al. (20 04) rep t1ed that the mo t imp011ant predi ctor in early reho pitaliza ti on follow ing di charg fr m a pri mary p ychiatric faci lity i fai ling to attend th e first outpati ent app intment. In thi retr p ctive tud y of p ychiatric inpati ent record (N = 8 1) fr m an acute p ychi atJi unit in the the author id entifi ed that there m ay be additional factor a ociated w ith aft ercare c mpli ance fo r indi idual w ith MI. T hey ·~ und th at ng ing care _with an outpatient clinic wa a m aj or influ ence in avo iding an acute psychiatri c admis ion. In thi s tudy, y tem re pon i ene was partiall y controll ed by en urin g that, pri or to di charge pati ents had a follow-up appointment within two weeks of di sch arge. 1-M allakh et al. noted that the type of serv ice area of the foll ow up appointment played no fac tor in compli ance and that patients without insurance w ere the least likely to attend the foll ow-up app ointment. The author did note that involvem ent with an outpati ent clini c prior to hospitaliza tion wa a po itive predi ctor to keeping the outpatient appointment. They ob erved that this m ay be related to established therapeutic relationships. The tud y conclud ed that foll ow-up rates rem ained suboptimal, even with secured appointments prior to di scharge, and that fut1h er re earch is needed to exp lore community v ariables The finding of thi s study, that patient with ut in urance wer 1 a t likely to attend fo llow-up appointment , wou ld not be applicabl e to anada' publi ci fund ed y tem. n 40 th ugh th rat f fi 11 -u in thi th r 1mp rtant findin g , u h e care tr n iti n [! 11 ing di harge fr m a ute p ychiatri tabli hed therapeuti c r 1 ti n hip . If uth r attribut d th th rap utic r lati n hip ha inte1 nti n, ith an utpati nt lini pri r t h pitaliza ti n, m ma b u ful in att mpting im1 r ar . Th tud r mam d ub- I tim 1, de 1 it the trial an f[i ct n linking a pati nt fr m ac ute care t pnmary care, th r int 1 nti n c nt red n th rapeuti relati n hip ma b beneficial t help crea te a tran iti n f care. eaml Comm u 11 ication hall enge ith in[! rm ati n baring and c mmunicati n between h a!thcare pr fe ional and ar 201 ). P tting are c mm n barrier t effecti care tran iti n ( h ng et al. , r c mmun1 ati n and inc mplete tran mi i n f pati ent in[! tm ati n are fact r that contribute to ineffecti e care tran iti n ( a I r Kea ting, 200 ). Further, a lack f communication between acute care and primary care i a ignifica nt factor that i c rrelated t poor care tran ition (Brimmer, 20 12). long with thi , the literature id ntifi d that barrier pro iding care to an adult family member with MI are further com pi icated by po r communication between hea lthca re provid er and familie (Rowe, 20 12). Five of the studie elected addre ed matter of communicati nand information tran fer that are barri er to effective ca re tran ition . Further, they provide recommendation for improvement. Two of the tudie were not pec ific to the mental healthca re y tem, but they inve ti ga ted i ue of ca re transition between acute and primary care in g neral; the e considerations are relevant to the purpo e of thi paper. A y tematic rev i w [ r levant literatur ( wa ca rri ed ut t de cribe the preva lence of p = 7 ) by r earch r Kripalani et al. (2007) r communi ati n and informati n tran fer at 41 h pita! di charg in rd r t id ntify int r nc mpa upon h pr nti n to impr d a wid range f ge graphical pita! di charg , d lay d r ina curat ider and primary ca re pr wer r viewed: b 1 id r ad ati nal tudi the proce . he tudi tting . Thi re rew a ba ed n the nc rn that, 1nmunicati n b tw een ho pita l-ba ed care af[i cted c ntinuit (n = 5 ) that in ti gated f ca r . Tw typ f tudi mmuni ca ti n and informati n tran fer at di charg , and c ntr 11 d tudie (n = l ) that e aluated th effi cacy f improvem ent inter ntion . Re ult aero the tudie and r flee ted the maj rit y f medical practic h w d that dela y and mi howed that only 3% of primary car pr i n in c mmunicati n w r consistent in th . The findings id r rep rted b in g inv Jved in the di charge di cu ion , and 17 to 20 % of primary care pro ider r ported con i tent n tificati n f di charges. The availability of a di charge ummary at the fir t po t di charge v i it wa low (12%-34%), with mode t improvement at four week (51 %-77%). Di charge summari e were identified a the most common mean of communication between inpatient and outpatient providers, but it was identified that they often lacked impm1ant infonnation. The study recommended tandardized fonnats that capture the mo t per1inent information to improve the quality of sumn1aries. Fm1her, interventions uch as computer-generated discharge summari es, standardized discharge fmms, and u ing patient as couriers would improve the d livery time of discharge information. The author suggested that a combined approach of technology and paper based solutions may help to overcome delays in con1111unication. De pite the fact the review wa not specific to mental health service , the result are convincing and relevant to this project based on the view that deficits in cmnmunication are common fmcling of h althcare pr vider . The revi w We ba eel upon pra ctice within the U This is applicab le within the anadian context where care is 1 rovid ed within the primary care 42 tting and care i tran D rred to peciali t when appr priat p y hiatric facility. Many i u t th in the ca £1 r e ampl admi with c nununica ti n, a de cribed in the r e ample h b et ati nal tudi a t dat range from 1970-2 0 . he ld er tudi e may n t ha ue o f infl 1mation tran fer a h althcare practic r the year . erall th re 1e re i w, were parall 1 elect d D r th review had a ac urately r fl eet d th current ha ad anced significantly wa w 11 d n and pr ented many k y finding and interv nti n that may b imp Iiant in creatin g Th qualitati and pr c i n to acut amle tran iti n f care fl r patient with MI. arch f John on et al. (20 12) included focu gr up interview with clinical team in ol ed with are tran ition m 1x Spain and the Netherland . Th purp untri , the , P land weden, Italy, e of the tudy wa to demo n trate how process m app in g can be utili zed to improve tran itions from acute t primary care by identifying barrier and ~acilitator of care. There earch wa ba ed on the a umpti on that safe patient tran ition depend on effective communication and effective care coo rdination. The study des ign allowed participant to refine and reflect on their experiences in real time, limiting recall error. The result were comparable aero all site and the geographical area studied increase the generalizability of the finding . Several notable facilitators to conununication surfaced during the mapping processe . These included effective conununication between care providers regarding preferred m ethod of contact, utilization of families a resources, and full integration of electronic re ource aero care sites. The authors concluded that the findings from the ix ite confirmed that there wa a breakdown in communication between hospital physician and primary care provider . Further, they highlighted some oppmiunitie for improved conu11utli ati nand co-ordination of patient 4 tran iti n . Th y id ntified that pr clini al pr mappmg wa an unp 11ant appr a h in under tanding the in the tran iti n f pati nt fr m acute are t pnmary car pr vid r . Th re ult of th tudy h wed that pr e mapping wa an H cti e m thod t id ntifying banier and fa ilitat r in car tran iti n . the and mappmg wa urop an c untrie and practic ffective aero all ite . hi anada . Fa ilitator that were id ntifi d aero could be applied to mental h alth e1 ice . from acute to primary car r nat lth ugh th may differ fr m tud y a p rfom1 d within anada, the u fpr c s ugge t th at the technique c uld be applied in the ite including u ing familie a res urc s tili zing fam ili a re ource t facilitate transiti n with finding fr m ther literature a ex1 lored und er confid ntiality in thi proj ect. One limitation t the tudy wa that it did n t includ e a de c ription of how the data wa analyzed. An Au tralian qualitative tudy by Wood et al. (2009) so ught to develop and te t a standardized conununication trategy for improv ing communication between acute care and community practitioner . One 86 bed private hospital and one not-for-profit m ental hea lth hospital were the focus of the tudy. The tudy investigated incongru ent di charge and communication practices between acute care and community practitioners. A plan-do- tudy-act (PDSA) cycle, conducted in three tage , wa used to develop a tandardized di charge proces and outcome assessment strategies. The researchers used written urveys to obtain c01rununity practitioners ' opinions on di charge and documentation processe ; telephone surveys were used to measure patient satisfaction regarding discharge. There ults bowed that standardized clinical han dover strategies improved the rate of primary care provider and pati ent sa ti faction. In addition, a notable impr v ment urr d with th number of discharg summari es fa ed to th primary care provider within 48 hours of di charge, and an increa in patient follow-up ca ll 7- 44 14 day p t di charg mmunity-ba 0 rdinat d apr r a h ~ Th auth r id ntifi d that a h y d are i criti cal in mental h althcar dem n trated that tandardi zed clinical hand er trat g1 u mg n nclud ed that thi can tudy b n fi ial in fa cilitating c nununicati no Re ult from pri at car facilitie ma n t be applica bl e t and n t-[i r-pr fit h alth d li re ource 0 H e f ariance in cared li ery m del and ry y t m becau r the finding fr m thi anada' publicly fun I d tud y are rel an t to id entifying impr vem ent in the tran iti n of car D r m ntal health pati nt t primary are in the anadian c ntext. Thi i du to the fact that within anad ian mental h althcar , th rei a tran iti n from care und er p ychiatri t in a ut h pitalization to primary care pr vider in the c mmunityo In additi n, the ca e exampl of t phen highlight that, in the d~ charge proces et al. anadian cont x t, there were is ue in th e and a lack of timely information h ando er to a primary care ph y iciano W ood (2009) tudy pre ent d many important intervention ugge tion including en uring discharge smnmmie are faxed to primary care provid ers within 48-72 hour of discharge, which may be helpful in attempting to create a seaml tran ition of care for pati ent w ith MI. The New Zealand quantitative tudy undertaken by Cleary, Freeman, Hunt, & Walter, (2005) was a well-de igned study used to obtain baseline data on the extent of family involvement in the support of a person with SMI. They wanted to examine patient and family perspectives on discharge planning and corru11unity care, and to id entify information and re ources they considered important. The basis of thi tudy was that the shift away from acute hospital care results in greater responsibility on th e pati ent ' famili e r earch, the auth r had n t d that Dw tudi 0 At the tim e of thi i ted n family involvement or the differing perceptions of patients and famili es regarding information and resource need 0 The length of 45 a ute ar admi i n had deer a d hil th 1 el f pati nt a uity had incr a d, re ulting in greater d mand . ac -t -fa n a ailabl r outpati nt (n = 200) and UI ur y int 1 iew f id ntifi d famili (n = 50) f inpatient (n = 26) and utpati nt (n = 24) were condu ct d and analyz d u ing th 1enc ( P fi r by th r ) V 10. T h family r p n e rat ar h r . Th r ult pati ent and famili e wa n important. h t th f inpatie nt (n = 207) and tati ti al Package for urv were 1 w but thi wa ace unted d that a b tt r und er tanding [ th d d t id enti f in~ nnati n and re ci al pectati n f urce b th group c n id ered ommunica ti n hall enge b tw en patient and th ir fa mili were [! und t be barrier to the provi ion f ad qu ate in~ rm ati n t b th . T he re ea rcher D und th at b th pati nt and famili wa nted clearl y c mrnunicat d indi idu ally tail red infonn ati on that included what to do when pati nt wa unw 11, medicati n and their sid e ffects and infonnati n on available re ource . In contra t, fa milie pl aced greater empha is on attending di scharge planning es ion , meeting ca e m anagers before di charge, and receiving written inforrn ati n about discharge arrangem ent and care pl ans. The authors conclud ed that re ponding to th e information need of both patients and famili e has the potential to improve the quality of the outcomes of mental health service . Other studie und er this secti on were more focused on conununication between acute care and primary care in the discharge transition process. However, Cl eary et al. (2005 ) highlighted what infmn1ation famili es and patients deem ed important in the di charge proce This tudy presented important finding regarding information needs for both patient and famili es. The results of the study prov id ed beneficial insight into incorporating famili e into the care of patient with SMI in an ffi rt to cr at am le tran itions of care. The finding of the tudy align with the literature, discu ed under confid entiality in thi proj ect, that familie need 46 in£ rmati nab ut r urc tudy had limited re p n medi cati n and id effect rate fr m famili tudy r li ed n patient to id ntify famil y in ,m m mpari identifi d were th e r le wa n t ackn dynmni to c n id r in the car Th tud y by Ro e f patient wi th er on and e he h w r c n id er d by th e pati nt a h m ay have be n ac ti ely inv lved in ledged by th e patient. T hi an tmp t1ant MI. arbo (2007) rep tied on the re ult care intervention c ndu cted in a large urb an medi ca l center in th e intervention in the tud y wa to addre rate . 1 ed in th ir care, de pite ac ti e famil y lv d in their care, and no t refl ecti e of the fa mili e a pati nt' care, but wh n t the p ati nt r p n 1 ed in th ir care. It i 1mp rtant t n te th at pati nt may n t ha e r c gni zed fam ilie a m m ol em ent. There£ re, th fa mili and di charge pl an [! r p atient . The fa transitional A . T he goa l of the the di continuity of care in ex i ting programs in an effort to m eet immedi ate po t di charge need of everely m ntall y ill per n . The interventi on were based on the transitional care intervention m odel (T M ) of care developed and tested in previous uccessful clinical tri als and then refin ed and applied to high -risk pati ent groups. This model h as b een succe ful in redu cing hospital! ngth of stay, and in preventing rehospitalization . The tud y p arti cipants (N = 4) were A ftican American. O f note, the Afri can American population was not specifica lly targeted for the study, but the inpatient unit where th e research took place served a mostly African American population. A Patient A e m ent and Intervention Form tracked interventions and goals for each nurse-cli ent and fa mily interacti on. The authors review ed th e nur e' notes with the nurse weekly during the stud y, and critiqu ed them for biases and un ubstantiated conclusions in order to provid e credibility to the findings. Poor conununication among healthcare provid ers, parti ularly in the area of family support, was identifi ed as an obstac le to seaml e tran ition from a ute care to outp ati ent car 47 The auth r id entifi d II ur at g n 111 a criti al targ t f int 1 enti n 111 a lud d ar g1 r c n rn and ar g1 r h alth tatu unp ding illn M . hey manag m nt, lack of tru tur and in ment in daily a ti iti e , tru tural and fun ti nal fa ct r affe ting adh r n n nd pr o f[i r d, but th d u c f mpt m at di charge. R mm ndati n II r impr m nt were n t 1 pment f tr ng therap utic relati n hip were id entifi ed a facilitat r f ful ar tran iti n , and\ ill be di u ed und er the foil wing ecti n in thi paJ er. R e t al. ' (2007 tud y ampl e ' a In additi n, all th pa11i ipant \ ithin th n t b dir tl tran II rabl e t empha i n an int 1 mall and limit d t pati ent fr m a ingle fa ility. tud y ther p pul ati n re fri can- m rica n, who r etting . maJ r trength f thi nti n targeting c ntinuity f care. imil ar t th re ult Mallakh tal. 2004 ), the p iti re ult expen enc may tud y wa it f the tud y by 1- f int rv nti n were th ught t be related to th e e tabli lunent f trong th rap utic relati n hip between care pr vid er and pati ent . urth er, thi tudy al o fo cu ed on communicati on with familie in their interventi n and incorp rated them into the care of the patient with MI. The recogniti n of family in the care of pati ent with SMI ha been an important finding throughout the literature. In an effort to create tran itions of care, intervention creating a eamle aml e uch a TCM, and a fo cu on famili , may be crucial to tran ition of care. Th erapeutic R elationships The aforementioned study by Ro e et a!. (2007) id entifi ed a con·elation between trong therapeuti c relationship and effective care transition . In addition , two qu alitati ve tudi e , on from the K and ne from Finland, and one mi xed method tud y id entifi d th rapeuti c relation hip a important in effecti ve care tran iti on and continuity of care. The e tudi e ar app licabl to the anadian cont xt of mental h alth ar beca u e they take plac in countri e 4 whi hare id ntifi d a p er t o perati nand D ( rganization [! r ""' co nomic anada under th 1 pment) . In iew f th ignificant burden f MI in m countri s, and th ariati n in financing, healthcare d li i p t ntial [! r cr -country I an1ing and baring f b t practice b tw c n ar Mt tru ggling t pr ry, and utc m e among th m , th r er th rei p tenti al fi r learni ng b t practice am ng 2013).Health that it i important t mad in memb rs. ide appropri ate car [! r indi idual with MI in the community; h w anada(2014)ad i t ami n where pr gr peer ( ha been anada, and ar und thew rld , in order t mak ad anc ment in patient care and health outcom The fir t K tudy by olan Bradl y, and Brimblecombe (20 11 ) ought to a certain h w individual experienced di charge from acute care i~prove inpatient care. rv1ce in ord er to under tand how to mi- tructured interview were c mpl eted wi th pati ent pre-discharge (n = 26) and po t-discharge (n = 1 ), and analyzed de criptively and themes were id entified from the transcribed interviews. Cunent literature and con ultations with staff from four acute psychiatric ward were utilized to develop the interview for the data co ll ection. There ult showed that upon discharge from acute care, in1mediate concern of patient revolved around social integration such as housing, emplo)'lnent, and e tablishing and ustaining interp er onal relationships . The author identified that loneliness, lack of dail y structure, and insufficient information regarding available con1munity services are the pri1nary concern of discharged patients. They found that the support and relationships established with other patients and taff were highly valued and the void from the loss ofth se peer relationships ca n be detrimenta l to pati ents' well -being. They concluded that tran ition from a ut care to home need to place greater emphasis on helping patient with MI cope with veryday life. Further, the tudy 49 mpha iz d the imp rtan e f making the inpati nt £ 11 wing di charge a addre ing th r a Th tudy had p n nc qually ab ut fo cu ing n life n rallimitati n that th auth r did n t n t . The ample iz wa relati ely mall n id ring th at th tud y t k pl ace r a nin m nth p ri d . The d In addition, the ard taff 1 in 1 ed in th tudy d content and the electi n f th parti ipant . Th rewa n di ign, intervi w de ign and u i n a t h w potential bi a e , that may ha e influ enc d the tud d 1gn r e lecti n f participant , were addre be ign.ificant a taff in ol ed in the tudy may have had cl tudy pmiicipant , which may ha e kewed the r in thi ult cripti n d . Thi may e th rap utic r lati onship w ith the f there earch. De pite the shortco mings tudy, there were everal imp011ant finding . In an ef£ rt t impr ve the quality f care for patient followin g disch arge, the tud y u gge ted that a great r empha is during an acute ca r admi ion need to be placed on addre ing the pati ent · ituation following di charge. For patients with SMI, the effect of lo ing established therap eutic relationship w ith taff and patient peers was identified a detrimental. Tailoring di charge platming to addre thi may be an impotiant consideration in creating eaml ess transitions from acute to pri1nary care. A large longitudinal study by Jones et al. (2009) examined continuity of care in m ental health services to identify points of care where continuity may be threatened . Transitional expe1iences, as described in the tudy, included tran ition at discharge, tran ition between care provid er team s, and transition to new care provid ers during reassignment of taff. Th perspectives f pati ents and their famili e were obtained through theoretica l and purpo iv sampling selected from the larger tudy to capture thee p ri n and iew of a sub ampl e of pati ent (n = 31) and their famili e (n = 14). In th se populati ns, care tran it ion and c ntinuity 50 f ar had b n pr bl m ati . The quantitati Ul han ge in car n a multipl referral t car pr d r lati nal di c ntinuit and pr bl m w ith tran iti n h ad b en ide ntifi d in th hang in healthcare pr m rged fr m the emi- tru tur d inte1 iew key them d per id er nalized tra n iti n , 111 ibilit and cri i , id er r f gr up , mmum a ti e ga p , ia l vuln rabilit Tran iti n betw en are pr ider ere iden tified a ourc f tre [! r pati ent a nd th ir famili . J ne et al. (200 ackn w l dged th at b th patient and fa mili e id entifi ed th e imp rtanc f th relati n hip ith a car pr partic ipant had ider. The auth r [! und that alth ugh m o t o f the peri enced a hang in car pr id r at m e p int thi tran iti n never becam e ea i r fl r th e pati ent and famili e . From the urvey, the auth r id entifi ed th at po iti ve car tran iti n occun·ed wh n are pr tran ition between care pro vid er id er pl aced a tro nger empha i o n per nali zing th e and inc rporated the tran iti on int th e dail y life f th pati ent. They und erlin d that thi per onali zati on play a key ro le in well-m anaged tran itio n . Th ey empha ized that care provid er wh udd enl y left w ithou t uffi c i nt wa rnin g undermin d an y po itive experi ence that had been e tabli hed with the m ental hea lth en tice . A illu strated in the tud y, care fo r pati ent w ith SMI can co ntinu e for yea r and w ithin that time fram e ch ange in care provid ers w ill mo t likely occ ur. Inco rporatin g the ch ange in care provider into a pati ent' life is one way to potentia ll y miti ga te th potential negative effect th is can have on a pati ent ' life. H owever, it is in ev itabl e th at so me change may ne d to occ ur sudd enly w ithout wam.ing for the pati ent. The author ugge ted that more r ea rch i needed on how to cop e w ith the e tran ition . R e ea rch into m anaging tran iti n m ay be a key elem nt in und erstanding how to olidify therap euti c relati on hip for pati ent wi th MI and rea te eam l transiti n of care from acute to primary care. 51 nother imp rtant p int rai ed in th ituati n . B th 1 ati nt and famili tud y i that rv1c were m recent r d n n 1 r p 11ed feeling that en nce wer la king [i r th w re n t an in1m diat danger t them 1 e r oth r . Pati nt and famili pr urc enti with the care wa lacking and thi a a e wh id entified that f fn1 trati n. he e fe ling f fru trati n r i e may nega ti ely af~ ct th therapeut ic r lati n hip e ta bl i hed with the care provid r and pr gram . Thi i minim all y e p lor d in th tud y and m re re earch i n thi area t ga in a b etter und r tanding f the effect f th erap utic relati n hip np ded in itiv care tran iti n . Fact r contributing to co ntinuity f car [! r patient di charged from the ac ute etting were identifi ed in a qualitati ve ph n men graphi c tudy by Hau tla-Jylha, (2005 ) in Finland . At the time of thi ikkonen, and Jy lha tudy, the author were of the opini n that n re earch h ad been can-i ed out to m ea ure continui ty of care in p ychiatric erv ice . The purpo e of thi s tud y was to describ e and analyze the parti c ipant ' perception of factors improv ing continuity of care. The data was collected through interviews of patients (n = 5) attending outp atient care in inpati ent adult psychiatric wards, ward staff (n = 13) and administrative staff (n = 5) in the hospital, and staff (n = 5) of the outpatient m ental health service were tudi ed. Through ix phases of analysis, seven categories describin g factors improving continuity of care were identified: (1) Adherence to a good cooperative relationship ; (2) adherence to the care enviro nment; (3) fl exibility in tailoring care; (4) active maintenance of contacts in care; (5) con ta nt possibility to contact the ward ; (6) up-to-date patient data; and (7) ac ti ve cooperation betw een outpatient servi ces and other collaborators achieved through acti e fl e ible cooperation betw een inpati ent ward and outpati nt ervice per onnel (p .3 ). 52 In thi tud y it wa identifi d that a ti e and fl e ibl e c utpatient er ice can impr p rati n betw een inpati nt ward and e the c ntinuity f ca r . In additi n n ir nm nt wa D und to impr pati ent ' fe ling to their car . Th auth r emph a ized th imp rtanc f ntinuity f the car curity ther by impr vm g f adh r n e t a g mmitm nt d car r lati n hip . Fmih r th auth r und rlin d th imp rtan e f patient b ing abl e t c nta t th ward and ' dr pin ' with ut a referral a anoth r fa t r in impro ing their c mmitment t car . he auth r relati n hip i th e fi und ati n fi r patient ' concluded adh renee t a g dc perati commitment to th ir car pati ent , wi th g dc pera ti e relation hip with taff, are m re inclined to eek help when needed. It i important to note that the tudy had a m all patient a1npl e and no inclusion or e clu ion crit ri a fo r pati ent we re di cu ~ ackground of the d. The tud y' part icipant were ma inl y taff and th e taff wa diver e in ord er to have a broad repre enta tion of per pective . The rationale for the number or type of taff and pati ent in the tud y was not di cus ed. Hautla-Jylha et al. (2 005 ) noted th at a pati ent' ability to wa lk in to the inpati ent ward fo r a sessment of their m ental health tatu s was key for patient with SMI. Th e author fo und that patients had established relationships with the taff m ember and tru ted their assessm ent of their mental health. The ability to walk into the patient ward fo r assessm ent m ay not be applicable in the current Canadian system, as care is provided fo r patients with SMI w ith a different ca re delivery model. However, a healthcare delivery m odel where patient are able to walk in to the w ard for assessment m ay be an impo1iant consideration in attempting to create seamle transitions of care for pati ents with SMI in Canada. The 17 a1iicles analyzed here w ere selected follo wing a th rough in e tiga tion of the literature applicable to a seamle s transition and co ntinuity of care of adult w ith e re mental 5 illn di harg d fr m acut car t prunary car . The critically apprai ed. Fr m the anal y i , fourth 1n tran ition of ar for indi idual acute car and primary car ith ha article w re then review d and em rg d a imp tiant t amless vere m ntal illne : c nfid enti ality, linkage between co11U11unication, and therap utic r lati n 'hip . Re earch pre nted i from a br ad range of c nte t and it pr ide imp rtant e idence ~ r thi paper. Many of the r co1nm ndati n id ntifi din the literature are feas ibl e within primary care ettings. Th e :fl llowing ecti n will pr vid e a ynthe i of the fi nd ing in th e articles, as well as rec mmendation fo r pra ti e du cati n, and re earch fo r F P practic in the anadian c ntext. 54 H PT RS Di cu ion and onclu wn Th aun f thi pr J t i t id ntify e idence ba ed practice and pr c of the P pra ti ing in prim ary ca r , that help t crea te eaml e e , at the I vel tran iti n and c ntinuity f care £ r m ntall y ill adult di charged fr m acut p ychi tric care t pnm ary care. urther, t offer r c mm nd ati n £ r practic £ r Family ur e Pr titi ner pra tiein g in primary care in anada . From thi analy i fo ur maj r them merged: c n fi dentia lity linkage betwee n ac ute and primary care, c mmunica tion, and th rapeut ic relati n hip . It i evident throughout the finding that m any of the e theme are inter-related. The lit rature id entifi ed that i ue unounding privacy and confid enti ali ty can b majo r barri ers in effective c mmunication; thi m turn can affect a pati nf tran ition fro m acute to prim ary care. Furthermore, a common thread throughout the literature wa that establishing positi ve therapeuti c relati n hip may impact eamles tran ition and continuity of care. The di cus ion will includ e th e application of the e frndings and their relevance to clinical practice, and w ill conclude with key recommendati on for practice, edu cation and research. Confidentiality Infmmation sharing between patients, familie , and mental hea lthcare provid ers has been shown to improve patient outcome . Although many treatm ent guid elines recommend fa mil y involvem ent in all aspects of the treatment proces , pati ent confidenti ality i sues hinder thi involvement (Gra y et al. , 200 8· W ynaden & rb, 2005 ; olomon et al. , 201 2) . The background ofthi paper id entified effective care tran ition fo r individual with SMI, including the involvement of famil y. The w ider literature related to pri acy of per nal 55 h alth inil nnati n upp rt th finding fr m th r guid lin r mm nd famil in la k f larity in 4). . H we er, m nt in f th trea tm nt pr c p a barri r t famil c ll ab rati n (Mar hall nfid nti alit p li mm nth me in th literature id ntifi ed that h althca re pr t withh lding in~ nnati n fr m fa mil additi n t thi , hi hindi at d that many tr atm nt nfid enti all y urfaced. In hen c nfu i n ar und 1 m n et 1. (20 12) il und that h alth are pr p rtinent in~ rm ati n harin g fr m Ca mili id r defaulted r w uld p tentially ign re regardin g th 1 ti cnt ' ell -b ing. 11 f the arti le i I ntifi d that c nfu i n un unding c nfid enti ality law , di rupted ami tran iti n of are. he anadian enate (200 ) identifi ed that famili e do n t want int nnati n ab ut confid nti al di cu i n b tw famili n d inil rmati n r garding di agn 1 , n hea lthca r pr id er an I pati ent ; h we er, m dica ti n , care pl an, and afety i ue . In the ca e f t phen, hi fa mil · chi f c ncern were centered n the prac ti ca l ide fund r tanding hi conditi n including pl an of ar id e effect f medi cation , management f ym ptom , and probl em that might be encountered post di charge, including the ri k f elf-harm . The prim ary care provider need to do an a ment of the fa mil y to id enti fy th eir need for relevant information and provid e that in formation a abl e, o that the family can care for their fa mil y member ( ray et al. , 200 8) . Without uch informati n, fa mily member are unabl to upport treatment goals and prom ote the recovery process (Mar hall, & olomon, 2004 ). Primary care provid er are ideally itu ated to id entify the famil y member who are central to the lit of patient and to approach the i ue of con ent with pati ent and their famili e . Thi re iev identifi e g d practice a ne that con id er famil y a an integral upp Ii ~ r the indi idu al with MI. Healthcare provid er have the opportunity t a t a interm di ari e between pati nt and famili e by neg ti ating onfid nti ality barrier and in[i 1111ati n haring. hi in lud di u 1 n 56 with the 1 ati ent and th famil reg rding ad anced dir cti e r plan [! r car r lated t acute de and acut care m ental h alth admi ion ( ray t al. ). Finding fr m th ider b dy f literature upp rt the ne d [! r adva n on in th care f indi idu al with Ml thi paper of per bl ugla , 2004) . dir ctiv earl y n ted in the background f mptom of Ml can impair capacit nal h alth in:D rma tion. capa ity to con ent, will addre d anced care planning whil e the patient i the e itu ation . tabl e and ha the d ancc care pl anning in mental health i. an emerging and key conce pt to help guid e a pati ~,; nt· . ca re dur ing ti me'> ofac ut~,; illn ess (M ood Di rd er ociation of Bri ti h olumbi a, 2008). By inco rporating thi s concept into the care of patients with mental illn e , it empower. the individu al and allow for them to have a vo ice in their care and during tim e of ac ute illnc . . It i important to con id r the occasion where there is no prior pportunity to estabJi h an advanced care pl an such a the primary onset of illne or initial encounter, as in Stephen' case. However, the evidence hows that basic info nnati on regarding di agnosi , care plan, medications and their sid e effects ymptom m anagement, and afety i sue are e sential for famili es to provide appropriate care and assist with afe tran ition (Canadian Parliament enate Standing Committee on Social Affairs, Science and Technology, 2006) . T hi will promote the involvem ent of fmnilies who may have in1portant info nnation related to the hi tory of the presenting illness, and m ay be involved in caring for the patient (O ' Reill y et al. , 20 10) . Healthcare provid ers have a respon ibility to be familiar with the laws that govern their practice, as well as the poli cie within their pmi icul ar organizations ( RNB , 201 0) . Th se articl how a need for responsive confid entiality policies and for h althcare profe ional receive edu cation on the applica ti on of patient confidenti ality to clinical practice (Chen, 200 57 tal. 201 2· W naden ann t b an 1 lated rb , 2005). nt· in t ad it mu t be c ntinu u pr wa y t m nit r th e tran lati n int practic he m mb IC f m ntal h patient w ith MI. lth are had di fG ring id ntifi d in th anal impl em nting du ati n 1 t und r land famili , a bi a I m n t al. furth r empha ized that du cati n e th at align w ith an effe ti e anadi an nate (2 006) hi ghli ghted th at key n the in 1 em nt f famil y in the care f f ol m n et al. an imp 11ant c n id erati n f h healthcar i nal are r luc tant l inv lve and mi und er tanding m a hind r pr gre in thi ar a. changing law r ga rding pri a y and c nfid nti a ll y may be requ ired t addre hen ex pl red h w the c nfu i n ar und inD nnati n haring betwe n healthcare pr vider , patient , and fa mili e . H w ver, The anadi an enate rep rted that enhancing th e law m ay n t b th e an wer· in tead, tran [! nn ati on of the anadi an m nta l health y t m a a wh 1 i n ded . n i lerati on f b th findin g may be required to v rcom e banier of infonn ati on harin g betw en patient , fa milie , and healthcare pro id er . Linkage between Acute Care and Primary Care The literature recognized that the peri od f transiti on from acute to primary care i a hi gh-risk time for individual with SMI. It empha ized th at continuity of care is cru cia l, and identified uccessful connecti on to primar y care a an important fac tor in the comprehen ive care of an individual with evere m ental illne s. Pat ient with MI uffe r exces morbid ity and mOJiality, and compared with the general population, they are m ore likely to have c n omitant medical probl ems, such as di abet and hyp e1iension (Kaufman , M cDonnell, ri tofalo, & Rie , 20 12). FUI1hermore, changing trend in hea lthca re delivery have r ulted in a m o em ent fro m ho pi tal care tow ard s community care, with the m ajority of p ychiatri c care now being pro id d in the primary ca re ettin g (Ru 11 et al. , 200 ). he di harge proc fr m acute care h u ld 58 be c n id r d in th c nte t f the pr -admi i n admi i n tr atment, di charg di barge c ntinuum (Ru ell et al. , 201 ). ho pital t t- ntinuity f are i cru cial during tran iti n fr m ommunity. The tran iti n b tween acut and primary car allow for an opportunity t initi at relati n hip betw en healthcare pro id r continuum f car ( ri and there[! re bridge th gap in the ld et al., 200 ). Pati nt r quiring [! ll w-up car fa e a umqu e et of challeng car . and p ften th e di charging pr 111 c nn cting to primary id r im ply give the pa ti ent th e name of a primary care provid er or lini . Thi i not helpful [! r a pati nt em rging fr m a p ychiatric cri i when further upport i needed ( ri wold et al. , 2005; ri wold et al. , 200 ). The literature id enti fied everal ugge tion to h lp link pati nt to primary care pro ider fo ll ow ing di charge from an ac ute p ychi atri c admi ion . Bat cha t al. (20 11 ) ugge ted that phy ically acco mpanyin g pati ent t their initi al primary care provid er appointm ent may be a way to ensure fo llow -up and a i t in transition. Ho wever, this interventi on could be co tly and put great demand on already limited resources. The literature also identified pre-an anged appointments prior to di charge as an effective method to ensuring a smooth tran ition between acute and primary ca re (El-M all akh et al. , 2004; Griswold et al. , 200 8). El-Mallakh et al. noted an emphasis on ensuring patients are connected w ith the primary care clinic prior to hospitalization. They identified that if patients do not have a u ual ource of care prior to an acute psychiatric admission, they remain at risk for di continuity of care following discharge. In situations where pati ent have no primary care provider prior to acute psychiatric admission , connecting pati ents with a primary care provid er during ho pitalization has the potential to create continuity of care. Involvement with the prim ary care provider pri r to, or during, admis ion to acute psychiatri c care was n ted in ev ral tudie to b po iti ely 59 c IT lated with tabli h d therap utic r lati n hip . wa t al. (20 12) n ted that redu cing barri ing primary ar , uch a waitli t , w re imp rtant t fa ilitate tran ition fr m a ut care t primary care. H we er they empha ized a ldr th tran iti n and that the ulnerability and illn tob addr edin ord ert cr -atea earn! ing th e barri r may not improve r lated ympt m f pati nt with MI need tran i tio n f car . Pati nt ar more lik ly t attend th ir app intm en t when ace mpanied by a ca e manager ran ad anc d practi c nur e ( at chaet al. , 20 11 ; the incr a ed pr ur t m anage c det rmining an appropri ate car pr ri w ld , t al. , 2008) . nver ely, t in healthcar ne d t be a con iderati n when id r t h lp pati nt navigate the m ental healthcare sy tern ( leary et al. , 2005 ). The mo t appropriate and co t effectiv care provid er h ould be appointed to helping pati ent navigate the y tern . H owever, it i noteworthy that a primary care pr vid er, or advanc d practice nur e, m ay not be the m o t co t effective care prov id er. M ental health worker or care aide m ay be more cost effective in thi role, however, more re earch is needed in this area. Another important consid eration in addre ing dem ands on the healthcare system i recognizing famili es. The broader literature identified that families are maj or sources of supp ort for peopl e with SMI and often provide housing, assistance w ith activities of daily living, finances, and ongoing suppmi (M acfarlane, 2011 ). In this context, fan1ili es who are w illing to be actively involved in patients ' care should be acknow ledged and their upport and a istance appropriately utilized. Therefore, when addre ing the is ue of linking acute to primary care, consideration of sharing information w ith family need to be a priority. There were inconsistencies in the literature around post di scharge fo llow- up . W o d t al. (2009) identified follow-up ca ll s from primary care providers within 7- 14 day p t di harg 60 w r a eptabl . 1-Mallakh et al. (2004) aimed£ r app intment within tw we k di charg . Th wid r lit ratur uicid tate that the fir t w anadian M ntal Health c1 ar that th r i t ph n uicid o pon re iewing the literatur it i hen di charge follow-up need t urred within a week f di charg . app intment with utpati nt er 1ce wa De pit th k f di charge ha a heighten d ri k f iation [ MH ], 201 ). nt tandard f care f fter hi death, it wa ccur. ered that an ch duled within th fir t week f hi di charge. emingly appr priat time frame of the fir t appointment .G r [! 11 w-up, n vidcnt plan wa in pla e to n ure hi att ndanc at thi app intment. In additi n t ad an ed care planning for acute p ychiatric admi 1011 di charge planning hould be initiated at th time of admi ion to d t rmm the patient' plan of care and the upport that the patient and hi or her family may require after di charge, including connection with primary care po t discharge to facilitate tran ition (Alghzawi, 2012). urrent literature indicate that healthcare services often function in isolation, widening the COllli11unication gap and narrowing the likelihood of assigning responsibility when problem arise (Coleman & Berensen, 2004). Therefore, pri1nary care providers, uch a Family urse Practitioners, need to collaborate with acute care providers to e tabli h expectation of each service in the discharge plan and follow-up. Families also need to be active partner in the discharge process. These approaches to family involvement and linking the patient to primary care providers prior to di charge are key in facilitating eamle tran ition to primary car . However, without effective communication between acute and p1imary care, endeavors to link newly discharged patients to primary care will be compromised. 61 Communication ffecti are tran iti n are fraught with cha ll eng c mmuni ati n b tw e n h althcare pr id er and care y tem £ r reliabl y d li ering in[! nn ati n b tween pr in in£ rm ati n haring and tting , wing largely to inad quate id r ( h ng et al. , 201 ). Th imp t1ant finding o f Krip alani t al. (2007) wa th at direct 111municati n betw en a cut and pnmary care pr id r id ntifi ed that p ati ent di charg id er umman ccur infrequentl y. Prim ary ar pr were the m t c mm n mea n f c mmunica ti on between inp ati ent and outpati nt pr v id r . Krip alani et I. not d th at th e a ailability of a di charge ummary at th fir t po t di charge vi it wa 1 w and it ften lacked imp ortant in£1 1mati n. Theca e exampl o f tephen al o reflec t a troubling delay and a lack of communicati on between pec ialty car service and th primar y care pro id r . u ch a lap e in communi cati on fail to m eet pati ent ' ,expectation th at their infonn ati on wi ll be u ed in a consistent way am ong all of th tr care provid ers (Hogg et al. , 200 ). The literature identified c larifi cati on of primary care prov id ers' co ntact info m1 ati o n and preferences for mode of contact to be an important and practical strategy to improve communication (Johnson et al. , 20 12). Progressive trategie , uch a computer-generated sun1111ari es, integrated acro ss care sites can fa cilitate more timely tran fer of relevant p atient infonnation to primary care provid ers. Further, it w ill make di charge summ arie more readil y availabl e durin g follow -up care (Johnson et al. ; Kripa lani et al. , 2007). Wood et al. (2 009) did not fo cu on specific mod es of information transmi ion, rather they emphas ized the impot1ance of a standardized clinical handover proce s. Until there is fu ll integration o f uch strategies, using p ati ents a courier of their wn di scharge ummary had been propo ed (K.rip alani et al. ). Howev r, as Dewa et al. (20 12) id ntifi d, th e vuln rabi lity and illness related symptom of M l 62 make thi a 1 d irable aJternati wa n t abJ t mana ge hi . Thi i n car mplifi ed in th ca e e ampl f tephen, wh and it highli ght the imp rtance [id entifying family a an integral ource f upp rt. n important findin g from th lit ratur a J hn n t a!. ' (2 0 12) u mapping t id entify th e c lini cal pr cedure in ed in th tran iti n f pati nt from acute t primary care. B y utilizing pr ce id er wer abl t e amine clinical pr ce es m ap , ca re pr and id ntify gap in care and ommunicati on. noth r area f concern wa the lack f communi cation between familie , p ati ent , and care provid r . l ary t al. (200 5) id enti fie d th at pati ent and familie have different infon11ation need . Both p ati ent and familie wanted per onalized inform ati on regardin g medication and side effect ymptom m anagem ent, and acce to re o urces . However , famili e placed a gr at r fo cu s on discharge care planning. More care is being provid ed in a community care context, and famili e are th e main source of uppoti for individual w ith MI. (M acFarl ane, 2011 ; Russell et al. 2003) . Within thi context it is impotiant for primary care provid ers to address communication n eeds w ith both patients and famili es in an effort to improve the outcomes in primary care mental health serv ice (C leary t al. ). Issu es surrounding privacy and confid entiality must be addressed in order to implem ent these strategies to improve communication. Th erapeutic Relationship s The literature id entified that therap eutic relationships are important to continuity of care (El-Mall akh et al. , 2004 & Jone et al. , 2009) . These continuing relationships between care provid ers and their patient and famili es, along with personalized care m anag ment, m ay be benefi cia l for seanlless care transitions (Bat cha , et al. 2011 ; Jone et al. ; N olan et al. , 20 11 ; 6 R , tal. , 2007). Tran iti n t th c mmunity may b m re difficult for pati nt with MI and care tran iti n ar :D und t ucc ful wh n are pr id er are upporti ( m ez, 2008) . Ian et al. (20 11 betw n car pr pla ined that therap utic r 1ati n hip ar imp rtant not nl y id r and pati ent , but al tran iti n fr m a ute care t with pati ent and their p r . h y e pl red that utp atient care need to pl a e a grea ter empha e eryday life and e tabli bing and u taining relati n hip . In teph en ' ca di engaged fr m all hi on c ping with , he had cial c ntact and alienated him elf from hi famil y. It app ea rs that ocial reconn cti n wa not a con ideration in tephen ' di charg planning. identified a ri k to pati nt ' lan et al. e ll -being can occur when therapeutic relationship e tabli bed with taff and peer are lo t following di charge. Jone et al. (2009) identifi ed that patient exp eri need peri od of tran iti on thr ugh multiple care provider . They found that if transitions between care provider were not personalized for the patient, it could undermine any po sitive experi ences with the mental health services. In the context of Famil y Nurse Practitioners, providing primary ca re, thi s is an important con ideration when workin g with patients with SMI. For exampl e, it is impmiant to prepare patients with SMI for any changes in care provid er well in advance, regardle of how brief this may b e. Hautala-Jylha et al. (2005) fmiher added that good cooperati ve relation hips with patients w ill improve their commitment to their care as patient are more willing to seek care with a provider they tru st. Another important findin g from Hautala-Jylha et al. wa that in a system where pati ents are abl e to return to th inpati ent ward for a ses ment of their m ntal health statu s, pati ents had increased cmnmitment to their care. Th author noted that pati nt had established relation hips with the staff n the wa rd and trusted th ir as e m ent of th ir 64 mental h alth tatu . In th curr nt H w er in c n id rati n f th e anadian m ntal health y tem , thi may n t be fea ible. m ental health y tem it may be rea to in rp rat thi c ncept. nat ' (200 ) ugge ti n fa tran ~ nnati n f th anadi an nabl e to on id er adapting an ad a' m ntal h alth sy t m tran fo rmation f the m ental hea lthcare y tem w uld be an ardu u und 11:aking and w uld require c n id erable tim and f.G rt. H wever, the e finding are ith MI, and pr mi ing in nh ancing car fo r pati ent the lit ratur , and 1 king t th er co untrie y tem can be mad (Hea lth anada 20 14 ). ucc anada could benefit fr m c nsid ring detetmine wher impr vement in our noth r key findin g fro m Jone et al. (2009) wa that pati ents ex peri enced fru trati on that en r1ce w re m re foc u ed o n cri i tabil iza ti on, ra ther than on preventative management. Thi frustration with erv1ce and healthca re provid er wa shown to have a n gative im1 act on establi h ed therap eutic relati onship . T he PH C (20 10) reported that health serv ices th at are more fo cu sed on prevention , rath er than reactive m an agement, need to be a priority and are n ecessary for the sustainability of the healthcare system . This findin g furth er suppm1:s th e idea that a change w ithin Ca nada' s menta l health care sys tem is needed . The e findings are congru ent w ith literature that ass igns prim e impm1:ance to the therap eutic p artnership and the perceived helpfulness of the primary care provid er (Mitchell & Selmes, 2007 ). Findings fro m the literature are fu rther suppm1:ed by th e wid er re earch literature, indi cating that the development and m aintenance of a therapeuti c relation hip in a nonthreatening environment is critical to achieving optimal clinical outcom e ( torfjell et al. , 200 8). It is cl ear that positive therapeutic relati onships are key to the uccess of tran itions of care for the severely mentally ill popul ation. 65 Conclu ion Thi int grati r ww ught to an wer the re earch qu practi e and pro that h lp to achi eve eaml m ntally ill adult di harg d fr m a cut p ti n: what are ev id ence- ba ed tran iti n and ntinuity of c · chia tri c ar t primary care . ~ r he finding d ri v d fr m the re i w id ntifi d e eral imp 1iant pra tice and pr ce e , at th e level f the pra tieing in primary care, in the fac ilitati n f eaml e P tran ition f care. In ummary, the e concern the D ll wing. arl identi fica ti n f patient with MI in the prim ary car famili e on an indi idu al ba i can a i t t determine n ed famil y. ettin g and a e m ent f pecifi c to the pati ent and th eir dvanced care pl anning with the patient to determine their directi ves during tim e acute illne f m ay improve tran ition between ac ute and primary care and lessen confusion during cri i (Gray et al. , 200 8; Jon s et al. 2009) . The valu e of und erstanding fmnil y role in care tran ition , appropri ate information sharing with the family, and the impotiance of the inclu sion of family were common findings from the literature (Canada Parli ament Senate tanding Corrunittee on Social Affairs, cience and Technology repmi, 2006 ; Chen, 2008; Gray et al. , 200 8; Wynaden & Orb, 2005 ; S lomon et al. , 20 12). Continuing education for healthcare prov iders on the appropri ate application of confid enti ality to clinical practice and establi shing tandardi zed process for info rmation sharing between healthcare providers can facilitate emnl e s transition of care (G ray et al. ; J hn on et al. , 201 2; Krip alani et al. , 2007; Solomon et al. ). F miher, a rai ed awareness of fa milies in the care of individuals with SM l, as well as an empha i on th importance of therapeuti c relationship s, ma y improve patients' tran ition fr m acute t primary care (Bat chaet al. , 20 11 ; leary et al. , 2005; ray et al. ; R se et al. , 2007). 66 Wh n u ed in i eaml lati n the e appr ache may ha e a limited effect n r ating the g al of care tran iti n . H w r, wh n u ed in conjuncti n with n an ther these approache can narr w the gap in car and crea te eamle care t prim ary ar m 1 e a c ll ab rati famil y in the di charge pl anning pr ce tran iti n f care. Linking patient fr m acute approach am ng a ute car , primary care and ( leary et al. , 2005 . 67 R ecomm endation Th purp f thi p r ~ amine cuiT nt lit ratur with the g al f btaining a t wa t m re c mpreh n i und er tanding of current practice in care tran iti n for pati nt with MI. urth r t in ibl y achie e eamle tiga te inte1 nti on that c uld p tran iti n and continui ty f care [! r p ychiatric car t primary car confid nti ality, linkag erely m entally ill adult di charged from acute part f thi r view, th four them e th at wer identifi ed, between a ute care and primary ca re, c mmunicati n, and therapeutic relati n hip , w r furth r ynthe ized and linked to practice and the wid er body f literature. Recomm ndation for practi , r earch, and edu ca tion were id entified. The in titution f the e recmnmended practice ha the potential to impr ve hea lth outcome of indi vidu al with evere mental illne , and in thi way, to create m mentum for the continu ati on of edu cation and _research initiative for impro ement in care tran itions for this population. While it i out ide the scope of thi s proj ect, it i important to recognize th at Famil y ur e Practitioners must be prepared to advocate for influencing change at the lo cal, provincial, and national levels to contribute to improving transition of care processes for adult patients with SMI. Family Nurse Practitioners can work at the iocal, provincial, and national levels to addre healthcare system issues that affect transitions of care for SMI patients. Thi proj ect ha foc u ed on offering recmnmendati ons for FNPs to improve care transitions for patients with SMI fr m a practice perspective, however, a participation in advocating for change at the policy and y tem s level is imperative in ord er to promote effective change that contribute to eamles tran ition of and continuity of care for adults with SMI. 6 R ecomm endation for Practice The but may al r c mm nd ati n are int nded :G r the F P practicing in primary car in an ada , b rele ant t me of ther h althcare pr th rec mmend ati n may al id er b th in anada and el ewher . b helpful b r th e acute p ychi atric care tting, or c mmunity m ental h alth pr gram . Table 2: R comm ndations for Pra ctic 1. Perf01m an a e m nt of the patient and th ir famil y to determine their le el of involvem ent in care • • • • • 2. FNP s as PCP should actively negotiate, document and update clear and detailed advanced directives as part of living care planning with the pati ent and family P rD rm an annual asse m ent of the fa mil y r with any change in the fa mil y itu ation or dynami c Be knowledgeabl e and und r tanding of confid entiality law and provid e appropri ate information to famili e and direct them to resource When applica bl e, invo lve fa milie in di charge planning Act a an interm edi ary between pati ent and famili e Individualize info rmation for the fa mil y • A sess the pati ent' s ca pacity to nego tiate an advanced care plan • Make advance care pl anning and information sharing with famili es a priority of care • Implem ent anti cipatory planning fo r pati ents with SMI by promoting hea lthcare provid er acceptance and embed practices which fac ilitate advanced care pl ans as pmi of routine care. • Share care plan with acute care • Refer to Appendix A : Component of an Advanced Car Plan 69 Table 2: R omm ndation for Pra tic n ure that th y ha a curr nt unci r tanding f rel ant nfid ntialit law and p licie a th y r lat t p y hiatric care 4. • rs • p • ec m familiar ith th c nfid entiality law and p lici within juri dicti n f pra ti c . • ub crib t rele ant lit ratur and web ite t ta y cun nt in c nfid ntiality law • Refer t th Mental Health ct peci fi c t juri dicti n f practi ce. For examp le in Briti h lumbia: http ://w w .bclaw .ca/c ivi /d umen idl mplete/ tatreg/96288_ 01 • Refer to The anad ian Mental Hea lth A ciati n: http ://www .cmha.c hould work to tabli h partnerships between acute care and primary care to outline expectation of re pon ibility for perfonning pecific role associated with care tran ition and to allow involvement of all es entia! care providers in discharge planning meetings • In coordination with relevant takehold r meet with member of th e p ychiatric acute ca re team to identify mutu all y agreed upon re pon ibilitie and pr ce e for perfonn ing pec ifi c role a cia ted with care transition • Contribute e sential infonnation fro m primary care in the communication tool u eel for patient management in the acute care etting • Be actively invo lved in quality improvement activities within healthcare ystems at the local, provincial, and national level . • Be actively involved in creating policie regarding care tran itions 5. Stmi collaborative discharge planning upon admission to acute care • Identify a date and/or time of eli charge as early as po sib le • Identify whether the patient has imple or complex eli charge planning needs • Id entify what the e need are and ho w they will be met • Work collaboratively to plan care, including both acute and primary care provid ers, agr e who is re pon ibl e for pecific action and the process and timing of discharge • on icier the ocial context of pr -admi ion and tabli heel interp er onal relation hip in the eli charg pr e s, communicat thi with acute care 70 Tab! 2: R 6. omm ndation fo r Pra ti cut car and primary car pro id er or upp rt taff t n ur th pati ent 1 chedul d fl r fl ll w- up ap1 ointm nt ith pnmary ca r prior to di charg 7. to n ure prim ary ca r pr id r c ntact infl nnati n i regul ar ly upd ated and a ailabl t acut car pr id r 8. • cut p to ch dul a telephon di barge • cute p y hi atri c care r prim ary care upp rt taff or care pr vid r t hedul e a fac -t -face app in tm nt within five day of li charg • cti ely neg ti ate and c llab ra t with acute ar to cr ate .G r arranging .G ll ow app intm nt . e ign ate up port taff to regularl y upd ate P P c ntact infom1ation and preference .G r m de f contac t, uch a cell ph ne, pager r ffic number a part of ffi e r utine • tabli h a pr ce t regul arl y di tribute accurate c ntact in..G nna ti n to all agencie and care pr vid er • proces e in collaborati on with th gr ater y tem collaborator and care tea m m ember to en ure that e enti a! patient infonnation is transmitted/received during care transitions. • • • • 9. Utilize and m aximize existing electronic systems, and/or paper patient records, ensuring all patient information i complete and kept up-to date • umman e reate a reference document clearl y outlining the c ntent process of sending and receiving patient info rmation during care tran iti ons. Acute and/or acute care provid er to co ll aboratively en ure that di charge ummary info rmation i available to the P P 24 hour prior to patient telephone contact or face- to-face appointment postdischarge. Ori entate new taff to the documents/process to afeguard continuity of care Ensure es ential patient info rmation i reviewed regularl y and acted upon, including requ e ting clarification when infonnati on is mi s ing or unclea r En ure both pap er and/or electronic records are compl eted in a timely fa hion • Adopt a positive attitude toward the u e of exi ting or emerging electronic medica l systems • Becom e a champion in the use of ex i ting and em rging technology that supports tim ly and comprehen ive trans£ r of patien t information • Advocate for and be acti vely involved within healthcare j urisd iction in working toward interoperable healthca re records y tem 71 Tabl 2: R omm ndatio n fo r Pra fi 10. • • • n affili ati n b tween P P and pati ent • • n and pnmary car car appr ci a! c nt x t in car pr v1s1 n Prepare pati nt [! r an y change in car pr vid r , i .. P P vaca tion K eep th line f c rrununicati n pen by creating an atmo ph re wh r the pati nt fe 1 fr e t e pr them elve h ne tl y i t n t the pati ent and in till optimi m in treatment m1e y i it during an acut e p ychiatric admi ion t pre erve e tabli hed th erapeuti c re lati on hips, adv ca t on th e pati ent' behalf and help c rdinate care and upp rt D r th e pati ent 72 R e omm endation fo r E du cation amil ur Pra titi ner and h althcar pr ider , in general , ha a re p n ibility t maintain c ntinuing ducati n t remain curT nt in th ir kn wl dg and kill D r pra ti h alth are pr fe i nal , F P arc bli ga ted t rcmam urr nt in ad ance and tr nd m health are deli ry. Primary are pr i lcr need t ub cribe t j urnal relevant t the ca r of pati nt ith MI and en ur all pra ti e guid eline are unent. need t eek educa ti nal pp rtuniti urther, primary care pr vid er wh n un 1 ar ab ut be t practi e rc mm nd ati n . Kn wl edge ab ut pri a y and c nfid ntiality law and th appr pri ate appli ca ti n f patient c nfid ntiality t clinica l pra tice i an 1mp rtant a p ct f pr viding pati ent car . dditional educati n r ga rding th e e i ue n ed t be includ ed in th e pr gram f tud y for Family ur e Practitioner and all healthcare pro id er . In additi on, primary care provider mu t perform an annual review of law unounding privacy and co nfid enti ality and eek educational opportunitie wh n avail able. It ha been mad e clear th at poor communication i a common problem in aml e care transition , partly because of a lack of und erstanding of the rol e of the famil y. In rai ing awarene s of the integral role of family throu gh education, there i potential to improve the outcome of pati ents with severe mental illne s. The core curTiculum for healthca re profe ionals, a well as co ntinuing edu ca tion, need to include education on working with famili es, e pec iall y in the context of mental health. Thi may includ educati on on a e ment and involvement of familie in care. In additi on, educa tion need to in lud e how to a t a an intermediary betw een patient and famili c . This may b important when nego ti ating ad an ed care planning. 7 R ommendation for R e. ar h Th lit r tur ar h [! r thi pr j t id entifi ed that th re i a limited am unt f a ail abl re ar h p ifi t tran iti n f are [! r indi iduaJ with m ( ign d t u full th r hi gh-ri k p puJ ati n . upp rt earl di charge and pr f th e amm d th appl i ab ilit and [! a ibil it r c ntJ h pitaliz d that that ar ntinu ed re ar h f[i ri ar p (20 12) wh ifi c t pati nt been u d tudie includ e I in thi int grati e M, adaptin g the interventi n D r and th ir fa mili he re ult w re pr m1 mg. hi indica te anan t d t a and m di fy car tran iti n inte1 enti n ith MI. Thi fi ndin g agree with the rew f Vi ggian et al. , tated that, in pite f th we ll -rec gni z d imp rtance f maintaining c ntinuity of ca re fr m tran iti on p int addre ent h pitali zati n , ha [! r individu al with MI th ere i a limited am unt f re arch to thi probl m. R ear h in anada n the u e of pr c ma1 ping in mental hea lthcare may be benefi cial to identifying facilitator and barri er to effecti ve care tran iti on . John on et al. (201 2) found promi ing re ult in other counti e , and utilizing thi m th d a r anadian healthcare j uri di cti n may highlight potential proce the va rying impr vement . More re earch i needed to tudy itu ation wh r fa milie , pati ent , and care pro id r confli ct over confid enti ality i ue , and to examine trategi information haring. M re [I r efG cti ve and inclu sive er, re earch on pa ti ent ' per pec ti v with rega rd to inD rm ati n baring between healthca re pr vider and th ir fa milie i need d to tr ngth n the adequa c nfid enti ality policie and informati n , baring pra tice . inall y, omparati c tu dic ar n eded t id entify the optimal time fram and m thod f initi al [! II di charge from an acute p y hi atri admi ron. -up app intm nt po t f 74 Limitation Lik m any ther re arch pr j ect , thi n i n t with ut it limitati n . Th fir t i that ar h paper were n t pec ific t F P prac ti e alth ugh the m aj rity many r f tudie w er largely rele ant t FNP pra ti c . T her wa p tenti a l bia in thi proj ct. Th auth r h as a p r na l nn cti on to th ca f t ph n and hi fa mil y a well a relevant backgr und and expenenc a ociated ith mental healthcare. e pite taking tep to avo id bia , thi c nnecti n ma y ha k wed the int rpr tati n of the literature and concl u ion . Th rec rrunend ati n of thi pr j ct are fo u ed n acti n F P can take at the practi ce l v J, however it i important that FNP contribute to poli cy and sy tern ch ange at the local provincial, and nati nal level to 1mpr ve car e tran iti n aero _proj ect. ~ r adult pati ent w ith SMI. Finall y, F P practi ce in prim ary care va ri e anada and thi mu t be con id red in th e appli cati on and recomm end ation of thi 75 onclu ion Indi idual w ith point o f di dir ere m ntal illn are am ng th m harg fr m a ut ca r i a criti cal tim in the c ntinuity o f th ir ca re. tl y fi 11 w in g di charg carri e th inc rea ed ri k h m le ne , r ui c id e . u h ut m ea ml e f ympt m relap e h hi peri d pital readmi i n , tran iti n fr m a ut p yc hi atri c care m ay pr vent . In genera l, hea lthca re for indi idu al with fra gm nt d, and epi proce t uln rabl pati ent and the MI in anada t nd t be n minal, di e. T hi integrative pr j ct e amin ed evid ence-ba cd prac ti ce and in ord er to id entify a t fac ilitate ea ml tran iti on and c ntinuity f care fi r m enta ll y ill adult di cha rged from acute p ychi atric ca re to primary ca re. Further , t recomm nd ati on fi r Fam ily ur e Practiti on r practic ing in prim ary ca re in ffer anada . . Background informati on on MI and care tran iti on , including a ca e exampl e, h ave been pre en ted. After a comprehen ive earch of the lit rature wa done, 17 tudi e were elect d for review and the evid ence in each ha been criti call y appraised to identify it trength and it relevance to Canadi an healthcare. Four k ey finding from thi s integrative review are the importance of confidentia lity, linkage b tween acute and primary care, co mmuni cati n, and therap eutic relationship and their releva nce to ea mle tran ition of care. The r co mm end ati on offered are directed to the FNP practicing in prim ary care in Canada, but they m ay be rei ant to any healthcare provid ers practi cing primary car . ome of the recom1n nd ati on m ay a! o be helpful in ther ettings, uch a acute p ychi atric care, or community m ental h althca re. Recomm end ati ons fo r further re ear h are ba cd o n gap id entifi ed in th e literature. R ecomm endation for edu ati o n addrcs th e need for primary are pro ider to b w 11 -infi rmed on th e appropri ate applicati o n o f pati ent c nfidenti ality t linica l 1 racti ce, to k du ation to 76 clarif an y 1111 m ncepti n , and t be kn wledgea bl ab ut cunent prac ti ce and guideline 1 ing famil y. In c nclu ion, thi proJe t how th at capacity t 1mpr P practi cing in primary care h ave the e tran iti n D r adult di charged fr m acute p ychia tri c care to primary care. Thi add t th cunent literatur r ga rding tran iti on of care D r indi vidu al with MJ, by t u ing nth ro le f the am ily them and t ur e Prac titi ner in th e tran ition , in rder t 1mpr e n ure c nti nuity f care. Thi i particul arl y impor1ant in li ght of the fact that m a ny anadi an h althca re y tem are not eamle tran itio n between e1 ice . and pro id onl y incompl ete or ineffective 77 lo ar of Term dvanced are Planning ( kn n ab ut h Rh , Zwar, id patient with th ability t mak th eir de i i n be tr at d if they 1 e eapa ity ( rtwright M ntg m ry, P): pr they uld lik nbur , 20 14) t pital-ba d a ute ar i a ke mp nent f th e ntinuum f hea lthca re e1 1 in anada. It pr id e nee ar trea tment ~ r ev re epi de f illn [! r a h rt peri od f tim e. The g al i t di barge pati ent a n a they are hea lthy and tabl ( IHI cute are: h 2014) Bipolar Di order (BD): a maj r p y hiatric di rd r characterized by in ten e vari ati n f m d and energy Mu enga, ara in , ani , Raggi, 20 0 ). pi de of depre ion characteri zed by low m d, lo en rgy, inability t e p rience plea ure in ac ti vitie u uall y found nj ya bl and apath y, altern ate with epi de f int n nerv u excitati n, hyp racti vity, elati n f mo d r iiTitability, and grandi id a . The e ari ati n in m d and energy affect thinking and jud gment, and in e treme ca , per on with BD e p ri ence delu i n and hallucinati n impairing many a pect of their life uch a work, and relati on hip Ho pitalizati n i oft en required during the e epi d . (Mu enga et al. ) · Boolean Operator : in a literature earch, thew rd that defin e the relationship between w rd or group of wo rd ; for exampl e. ''A "'' R"," T ', or "N AR '. (L Bi ondo-Wo d et al. , 2013) Borderline Personality Disorder (BPD): a MI characterized by perva ive in tability in mood , interpersonal relation hip , elf-image, and b havior (Mental Hea lth anada, nd). Family, w rk li£ , long- term planning, and the individu al' en e of elf-id entity are often di rupted a a re ult of the perva ive charact ri tic of th di order (Mental H alth Canada). Thi di order i le well known than chizophreni a or BD, but i more common, affl cting two percent of adult , mostly young women (Mental Hea lth anad a). With BPD th re i a hi gh rat of elf-hann without suicide intent, a well a a ignificant rate of suicid att mpt , and completed uicide in severe cases. Individual with BPD oft en need exten ive mental health services, and acco unt for 20 percent of p ychi atric hospitalization (Mental Health anada) Care Aide: Aka Health care aid e. Provid e person al as i tance or upport ervice for eld erl y, disabled, acute, or chroni call y ill p ople. They provid e both hort tenn a i tance and ongoing up port. (Aibe1ia Governm ent: lbe1ia Learning Information rvice , 201 4) Collaborative Care: ce ur when multiple hea lth provid er from different profe ion pro id e mprehen ive rvi e by wo rking with people, their famili e , car pro id r , and ommuniti t deliver th highe t ca re a ro ' etting . Practi ce include both clinica l and n n-clinical hea lthrelated work, uch a diagno i , tr atm nt, urveill an e, h alth mmuni ati on , management, and upport ervie (WH , 201 0) 7 om1nunity are: i d li er din c mmunity clinic , pri at h m ar h me orr tir ment con1Jnuniti ( IHI, 2014) r idential or long-t nn onfidentiality : i a typ f in.G nnati nal priva y in which ne indi idual r rganization agr t a.D guard in£ rmati n about another individual r rgani zati n ( RNB , 201 0) on tin uity of are: unint 1rupt d, c rdinated ar I ei ice a ro rganizati n , and 1 el f care/ ervice er tim ( I I 2009) pr gram , practiti n r Continuum of are: i a c ncept in lving an integrated y tern f ca re that guid e and trac k patient over time thr ugh a omprehen ive array f health e1 icc panning all levels of int n ity f ca re ( a hw ick, 1989) Di charge Planning: i a proce that aim t impr ve the co rdination of erv1ce after di charg fr m h pita I b c n id erin g th e pati ent' ne d in th e co mmunity. It see k t brid g the gap between ho pi tal and the place to which the patient i di char ged, r du ce 1 ngth of ta y in ho pita! , and minimiz unpl anned r admi ion t ho pital (Katikireddi & 1 ud , 2009) Evidence-Based Practice: th conscious, explicit, and judiciou u e of the cunent be t vid nee in the care of patient and the delivery of hea lthcare ervi ce (LoBi ndo-W od et al. , 201 3) Family/Families: in matter of caregiving famil y is recognized to be tho e people id entifi ed by the per on receiving care or in need of care a providing familial upport, whether or not there i biologic relation hip (C A, 200 8) Freedom of Information and Protection of Privacy Act (FOIPPA): contain privacy protection measure that public healthcare organi za tion , such as hospitals, health authoriti es, and the health ministrie are subj ect to . It prevent the unauthorized collection, u e, or di clo ure of personal infonnation b y public bodie and it requires that reasonable sa feguards be in pl ace to protect personal infonnation (Briti h Columbia M edical As ociation, 2009) Major Depressive Di sorder (MDD): a complex di sabling condition characterized by phy ical, emotional, and cognitive changes (Catena-Dell ' O o, Marazziti, Rotell a, & Bell antuono, 201 2). Sympton1s can includ e irritability, anxiety, hostility, with dangerous impul ive behavior, and potentially lethal acts of self- han11 (Sn1ith & Blackwood, 2004). For individuals with MDD, all a pects of their life can be affected, such a famil y, per onal relation hip , work, and gen ral health . Thi mental disorder represent a m ajor cau e f morbidity worldwid e, and i cunently o et al. ) considered the fourth -leading cau e of di sease burden ( atena-Dell' Mental Hea lth Act: all anadi an provinces and ten-itori have legi lation to treat and pr te t people with SMI and to protect the public. The M ntal Health ct provid e peo ple with mental disord ers the treatm ent and care they need when they ar not willing to accept it (Briti h olumbia Ministry of Health, 2005) 7 Menta l H ealth Work r: ka mmunity upp rt w rk r. Help pe pl d al with er nal and cial pr bl m by t a hing r !at d kill and pr iding in[! rmati nand upp Ii ( lberta I berta L aming In.D nnati n , 2014 ). Ob n ther [! rm fan i ty di rd r. Th indi idual who i n and c mpul i n D r m r than an h ur a h en ele. , di tr ing, and e tr m ly difficult t r m in a a that interfer r her liD (M ntal Health anada , nd ; MI, 20 l 4 . It an ct m r than tw per ent f the p pulati n, and i tw t tlu· time m re mm n than MI· M ntal Health anada) chiz phrenia , and B ( Panic Di ord er: fall und er th umbrella fan iet di rd r ; a onditi on th at fill peo ple ' li with 1whelming w rry and fear (Mental Hea lth anada, nd ). n i ty di rd r ar and can be me e ere if n t trea ted (M ntal h alth anada) . Pani c di rd er clu·oni , r 1 ntl ar chara t ri ti f [! ling f ten· r that trik udd nly and r p ated ly with n warning (M ntal Health anada) . The unpredic tabl e nature f pani c di rd er ca u e the individual to ag nize er wh n and her th n t ne will trike ften precipitating inten e anxi ety b tw n epi de . Plan-Do- tud y-Act Cycle: a tructured trial f pr ce change by developin g a plant t t the chang , canying out the te t, an anal y i of th re ult f th e trial and determining what modification h uld b mad e t th te t ne t tep ba ed on the analy i (Luther Hamm er ley, & hekairi 2014) Post-Traumatic tr es Di ord er (PT D): an anxiety di order characteri zed by Oa hback , con tant frightening thought , and memori e , anger or initability in re pon e to a traum atic experience in which phy ica l hann occuned or wa threatened ( uch a rap e, child abu e, war or natural di a ter) (PHA , 20 12). It can occur at any age, and i often accompanied by depre Ion ub tance abuse, or one or more other anxiety di sorders (M ntal Health anad a, nd) Primary C are: refer to the fir t contact with the healthcare ystem. In anada, the primary divi ion of labor i organized mainly around family phys ician , general practitioner and nur e practitioners (Bourgeault & Mulvale, 2006) Primary H ealth care: refers to an approach to health and a pectrum of servic b yo nd the traditional hea lthcare ys tem. It include all rvice that play a part in health, uch a income, housing, edu cation, and environment. The fi ve principle u ually a ociated with the primary healthcare approach are: acce sibility, health equity, community participation, and inter ectoral appr ache to health (Muldoon, Hogg, & L vitt, 2006) Privacy: i the right of individual to determin how , when, and to whom and for what purpo e any per onal information will be divul g d ( RNB , 20 10) chizoaffective Disor der : a di order in which an individual ha ympt m of both major d pre ion r BD and hizo phrenia . It i a combination of chi z phr ni a ym ptom (ha ll ucinati n , delusion ) and mood di order ym pt m (mania or depre i n) ( MH , 201 ). 0 chizophrcnia: a mpl e hr ni di rder with a div r pre ntati n f ympt m uch a d lu i n hallucinati n c n ptual di rganizati n, paran ia agitati n, and h tility. ther ia l withdrawal. h c ur f mpt m in lud blunt d af.fl ct and em ti nal and hiz phrenia i ft n characteri zed by acut p ych tic epi d , ften requiring h 1 italiza ti n. Th e di turban e ha a p 1 a i e impa t n many ar a f li~ fun ti ning and quality f life ( bi da , M rakin Ibrahim , 20 12 . eamle are : 1 a m th and afe tran iti n fa pati nt between car etting ( pehar t al. 2005) uicid e : the a t f delib erately killing n elf and i the grea t t cau e of iolent dea th ar und th world; it i am ng the t p thr leading au e f dea th in y ung pe pie aged 15-3 4 yea r , 2014 ). ri u m ntal illn i the ignifi ant fact r that w rid id e (WH , 200 ; W p opl t ui cide (M ulif~ , P ny, 2007) . r indi idual with evere and pr di po nduring mental h alth pr blem , a many a 4 percent f uicid c ur within three m nth di charg , with a heightened ri k peri d in the fir t fi da y foil wing di charge (Harkavyri dm an et al. , 1999) Transition s of care : c nn t the cenano fa pati nt lea ing ne ca re etting (i .e. h pi tal, nur ing fa cility, a i ted living facility, primary ca re phy ician care, home care, r peciali t are) and m in g t anoth r ttin g or to the patient' home. he tran iti n frequently in vo l e multiple per on , including the patient, fami ly, or other ca regi er( ), nur ( ), ocial worker( ) 2008) ca manager( ) pharmaci t( ), and other pr vi der (NT f 81 References bbey ., harb nn au M ., Tranuli , tigma and di crin1ination. ., M P ., aici, W ., anadian Journal of P abby hiatry.Revu ., ... 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International Journal of M ental H ealth ursing, 14(3 ), 166- l 71 . 99 App endi x A The foil wing table f e idence u Le 1 I-VII t id entify th typ and trength of each re ar h articl e. iden pr ided by qualitative tudie i rank d 1 wer in the hierarchy of id n e, h wever, the e m eth d are th e m re arch qu 2013) . t effe tive in attempting to an wer clinical and tion wh n little i kn wn or a new per pective is needed (LoBiondo-W d et al. , Tabl e 3: Le\' ! of E1·id n e Le el id ence I ystem ati c re iew or m eta-analy i of randomi zed controll ed tri al (R T); inf01med clinical practi ce guid eline ba ed on ystem ati c reviews II A w ell design ed RCT III A controll ed tri al without randomization (qu a i-experimental tud y) IV Single non-exp erimental tudie - ca e control, correlati onal, cohort studi es V Sy tem atic reviews of de criptive and qu alitative studie VI Single de criptive or qualitative tud y VII Opinions of authoriti es and/or rep01is of expe1i committees v idence 100 Appendi ' B Tabl 4 : Table of Evid n Author Bat ha et al. D e ign uantitative (20 ll) h n (2 00 ) Cleary et al. T explore th e [! asibili ty of using an 15 pati nt ur e (APN) to with a d anced Pra ti c link patient with MI to their fir t diagno i of Qu alitative Quantitativ healthcare provid ers hare inform ati on with the ir pati ent ' fa mili s mana g rs To obtain b aselin e data on th e ex tent 407 (207 MI 24 c mmunity ca e Quantitative El-Mallak.h et Quantitative al. (2004) Gray et al. Qualitative inpati ents and 200 patient in the community) and 50 famil y m embers T o examine the characteristi cs of 11 2 patients with SMI who do not have a individual primary care provider with SMI To determine predictors of not 8 1 p ati ents attending follow -up after discharge with SMI To explore the challenge of 65 staff: confidentiality issu es from the m anagers, p ersp ectives of professionals and sem or implicati ons for professional leaders, practice and training GPs, pnmary car taff, advocacy gro up and Level f Evidence Ill VI IV f famil y involvem ent in th e care of a famil y m emb er with SMI (2011) (2008) ample app intment po t di charge T e plore how community mental (2005) Dewa et al. UTI ocial work r IV IV VI 101 A ppendi B able 4: Tab / of £ ,•id n r Ign ample c ntra t t u ual car , ca e management will re ult in higher rate of connection t pnm ary are (200 ) Hautala-Jylha t al. (2005) ualitati J hn n et al. (20 12) ualitati ve 175 patient with ut a 1 nmary care pr vid er 15 pati ent with MI- inpati ent and outpati ent per onnel ( 13 ); adm ini tra ti ve taff (5) To demon trate how process linical t am mapping can be utili zed to invo lved with improve tran iti n fr m acute care tran ition care to primary care m ix countri e To lc cribc and analyze percepti n of fac t r for improvi ng co ntinuity f care fo r ind i id ual with Ml l one et al. (2009) Mixed-method To capture the experiences and views of patient and famili e foc u ing on the meanmg a sociated with problematic care Kripalani et aJ. (2007) y tematic review Lev 1 f Pati ents (n = 3 1) fa mili es (n = 14) To characterize the pr valence 73 ar1icle for of defici t in con1munication review and in ~ nna tion tran fer at hosp ital di charge and t id enti fy interventi n fo r impr vement VI VI Ill I 102 App endix B Tab! 4: Tab! of £1 id nee D tgn Nolan et al. (20 ll) Ro e et al. (2007) Qualitative The tanding R port Senate Corrunittee on ocial Affair Science and Technology (2006) Qualitative Solomon et al., (2012) tudy Aim e perience di charge fr m acute care erv1c m rder t und r tand how to 1mpro inpatient care To addres the Jack of continuity of care in exi ting programs to meet the immediate p t di charge needs of individual with MI To tran fmm mental health, mental illne and addiction erv1ce m Canada To gain knowledge of confidentiality issues related to families Wood et al. (2009) Quantitative To develop and test a standardized cmmnunication strategy for improving communication between acute care and con11nunity practitioners Wynaden & Orb (2005) Qualitative To report on the problem that familie expen nee as a re ult c nfid entiality ample Level of vidence 44 patient with MI VI 4 patient with VI MI Over 2000 personal ace unt from across Canada VII 640 participants (care provider staff, administrator and student 150 participants from one 86 bed private and one not-forprofit m ental hospital 27 family memb rs VI III VI 10 A pp eodi 11 ar h R u/t Search Te rms M ntal l rd er OR P y hiatric Pati nt AND Primary Hea lthcar OR ur e Practiti n r Data Bases C IN AHA L w ith full tex t PubMed P ychiNFO 248 M ntal i ord er OR P ychi atric Patie nt D Tran fe r Di charge OR Patie nt i charge C INA HAL w ith full tex t PubMed P ychiN ~ o 27 478 55 M ental Di r ler OR P ychi atric Patient ND are Tran iti n OR Pati ent Tran fe r OR ntinuum f are OR onti nuity of P ati ent Care M ental Di rd er OR P ychia tri c Patient AND Privacy and onfid ntiality M ental Disord er OR P ychi atric Patient AND Family P ychi atric Units OR P ychi atric Ho pital AND are Tran ition OR Pati ent Tran fer OR ontinuum of are OR ontinuity of P ati ent are CI 25 P ychiatric U nit OR P ychi atric Ho pital AND Primary H ealthcare OR N ur e Practiti oner OR Famil y N ur e Practitioner P yc hiatri c U nits OR Psychiatric Ho pital AND T ransfer Discharge OR Pati ent Di charge P ychi atric Unit OR P yc hi atric Ho pita! AND Privacy and onfid cnti ality H L w ith full t x t N 88 n/a PubM d 285 P ychiN FO 38 CINAHA L with full text PubMed PsychiN FO CINAHA L with full tex t PubMed PsychiNFO C INAH L w ith full tex t 157 3 23 392 71 25 PubMed 15 P ychiNFO 6 !NAHAL w ith full tex t n/a 3 PubMed 29 P ychiN FO 0 CINAHA L wi th fu ll te t 70 PubM d 114 P ychlN FO 0 CINAHAL w ith full tex t PubMed PsychlNFO 0 8 9 104 ppendix Ta bl 5: fa ar ·h R ult Search Terms p hiatric nit OR P A D amil y hi atri c H pi tal C are T ran iti n OR Pati ent ra n fl r OR ntinuum f ar OR ntinuity f Pati nt are A D Primary Hea lthcarc OR ur e Pra ti ti ner OR Fa mil y ur c Practitioner ar Tran iti n OR Patient T ran fe r OR ntinuity f ntinuu m f are OR D Tran fer Di charge OR Pati ent are Patient Di scharge C are Tran itio n OR Patient Tran fer OR ntinuity of ontinuum f are OR Pati ent are AND Privacy and Confid enti ality are Tran ition OR Patient Tran fe r OR Continuum of are OR ontinuity of Pati ent C are AND Famil y Primary Hea lthcare OR N urse Practitioner OR Family ur e Practitioner AND Transfer Di charge OR Patient Di scharg Primary H ealthcare OR N ur e Practitioner OR Famil y N ur e Practiti ner AND Famil y Tran fer Discharge OR Patient Di charge AND Privacy and onfidential ity P ychiatri c U nits OR P yc hi atric Ho pital AND Transfer Di charge OR Patient Di scharge N Data Bases C IN H L w ith fu ll te t PubM d P ychiN C INAHAL w ith full tex t PubMed P yc hiNFO 5 5 80 32 285 52 C INAHAL with full tex t PubMed P ychiN 179 173 22 INAHAL with fu ll t xt 1 PubMed 9 P ychiNFO 2 CINAHAL with fu ll tex t PubMed PsychiNFO CINAHAL w ith full tex t PubMed Psyc hiNFO CINAHA L with full tex t 123 144 30 18 10 0 220 PubMed n/a P ychiNFO 4 CINA H L with full tex t PubMed 29 P ychiN 0 C IN A H L w ith full te t l PubMed 10 P yc hiNFO 0 - 105 A pp endix Tab le 5: ta n a r h R , u Its Search Terms Tran fer i charge OR Patient Di AN D amily D ata Ba ses harge CINAHAL with fu ll tex t PubMed PsychlNFO Pri acy and D Family CIN H L with full te t nfid enti ality PubMed Psych INFO CINAHAL with full tex t T tal PubMed PsychiNFO CINAHAL with full tex t Total aft r duplicate rem ed PubMed PsychiNFO E lectro ni c D atab ase R es ults DATA BASES TOTAL Total after duplicates removed Total k pt after reading titl e Total kept from abstract Total kept after in depth reading N 43 157 5 157 n/ a 5 1305 2366 661 897 1837 403 4074 3200 380 140 17 106 App endix D T abl : Journal arch d 4-< 0 4-< 0 ,_..., ·-ro (_) 0 C/) 4-< 0 T e1m C o ntinu ity of are Di charge Planning Tran ition of Care Primary H ea lthca re Primary Care P ychiatric P ati ent Family Pri vacy and Confid enti ality P ychiatric U nit OR P ychi atri c Hospital N urse Practitioner or Fa1nily N urse Practitioner M ental Illness AND Continu ity of Care M ental Illne s AND Disch arge Planning M ental Illness AND Transition of Care M ental Illness AND Primary Healthcare 6 1 0 0 3 79 n/a n/a n/a n/a n/a 0 n/a 2 44 n/a 442 n/a n/ a n/a n/a n/a 10 40 1 n/ a n/a n/a n/a n/a n/a n/a n/a 45 n/a n/a 5 n/a 4 59 0 n/a n/a 37 13 0 93 n/a 13 n/a n/a n/a 1 n/a 1 n/a 0 r a 0 n/ a 4 51 42 286 0 0 n/a 29 44 49 0 8 8 28 n/a 7 n/a n/a AN D n/a = 38 n/a 25 n/ a n/a 0 n/a 11 5 n/ a n/a 75 62 269 131 408 18 1 107 A pp endix D T ab! 6: Journal ar hed c......, 0 4-< 0 Tenn ---< C\l E ::l ·- 0 ,_,c: .c. . . (/) ro u 0 4-< 0 --o ~ ...... C\l ---< C\l 6 C\l...c: c: u ro G" ::l ~ U P.. M ental Illne AND Primary Care M ental Illness AND P ychiatric Pati ent M ental Illne AND P ychiatric nit OR Psychiatric Hospital M ental Illne AND Nurse Practitioner or Fam ily Nurse Practitioner M ental Illness AND Privacy Confidentiality M ental Illness AND F amil y Number taken based on title Number taken after reading titles nJa 119 n/a n/a 1 0 n/ a n/a 67 n/a nJa 0 2 n/a nJa 51 n/a nJa 0 4 n/a nJa 152 nJa nJa 0 0 n/ a nJa 16 n/a nJa 1 17 n/ a nJa 147 n/ a nJa 8 97 n/a 18 42 33 16 9 1l 50 5 2 1 7 4 1 1 - n/ a: Res ults th at produ ced numbers g reater than 500 108 App endix E Table 7: uid lin for ritiquing a Qualitatil R , ar h rudy Que tion Ele ment El m nts injlu ncing r liability and mlidity of th e r arch I the repo1i well written - concise, grammatically co rrect, avoids the u, e of jargon? I it well laid ut and organized? Do there earcher' qualification,/po ilion indicate a degree ofkn wledge in this field? Author I the rep rt title clear, accurate and unambiguous? Report title Doe the ab tract offer a clear overview of the study , including there. earch pr blem, Ab tract , ample meth dol gy finding and recommendations? Elem nt injluen ing rigor of the research L the phenomenon to be st udied clearly identified . Statement of the re the ph nomenon of intere t and there earch que tions consi tent? phenomenon of intere t I the purpo e of the tudy clearly identified? Purpo e igni ficance of the tudy Literature review Ha a literature review been undertaken . Doe it meet the philosophical underpinning of the study? Doe the review of the literature fulfill the objecti e? Theoretical framework Ha the conceptual or theoretical framework been identified? I the framework adequately de cribed? I the framework appropriate? Method and philosophical Ha the philosophical approach been identified? underpinnings Why was this approach cho en? Have the philo ophical underpinning been of the approach bee explained? Sample Is the ampling method and ample ize identified ? I the sampling method appropriate? Were the participant uitable for informing re earch? Ethical consideration Were the pmiicipants fully informed about the nature of the research Was the autonomy/confidentiality of the participants guaranteed Data collection/data analysis Are the data collection trategie de cribed? Are the trategies u ed to analyze the data described? Did the researcher fo llow the steps of data analysis method identified ? Was data aturation achieved ? Rigor Does the researcher discuss how rigor wa assured? Were credibility, dependability, transferability and goodness di cus ed? Findings/discussion Are the findings presented appropriately? Ha the rep01i been placed in the context of what wa already known about of the phenomenon? Ha the original purpo e of the tudy been adequately addressed? Writing tyle onclusionlimplication and recommendations Are the importance and implication of the finding identified? Are the recommendations made to uggest how there earch findings can be deve loped ? References Were all the books, journal and other media alluded to in the study accurately referenced ? Adapted from Ryan, oughlan, & Cronin , 2007 109 ppendi F Table 8: · uidelin for ritiquin a Quantitativ Re arch tudy Element Qu e tion El ment influencing reliability and 1'0/idity ofth r 'S arch Writing tyle I the report well writt n - on r e, grammati ally correct, a oid the u e of jargon? L it w II laid out and organized? 0 there ea rcher' qualificati n p ition indicate ad gree of knowledge in thi field? Author I the report title clear, accurat and unambigu us? Repor1 title D e, the ab tract offer a clear o erview of the study, 111cluding the research problem, b tract , ample, methodology, finding and recommendation, ? Element injlu ncing ri or of the r search Purpo e/re earch problem I the purp e of the , tudy/research problem clearly rdenti fied? Doe. the research report G !low the tep of the research process in a logical manner? Logical con i tency Do the e tep naturally flow and are the link clear? I there iew logically rganized. Doe it offer a balanced critical analysi of the Literature review literature? 1 the majority ofthe literature of recent origin? I it ma111ly from primary ource and of empirical nature. Ha the conceptual r theoretical framework been identified? Theoretical framework I the framework adequately de cribed . I the framework appropriate? Aims/objective /re earch Have aim and objective , are earch que tion or hypothe i. been identified? If so are they que tion/hypothe e clearly stated? Do they reflect the information pre. ented in the literature review? ample Ha the target population been clearly identified? How were the amples collected? Wa it a probability or non-probability ample? I it of adequate ize? Are the inclusion/exclu ion criteria clearly identified? Ethical con ideration Were the pariicipant fully informed about the nature of the research? Was the autonomy/confidentiality of the participant guaranteed? Were the participant protected from harm? Wa ethical permis ion granted for the tudy? Operational definition Are all the terms, theories and concept mentioned in the tudy clearly defined? Methodology I there earch design clearly identified? Has the data gathering in trument been de cribed'? Is the in trument appropriate? How wa it developed? Were reliability and validi ty te ting underiaken and the result di cu ed? Wa a pilot study undertaken? Data collection/data analysi What type of data and statistical analy i wa undertaken? Was it appropriate? How many of the ample par1icipated? Significance ofthe finding? Discussion Are the findings linked back to the literature re iew? If a hypothesis wa identified was it upported? Were the trengths and limitation of the tudy including generalizability dis u 'Sed? Wa a recommendati n for further re, earch made? References Were all the books, journals and other media alluded to in the study accurately referenced? Adapted from oughlan, r nin , & Ryan, 2007 110 pp endi Tabl e ompon nf of an A d1 •an am Purpo e d ar Plan • • f th eir • ommunicati on Plan of Action ancellation Periodi c review ignatures and D ate • lari fy w hat can and cannot be hared : begin w ith th a umpti on th at in[i rmati n will be hared and m e the nver ati n t ward cla rifying what pecifi ca ll y can and cann ot be talked about • R ecord h w the pati ent wo uld like t dea l w ith i ue of c nfidentiality • Record the acti on th at th e pati ent requ e t other to take in the event of ac ute illne • D e crib e th e m anner in w hich th agreem nt can be ca nce ll ed • It i important that th proce of cancell ati o n require a p ri d of time and a equ enc of tep : during acute illne th e pati ent might attempt to cancel thi agreement . Therefore, th e pl an need to clearly outline the proces of cancell ation of it • D e crib e the manner in which the agreem ent w ill be review d (a t least annu all y, a we ll a after each time th e agreem ent i u ed) • During the review , a co py of the agr ement hould be gi en to everyone nam ed on it, and each per on hould be cl ar about hi or her role • ignature of the pati nt and p1imary care pro id r • ignature r th e pati ent' d ignated u ) ort y tem Adapted from Mood Di ord ers Association of British olumbia , (2008)