Continuity of care in serious mental illness

It has been claimed (Abbati et al, 1987) that patients benefit from continuity of professional involvement sustained over a long period. Schizophrenia sufferers in particular find it harder than non-sufferers to articulate their difficulties and concerns, and may adjust poorly to change, only building up trust in professionals over an extended period. In their turn, professionals need time to get to know such individ uals and to recognise 'early signs' (Birchwood et a/,

It has been claimed (Abbati et al, 1987) that patients benefit from continuity of professional involvement sustained over a long period. Schizophrenia sufferers in particular find it harder than non-sufferers to articulate their difficulties and concerns, and may adjust poorly to change, only building up trust in professionals over an extended period. In their turn, professionals need time to get to know such individ uals and to recognise 'early signs' (Birchwood et a/, 1989) of possible relapse. Management of potential decompensation involves a knowledge of how the individual has responded to changes in medication in the past and what psychosocial factors may be relevant. Working with such patients refines the clinician's skills in interacting with them, obtaining their compliance with a particular regime, and pre-empting potential problems. Without this back ground of knowledge and experience, the manage ment of sufferers may be crude with adverse results for the patient.

The study
A senior clinician, Dr C. A. B., was on sick leave for 21 weeks in December 1989. She manages a large intramuscular therapy clinic based in a Day Hospi tal, and is the main source of professional supportapart from the nurse who gives the injection (not always the same person) -for the patients. Thus an opportunity was presented for ascertaining whether any adverse outcomes occurred as a result of her absence. At least three doctors were involved in covering the clinic during this time. The records of all patients attending the clinic were retrospectively examined for the period of Dr C. A. B.'s absence and for the following six weeks (7 December 1989-7 June 1990)-Period Y. The rationale for including the following six weeks was to accommodate the on going effects of the management and medication prescribed during her absence. The equivalent six month period in 1988/89 (Period X) was used as a control with records of the same patients being examined.
One hundred and eighteen (73 male, 45 female) patients were involved in the clinic during both periods.

Admissions to hospital
During Period X there were eight admissions involv ing a total of 238 days hospitalisation. There was a significant increase (P<0.05) in admissions for Period Y with a total of 15 involving 458 days.

Clinic appointments kept
For Period X 796 clinic appointments were kept with Dr C. A. B. alone. This was significantly greater (P< 0.01) than the total of 283 appointments during Period Y.
A breakdown of the Period Y appointments showed that 157were kept with other doctors during the first 21 weeks while there were 126 with Dr C. A. B. during the final six weeks.
The average number of appointments was 6.75 per patient in the first period and 2.4 per patient in the second.

Missed clinic appointments
During Period Y, approximately a third of the number of clinic appointments was given, so the opportunity for missing was also reduced. However, missing an appointment can be an alerting signal that a patient is experiencing problems. Dr C. A. B. is aware of these cases and immediately initiates follow-up in the form of a letter giving a new appointment which, if not responded to, leads to a visit from a community psychiatric nurse.
Missed appointments and follow-ups were reduced in Period Y: Period X 29 (25)* leading to seven follow-ups Period Y 5 (5)* leading to one follow-up (*figures in brackets show number of individuals involved).
In Period X, one follow-up led to admission, while, of the 22 not followed-up, only one was admitted. The single follow-up in Period Y did not result in admission, whereas one of the missed appointments that had not been followed-up did.
Sometimes early attendance occurs because a patient has problems. Such requests are taken seriously as they may indicate the onset of relapse. These frequencies were: Period X 33 (20)* leading to one admission Period Y 13(7)* leading to two admissions As frequent attendances in Period X led to only one admission as against two admissions after fewer attendances in period Y, it would seem that this procedure may be an effective means of forestalling admissions. Patients' confidence in the usefulness of early attendance may have been undermined in Period Y when they did not know whom they would see at the clinic.

Comment
The significant increase in admissions for clinic patients during Dr C. A. B.'s absence supported the hypothesis that schizophrenia sufferers whose psy chiatric management remained in the hands of an experienced and trusted clinician, who knew them well, were less likely to relapse than when their management was in the hands of unfamiliar doctors.

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The data regarding missed appointments and early attendance underline the extent to which the experi enced clinician was able to respond flexibly to known patterns of behaviour, in a way that was impossible for colleagues unfamiliar with the patients. The great reduction in requests for an early appointment during Period Y suggests that patients may have been less prepared to approach the services when they knew that Dr C. A. B. was not available, although an early appointment might have circumvented a relapse.
Service planners could therefore usefully take into account the beneficial effects of continuity of management when considering maintenance of patients in the community.