Phil Klassen MD FRCPC Vice-President, Medical Affairs Ontario Shores Centre for Mental Health Sciences Assistant Professor, University of Toronto Quality Standard for Schizophrenia

Introduction 1.Project scope 2.Panel composition and selection 3.Methods for the development of quality statements –Identification of key areas for quality improvement –Prioritization of key areas –Review of evidence for each prioritized key area –Drafting of quality statements –Finalization of quality statements 4.Prioritization of key areas for quality statements –Results of topic prioritization survey –Potential guidelines for inclusion –Prioritization of key areas from survey and potential guidelines

Concise sets of 5-15 strong (“must do”), measurable, evidence-based statements guiding care in a topic area Developed in topic areas identified as having high potential for better quality care in Ontario Each quality statement accompanied by quality indicator(s) Every quality standard will be accompanied by a plain language summary for patients and caregivers Strong emphasis on implementation through a variety of vehicles (monitoring/reporting, QBPs, Quality Improvement Plans, etc.) Strong emphasis on partnerships to support development and implementation Quality standards – what are they?

Population and Topic Scope Adults aged suffering from schizophrenia From the ER/hospital admission to discharge Community treatment for next iteration Adolescents and the elderly Not specifically about first episode psychosis Not specifically about concurrent disorders

Panel Composition

High Level Timeline

Method Overview Identification of Key Areas Prioritization of Key Areas Review of Evidence Drafting Quality Statements Finalization of Quality Statements Current activities are focused on review of evidence and drafting quality statements. Expert group meeting to discuss scheduled December 3, 2015.

DRAFT QUALITY STATEMENTS (FOR REVIEW AND DISCUSSION PURPOSES )

Primary Key Areas Secondary Key Areas Support for carers & family members Patient education Transition to community / ACT teams Assessment Supporting healthy eating & exercise Supporting smoking cessation Early intervention Treatment of substance misuse Monitoring for adverse events to treatment Engagement CBT Self- management Monitoring patient health Management of acute risk Supporting adherence to treatment Choice of pharmacological treatment Alternative therapies Peer support Non-response to treatment Services for people in crisis Training & education of HCPs Access to psychiatrist Psychosocial interventions Neurocognitive training

Draft Quality Statements Adults with schizophrenia who are assessed as inpatients in a hospital setting for a mental health diagnosis undergo a comprehensive, multidisciplinary assessment. Definition: Assessment should be both comprehensive and multidisciplinary, undertaken by health care professionals with expertise in the treatment of people with schizophrenia. The assessment should address the following domains: –Current and identified sources of distress, including risk of harm to self or others –Family/developmental (social, cognitive and motor development and skills, including coexisting neurodevelopmental conditions) and education history, including history of trauma/adversity –Social history (accommodation, culture and ethnicity, leisure activities and recreation, and responsibilities for children or as a carer), social networks, and history of intimate relationships –Occupational and educational (attendance at college, educational attainment, employment and activities of daily living) history, and economic status –Medical history and full physical examination to identify physical illness (including organic brain disorders) and prescribed drug treatments that may result in psychosis, and history of substance misuse –Assessment of self-identified goals and aspirations as regards outcome of mental health care

Draft Quality Statements Adults with schizophrenia who are assessed in a hospital setting for a mental health diagnosis are assessed for substance misuse. Definition: The use of alcohol, tobacco, prescription and non-prescription medication and illicit drugs should be discussed with the individual, and carer if appropriate. The possible interference of substance misuse with the therapeutic effects of both pharmacological and non-pharmacological treatments should be discussed.

Draft Quality Statements Adults with schizophrenia are offered peer support during their hospitalization by a trained peer support worker who has recovered from psychosis or schizophrenia and remains stable. Definition: Peer support programs may include information and advice about: Psychosis and schizophrenia Effective use of medication Identifying and managing symptoms Accessing mental health and other support service Coping with stress and other problems What to do in crisis Building a social support network Preventing relapse and setting personal recovery goals

Draft Quality Statements Caregivers of adults with schizophrenia who are assessed in a hospital setting for a mental health diagnosis are offered access to relevant and appropriate carer-focused training and education. Definition: Carer-focused training and education is designed to improve caregivers’ experience and reduce burden and may include: Psychoeducation Support groups Self-help interventions

Draft Quality Statements Adults with schizophrenia who are assessed in a hospital setting for a mental health diagnosis undergo physical health assessments focusing on problems common in people with schizophrenia. Definition: Physical health interventions should measure: Weight/body mass index/waist circumference Pulse and blood pressure Fasting blood glucose Lipid panel (total cholesterol, low-and high-density lipoprotein, cholesterol, triglycerides) Extrapyramidal symptoms and signs Overall physical health

Draft Quality Statements Adults with schizophrenia who are assessed in a hospital setting for a mental health diagnosis are offered combined physical health and healthy eating interventions. Definition: Behavioural interventions that combine support for healthy eating and physical exercise should be considered for initiation in the acute care setting. Such interventions may follow a psychoeducation/information-based approach and provide information and support for how to increase levels of physical activity and healthy eating.

Draft Quality Statements Adults with schizophrenia who are assessed in a hospital setting for a mental health diagnosis are offered help to reduce or stop smoking through behavioural or pharmacological interventions. Definition: A range of interventions to help reduce or stop smoking should be considered for initiation in the acute care setting. These may include: Behavioural support Pharmacotherapy –Nicotine replacement therapy products (e.g. transdermal patches, gum, inhalation cartridges, sublingual tablets, or spray) –Varenicline –Bupropion

Draft Quality Statements Adults with schizophrenia who have failed to respond to treatment with at least two antipsychotic medications including a second- generation antipsychotic medication are offered clozapine.

Draft Quality Statements Adults with schizophrenia who are assessed in a hospital setting for a mental health diagnosis are offered individual cognitive behavioural therapy for psychosis in addition to oral antipsychotic medication. Definition: Cognitive behavioural therapy (CBT) for psychosis should be delivered on a one-to-one basis over at least 16 planned sessions and should be delivered according to a treatment manual. CBT psychosis can be initiated during all phases of psychosis (including the initial phase, the acute phase, or the recovery phase) and should be delivered by professionals with an appropriate level of competence who, wherever possible, receive regular supervision by the relevant specialists.

Draft Quality Statements Adults with schizophrenia who are assessed in a hospital setting for a mental health diagnosis are offered family intervention in addition to oral antipsychotic medication. Family members of adults with schizophrenia are also offered family intervention. Definition: The term ‘family’ can describe members of the individual’s family or caregivers who live with or are in close contact with an adult with schizophrenia. Family intervention should: Include the person with psychosis or schizophrenia if practical Be carried out for between 3 months and 1 year Include at least 10 planned sessions (these may or may not be part of the acute setting and planning for subsequent sessions should be part of the discharge planning) Take account of the whole family’s preference for either single-family intervention or multi-family group intervention Take account of the relationship between the main carer and the person with psychosis or schizophrenia Have specific supportive, educational or treatment function and include negotiated problem solving or crisis management work

Draft Quality Statements Transition to the Community: Adults with schizophrenia are assessed prior to discharge to determine further levels of care and linkage with primary care or community care support. Adults with schizophrenia discharged from a hospital setting are scheduled a follow-up appointment with a psychiatrist within X days of discharge.

Additional Areas for Draft Quality Statements 1.Recovery 2.Trauma-informed care 3.Early intervention 4.Polypharmacy and LAI 5.Other non-pharmacological interventions –Art therapy –Social skills training –Psychoeducation –Supportive therapy –Mindfulness –Motivational interviewing –Cognitive remediation

Key Next Steps Further refinement of draft quality statements and review of evidence Expert group meeting – December 3, 2015

S.CA QUESTIONS?

APPENDIX

Methods: Identification of Key Areas Topic Prioritization Survey –Aimed to engage panel members to identify key areas for quality improvement –Modelled on NICE’s method of stakeholder engagement during their Quality Standard development process

Methods: Prioritization of Key Areas Clinical epidemiologist (CE) summarizes key areas identified in topic survey, along with areas identified through scoping exercise Panel will prioritize up to 10 key areas for quality statement development Considerations for prioritization: 1.Potential to improve health outcomes or health resources 2.Variation in current practice 3.Maintenance of important current standards of care

Methods: Review of Evidence CE will identify recommendations or statements from relevant guidelines (such as NICE or NICE-accredited guidelines, guidelines used in current practice, or those otherwise identified through scoping exercise) that may support potential quality statement development Summary of relevant recommendations and guidance statements If limited or no evidence exists for key area, the CE will conduct an evidence review using the most appropriate review method Evidence review If there is no evidence, the panel may wish to: Use expert consensus Note prioritized key area for future consideration Establishment of consensus For each prioritized area:

Methods: Review of Evidence Identification and Inclusion of Clinical Guidelines –Identify relevant guidelines covering the population(s) and setting(s) of interest –Use the AGREE II instrument to select 4–5 highest quality clinical guidelines, including at least 1 contextually relevant (Canadian) guideline Appraisal of Guidelines for Research & Evaluation II 1)Scope and Purpose 2)Stakeholder Involvement 3)Rigour of Development 4)Clarity of Presentation 5)Applicability 6)Editorial Independence

Methods: Review of Evidence Acceptable Evidence Threshold –The recommendations or statements identified from relevant guidelines will be examined by the CE to determine whether they meet an acceptable evidence threshold –Suggested thresholds: Moderate to high quality of evidence for diagnostic or therapeutic interventions Expert consensus is sufficient when quality of evidence is low for certain principles, processes, or system-level interventions

Methods: Drafting of Quality Statements Up to 15 quality statements will be drafted, based on either recommendations from relevant guidelines or an evidence review Quality statements are not verbatim restatements of the relevant recommendations from source guideline(s) One quality statement may map to recommendations from one or more guidelines, and/or may be derived by rewording one or more recommendations into a single statement

Methods: Finalization of Quality Statements The panel will agree up to 15 quality statements for publication within the quality standard and clinical handbook

Key Areas Identified by Topic Prioritization Survey Topic Areas Early intervention: Early intervention may improve clinical outcomes, such as admission rates, symptoms and relapse Services for people in crisis: Crisis resolution and home-treatment teams to support people in crisis Support for carers and family members: Family-based interventions; family psychoeducation; family education Non-pharmacological interventions: Cognitive behavioural therapy; alternative therapies; neurocognitive training; psychosocial interventions Promoting physical health: Education and interventions to encourage healthy eating and exercise; assessment and treatment of substance misuse; supporting smoking cessation; improving medical care and monitoring of physical health and metabolic parameters Pharmacological interventions: Choice of antipsychotic treatment (drug and route; access, use and monitoring of clozapine); supporting adherence with treatment; partial or non-response to antipsychotic treatment; monitoring of adverse events Transition to the community: Supportive and knowledgeable staff to ease transition; strategies and methods to facilitate care transition Peer support: Support from people with lived experience can help individuals with schizophrenia Training and education of healthcare providers: Specialized training for all providers who care for people with schizophrenia Access to psychiatrist: Access to psychiatric care is often limited

Other Key Topic Areas Topic Areas Assessment: Psychiatric assessment; comprehensive multidisciplinary assessment; physical health assessment to identify co-existing or comorbid conditions Management of risk: Management of individuals at immediate risk to themselves or others during an acute episode Patient education: Improved patient understanding of the assessment process, their diagnosis, and treatment options Engagement: Experience of staff in working with people from diverse ethnic and cultural backgrounds Self-management: Self-management to promote recovery and empower individuals

Out of scope Emergency department or inpatient setting (including transition to community) People in the criminal or youth justice systems Pre-natal and post-natal support Support of people with learning difficulties Prevention of psychosis in those at higher risk People with PTSD symptoms Transition from youth to adult care In scope? Services for people in crisis Transition to the community / ACT teams Early intervention services Promoting physical health Encouraging healthy eating and exercise Monitoring of patient health status Supporting smoking cessation Treatment of substance misuse Support for carers and family members Access to psychiatrist Engagement (e.g., First Nations, immigrants/ refugees) Training and education of HCPs Self-managementPeer support Improving community attitudes (reducing stigma) Access to primary care Supportive housing/assisted living Supporting employment Community integration Management of acute risk Patient education *BLUE indicates identified by topic prioritization survey Non-pharmacological interventions Cognitive behavioural therapy Alternative therapies Psychosocial interventions Neurocognitive training Assessment Psychiatric assessment Comprehensive multidisciplinary assessment Physical health assessment (for co- existing conditions) Pharmacological interventions Choice of antipsychotic medication Supporting adherence to antipsychotic medication Monitoring for adverse events Partial- or non- response to anti- psychotic medication