The literature review identified themes and issues relating to: Organization; Resources and Outcomes; Information and Documentation; Patient and Family’s Participation; Clinical Care and Teamwork; and Ethics. Articles supporting the included studies are indicated with reference number in italics.
Issue concerting the first of our themes, organization, seem to embrace our findings concerning improving pathways of care, and system and procedures should be developed to ensure clear responsibilities and transparency at each stage of the pathways of care.
Effective transitional interventions at patient, provider and system levels were found to be feasible and likely to be cost-effective. To address transitions in the health mental population more effectively care pathways need special procedural guidelines, instructions and links to national guidelines provided in the prehospital, hospital, outpatient, and home phase (Viggiano et al., 2012). A study of Sather (2020) concluded that to achieve sustainable integrated care, pathways of care should also describe content of the transitional phase in and out of hospitals and community services
Facilitated pre-discharge, post-discharge, and transition processes, and promoted timely communication of inpatient staff with outpatient care or community service providers after discharge were successful components (Vigod et al., 2013). First contact is important in pathways of mental health care, and there is lack of integration between emergency departments, hospitals, and community (Amaral et al., 2018). Care pathways led to better coordination of care and follow up with primary care (Biringer et al., 2017). The first contact for patients was a physician, but the referral source was emergency services. Ethnic determinants of the pathway, or the impact of the pathway to care on treatment delay was not found (Anderson et al., 2010). Earlier research has stated that the context of care pathways implemented in complex organizations must be considered in both external and internal contexts and have better descriptions of implementations and the contextual factors (Øvretveit, 2011, Seys et al., 2019). An understanding of the development changes and implementation process of a particular context is critical to support multidisciplinary teams in their search for excellence; and it is recommended that clinicians and managers should evaluate each of their individual projects to ensure that patient and organizational outcomes are improved (Vanhaecht et al.,2009, 2012). Information technology supported care pathways and improved objectively measured patient outcomes and resources (Akehurst et al., 2018, Neame et al., 2019). It supports decision-making and referral, and available resources; made more cost-effective care pathways and allows for active case management and clear leadership, relationships, support decision-making and referral, and available resources (Seys et al., 2017; Akehurst et al., 2018; Mutschler et al., 2019). It was found that care pathways may lead to better clinical outcomes, ensure more focused interventions and be valued by workforce (Allen et al., 2009; Khandaker et al., 2013; Vigod et al., 2013). This is in line with Mater (2014), who emphasized that development and implementation of care pathways are knowledge-based systems, care pathways optimize medical behaviour, and as clinical decision support systems, care pathways play a role in improving healthcare quality (Mater et al., 2014). Our review revealed that pathways are a solution to safety problems and can improve extended care episodes as part of preventing unnecessary hospitalization (Wright et al., 2016; Mutschler et al., 2019; Storm et al., 2019). Development and implementation of care pathways is labour-intensive; thus, resources should be optimally used.
Care pathways in mental health were found to be effective and improve information and documentation, providing patients with enough detail about their care and structured, documented plans at the appropriate time. Former mental health patients reported that shared information between all parties involved in care pathways is key. Proper documentation systems between health personnel, and patient participation in plans were success factors.
Opportunities for information sharing, implementation of systematic plans, use of e-messages were identified for successful patient transition, and the absence and systematic plans and delay in information sharing were barriers found to impede the patients’ transition between levels of care (Sather et al., 2016, 2018, 2019).
Care pathways were found to reduce in-hospital complications and improved documentation without negative impact on the length of stay and hospital cost (Rotter et al., 2010). This is in line with research in somatic health care (Aziz et al., 2012; Letton et al., 2013) that has shown that the implementation of a care pathway leads to increased or clearer documentation of care, and better interprofessional teamwork and better organized care (De Bleser et al., 2006; Gulbrandsen et al., 2016).
Continuous collaborative decision-making and patient and family’s participation was found to be an important factor related to pathways to care. Care pathways affected patient safety, supported autonomy and activities in community (Mutschler et al., 2019). It was found that patients revealed oscillation between feelings of strength and vitality to vulnerability and despair in transition phase and emphasized supportive relationships and work (Hasson-Ohayon et al., 2016). Continuous collaborative decision making was emphasized, but this was not regularly experienced. Families perceived that care planning was uncoordinated and that their lived experiences were not always appreciated (Doody et al., 2017). It was also found that improved information sharing in/between all care systems is imperative to strengthen patients’ participation in decision making, ownership of care plans and improve adherence to treatment. Additional, patient participation in care plans were success factor (Sather et al., 2016, 2018, 2019) as well as shared decision-making support for caregivers. Power and trust seem to be important factors that may increase as well as decrease patients’ dependency, particularly as information overload may increase uncertainty (Pelto-Piri et al., 2019).
Clinical care and teamwork were found to be important in pathways of care; collaboration between mental health and other professionals was a guarantee that planned activities meet patients’ needs, and pathways gave more interprofessional aspects, changing professional attitude positively (Allen et al., 2009). Regular meetings sharing key information and avoidance of delays that extend inpatient status and block satisfactory transition to the community setting are key (Sather et al., 2018). It was revealed that care pathways have the potential to support interprofessional teams in enhancing teamwork. The most frequent positive effects were on staff knowledge, interprofessional documentation, team communication and team relations (Deneckere et al., 2012). Open communication, well organized and delegated coordinating roles for interprofessional care team delivery are essential elements so that the service is consistent with agreements reached with patients and relatives (Vanhaecht et al., 2016, Aoki, 2020).
Mental health professionals support is key in help seeking for patients and important to their recovery process in general alongside transition to the community (Hasson-Ohayon et al., 2016). Patient-centred care was among the least investigated topics between mental health specialists (Durbin et al., 2012). Research indicated that creating reliable treatment and care processes, a stimulating social climate in wards, and better staff-patient communication enhances patient perceptions of safety during inpatient care (Pelto-Piri et al., 2019).
The review showed considerable variations in the ethics relating to mental health care pathways. The role of general practitioners could either decrease or increase the referral time, and stigma and discrimination towards patients with mental illness are limiting factors for the equal delivery of mental healthcare (Volpe et al., 2015). The results highlighted the disconnect that occurs for patients as they transition from hospitals back to their communities, indicating the need for effective, ethical transitional interventions that target these challenges (Mutschler et al., 2019). Lack of information could result in increased perceived stigma and devaluation of people with mental health challenges. Stigma and lack of awareness where treatment is available were barriers to seeking appropriate care for patients with various diagnoses of mental illness. The complexity of welfare systems negatively affected patient dignity, with patients and health personnel viewing treatment options differently. Respectful communication to avoid humiliating the patients was emphasized (Sather et al., 2016; Wright et al., 2016). Without ownership in decision making, patients in psychiatric inpatient care settings may prove less treatment compliant (Pelto-Piri et al., 2013). A recent study suggested that greater epistemic justice might be achieved by shared decision-making processes in which patients are engaged as a full, collaborative partner in their care (Grim et al., 2019)
Many of the studies were characterized by small study samples, no randomization and lack of control group, which increases the risk of bias and the ability to draw conclusions about outcomes (Higgins et al., 2011). Despite a comprehensive literature search of multiple databases that used broad search terms, the search may have missed relevant studies. These searches did not result in the inclusion of additional studies. It is recommended to consult experts in the fields as a separate but optional stage in the search strategy (Arksey & O’Malley, 2005; Tricco et al., 2016). However, expert consultation was not feasible in this study. Discussions among the authors on the depth and breadth of the review during the study selection stage may have resulted in a reduction of the scope. An assessment of methodological quality of the studies is debated within the scoping review tradition (Pham et al., 2014). In the present review, the quality assessment was performed to identify the strength of the evidence base and was not used as a tool for the exclusion of studies.