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Coordinated Specialty Care Discharge, Transition, and
Step-Down Policies, Practices, and Concerns: Staff and
Client Perspectives
Nev Jones, Ph.D., Becky Gius, B.A., Tamara Daley, Ph.D., Preethy George, Ph.D., Abram Rosenblatt, Ph.D.,
David Shern, Ph.D.
Objective: In recent years, optimizing the process of transi-
tion and discharge from coordinated specialty care (CSC), a
program that provides early intervention in psychosis, has
emerged as an important focus area for program adminis-
trators, clinicians, and policy makers. To explore existing CSC
policies and practices and to understand frontline provider
and client views on discharge, the authors conducted a
comprehensive analysis of staff and client interview data
from the Mental Health Block Grant 10% Set-Aside Study.
Methods: Data from 66 interviews with groups of CSC
providers and administrators representing 36 sites and
22 states were analyzed, as well as data from interviews with
82 CSC clients at 34 sites. Transcripts were coded by using
systematic content analyses.
Results: Analyses of data from providers and administrators
showed the heterogeneity of CSC program practices and
strategies regarding discharge and highlighted a range of
concerns related to postdischarge service accessibility and
quality. Analysis of data from client interviews reflected the
heterogeneity of transition challenges that clients confront.
A significant number of participants reported concerns
about their readiness for discharge.
Conclusions: CSC discharge policies and practices vary
across CSC programs and states. Frequent clinician and
client concerns about optimal program length, transition,
and postdischarge services highlight the importance of
sustained policy and research efforts to develop evidence-
informed practice guidelines and possible modifications to
the time-limited CSC model that currently dominates the
field.
Psychiatric Services 2020; 71:487–497; doi: 10.1176/appi.ps.201900514
First-episode psychosis (FEP) is a serious mental health
condition with historically poor long-term outcomes, par-
ticularly for young people with nonaffective psychosis (1, 2).
Fortunately, the development of specialized services for
early intervention in psychosis (EIP)—widely referred to as
coordinated specialty care (CSC) in the United States (3, 4)
has substantially improved 2- to 3-year postonset outcomes
(5–9). However, both premature disengagement (10) and
longer-term postdischarge erosion of the advantages of
EIP/CSC participation relative to status quo services re-
main significant concerns (8, 11–14). In particular, concerns
about postdischarge outcomes and uncertainty regarding
optimal length of EIP/CSC services have prompted a series
of recent “extension”trials (15–17) as well as international
dialogue about the long-term impact of variables such as
duration of untreated psychosis and the quality and in-
tensity of EIP/CSC program components focused on
functional and vocational recovery in addition to symp-
tom remission (18–21).
To date, studies of EIP/CSC client discharge outcomes and
trajectories have been limited in number and predominantly
conducted in the context of programs located outside the
United States. This is particularly true with respect to
HIGHLIGHTS
•Current policies and practices regarding discharge and
transition from coordinated specialty care (CSC) pro-
grams vary across the United States, and the number of
programs with formal step-down or discharge services is
very limited.
•Both clinicians and current and former clients expressed
concerns about postdischarge service availability and
quality.
•The development and rigorous evaluation of discharge-
related programming and step-down or extension strate-
gies are critical priorities for the field.
Psychiatric Services 71:5, May 2020 ps.psychiatryonline.org 487
SPECIAL ARTICLE
clinicians’and clients’perspectives. In fact, to the best of our
knowledge, we are aware of only three qualitative studies—
two studies based in the United Kingdom and focused on
clients’transition experiences (22, 23) and one study of staff
perspectives on discharge (24). In the United States, the
heterogeneity of state and regional funding and support for
mental health services (25), fragmentation of health care
more broadly (26, 27), and diversity of EIP/CSC models,
programs, and standards (3, 28) all raise questions regarding
the circumstances and consequences of program duration
and discharge practices that international studies can only
partially address.
The analyses reported in this article focused on the sub-
jective views of two key stakeholder groups: CSC program
staff and current and former CSC clients. Primary research
goals for staff interviews were to better understand the na-
tional landscape regarding discharge and transition, the
range of transition strategies that diverse CSC programs
have developed, and concerns regarding transition. Primary
research goals for client interviews were to explore how
recipients describe their communication with CSC clini-
cians about discharge and their concerns and perceived
readiness for discharge.
METHODS
Design, Sampling, and Procedure
The research described in this article is part of a larger,
longitudinal, mixed-methods study evaluating the imple-
mentation and outcomes of CSC services that are supported
at least in part by Mental Health Block Grant (MHBG)
10% set aside funds (29). Additional details regarding study
methodology and design are provided in an online supple-
ment to this article.
Study sites. The study includes 36 sites implementing ser-
vices with varying levels of fidelity to the CSC model, se-
lected from among more than 200 CSC programs across
the United States. Sites were selected in collaboration with
federal sponsors and were chosen to ensure diversity in
geographic distribution, specific program model (OnTrack,
EASA, NAVIGATE, etc.), and urbanicity.
Recruitment and interview procedures. Data presented here
were collected during two visits to each site, conducted be-
tween January and June 2018 and between January and May
2019. Site visits included semistructured interviews with CSC
team members and administrators and between one to four
CSC clients per site. Clients were selected by local program
staff without imposition of inclusion or exclusion criteria, and
demographic data collection was limited to age, gender, race-
ethnicity, and length of time in CSC services. All interviews
were conducted by experienced mental health services re-
searchers, including several authors (TD, PG, AR, and DS).
Interview protocols were developed by the MHBG eval-
uation team, incorporating feedback and suggestions from
governmental sponsors, expert advisors, and partners. Ques-
tions covered a range of areas related to CSC program
implementation, including explicit questions regarding tran-
sition practices—namely, Does the program have a step-down
program or any services for clients after they have participated
in the program? Has the program had any clients “graduate”
or leave the program over the past year, andif so, did they leave
because they were doing well, because they hit some type of
eligibility limit, or some other reason? Was there anything
that the program did to help with the transition? Does the pro-
gram have any contact with clients who have left the program?
For clients, the two primary questions asked were, Is
there a set length of time that the participant will be enrolled
in the program? and What does the client think it will be like
when he or she is no longer part of the CSC program? If
participants were nearing the end of their time in the pro-
gram, they were also asked how they felt about the idea of
moving on (e.g., whether they felt ready) and whether any-
one was helping them connect with services.
Sample characteristics. For providers, individual de-
mographic characteristics were not collected. A total of
338 CSC team members and administrators participated in
interviews across the 36 sites and two time points. At each
site, between three and 11 staff and administrators partici-
pated in each interview, with participants potentially in-
cluding care managers orcase managers, nurses, psychiatrists,
supported employment and education specialists, clinicians,
support staff, peer specialists, and individuals in a range of
administrative roles. For the discharge and transition sections
of the interviews included in this report, discussions and
comments from a total of 108 staff were actively coded (i.e., in
many interviews, additional staff were present but did not
actively weigh in or speak about these focus issues, and thus
they did not provide material that could be coded).
Eighty-two clients (45% female, N=37) at 34 sites
responded to questions about transitions. Clients were Cau-
casian (57%, N=47), African American (36%, N=29), Asian
American (5%, N=4), American Indian/Alaska Native (1%,
N=1), and individuals identifying as two or more races (1%,
N=1), with 21% (N=17) reporting Latino or Latina ethnicity.
The mean6SD age of client respondents was 22.564.46
(range 14–33). The length of time enrolled in the CSC pro-
gram at the time of the interview ranged from 1 month to
4 years, and six participants were either close to discharge or
had already been discharged. Two of the discharged clients,
although they had transitioned from initial CSC services, were
actively enrolled in an early psychosis–specificstep-down
continuation program at the time of the interview.
Data Analysis
Using interviews across both data collection time points,
we extracted all material containing responses to protocol
questions concerning transition and discharge as well as
additional discharge-relevant material arising in the context
of other protocol topics. To verify that all text relevant to
488 ps.psychiatryonline.org Psychiatric Services 71:5, May 2020
CSC DISCHARGE, TRANSITION, AND STEP-DOWN POLICIES AND PRACTICES
transition was captured, systematic key term searches were
also conducted—i.e., searches for key terms such as step-
down, transition, graduation, discharge, and other related
words—and the surrounding narrative was reviewed in or-
der to verify that no relevant text was missed. Extracted
sections were then coded by using systematic content anal-
ysis (30, 31), with the research goal of characterizing all
information relevant to transition and discharge.
A priori codes were generated on the basis of both in-
terview protocol questions and the team’s understanding of
discharge-related CSC issues (e.g., use of discharge planning
tools). Additional (emergent) codes were generated through
the comprehensive coding of approximately a third of par-
ticipant transcripts (until code saturation was reached).
In some cases, uncertainties in the interviews prompted
additional triangulation work. For example, ambiguous re-
sponses to questions regarding state or regional discharge or
length-of-service policy prompted the research team to re-
view existing administrative policy (including manuals and
policy documents where available) or to clarify policy with
appropriate administrative leadership.
Following a multiphase, iterative code development
process, the combination of a priori and emergent codes was
piloted on additional transcripts prior to finalization by the
coding team (NJ and BG). Because we wished to ensure code
reliability, 15% of transcripts were blind double-coded; code
disagreement was minor (less than 10%), primarily consist-
ing of missed codes rather than disagreement about correct
application of existing codes. The qualitative software pro-
gram Atlas.ti (32) was used for all coding and initial analysis,
and codes were exported to quantitative software (Stata
[33] for clinician data and SPSS [34] for client data) for the
computation of frequencies.
For staff interview analyses, we sought to provide both
code frequencies, where appropriate, and narrative report-
ing intended to characterize the nature and range of par-
ticipant perspectives. Wherever thematic frequencies are
provided, a denominator is included, with the denominator
varying relative to the number of interviews in which ma-
terial relevant to the code in question was present. For client
interviews, frequency reporting includes both overall fre-
quencies as well as further breakdowns by length of time
in CSC services at the time of the index interview. This
breakdown is reported because of the very different impli-
cations of, for example, perceived lack of understanding of
discharge policies after only 2 weeks in CSC versus 2.5 years.
For these purposes, clients were grouped into four service
length categories: enrolled for 0–12 months, enrolled for
13–23 months, enrolled for $24 months, and at discharge or
already discharged.
RESULTS
Staff Themes
Codes developed for the staff interviews were grouped into
three higher-level domains, reported as subsections below:
policies and practices related to discharge and transition,
discharge strategies, and clinician experiences and concerns.
Policies and practices related to discharge, transition, and
step-down. Table 1 summarizes policies regarding planned
or maximum program length for all 36 CSC sites. A 2-year
target, with flexibility to extend services, was the modal
response. Variations in flexibility were considerable, with
some programs able to extend services for a few weeks
or months, whereas others were able to extend in fixed
6-month increments. Several sites noted greater flexibility
when the program was below census. Three of the 36 pro-
grams were described as abandoning an initially rigid 2-year
limit and adding flexibility in response to clients’extended
service needs (“It’s not 24 months anymore. It was. We were
limited at first. But now since the research is starting to
show that people are benefiting from 3 to 5 years of service,
we’re keeping people longer.”). Conversely, three programs
that initially allowed services beyond 2 years subsequently
established a 2-year limit to more strongly emphasize a
transitional focus.
Only one of the 36 programs was described as having a
time-limited effort to assess postdischarge outcomes
through informal qualitative interviews with two client co-
horts. Staff at one additional site mentioned quasi-systematic
follow-up to ensure that clients had successfully engaged
with other services (“We check in [with discharged clients]
every once in a while to see how things are going.”) Although
staff of other programs described occasional informal
contact with selected discharged clients—seeing clients at
agencywide events, for example, or at CSC program–hosted
reunions—these interactions provided, at best, a very partial
window into postdischarge trajectories.
Discharge and transition strategies. Although staff at only
two programs described early psychosis–specificpost-
discharge services, sixteen were able to refer clients to
within-agency programs of varying intensity. In six of these
16 cases, programs were also able to facilitate ongoing
treatment from one or more members of the client’s CSC
team. For example, one staff member said, “A lot of our
clients once they discharge from the program continue to
see the exact same prescriber and therapist. ...Itjust
wouldn’t be as part of the [CSC] program anymore.”Another
staff member noted, “When we say ‘graduate,’a lot them will
continue to see the [same] psychiatrist for medication, but
that might no longer be a part of the program because they
will only be receiving one service.”
Although continuity predominantly centered on thera-
pists or psychiatrists, staff at one program described the
ability and capacity to provide indefinite supported educa-
tion and employment services for clients who had graduated
or been discharged. Of the 16 programs that were able to
refer clients to within-agency programs, all nevertheless
described discharging clients to outside services at least
some of the time. In some cases, this was based on client
Psychiatric Services 71:5, May 2020 ps.psychiatryonline.org 489
JONES ET AL.
needs or the availability of appropriate within-agency ser-
vices; for example, one agency could place transition-age
youths internally but not clients who were age 25 or older.
CSC staff described a range of strategies and tools
designed to ease the transition. Three notable examples are
described here. First, some programs used specific struc-
tured or semistructured tools or checklists, completed with
clients prior to discharge. Some of these procedures in-
cluded advance crisis planning or advance directives and
collaborative development of a plan for accessing diverse
postdischarge services across service domains (housing,
medications, and employment). Second, some CSC staff
described in-person linkage and hand-off prior to discharge—
i.e., CSC clinicians would accompany clients to initial
meetings with prospective postdischarge clinicians or pro-
grams, ensuring client satisfaction with new services prior to
finalizing their discharge. Third, a number of teams de-
scribed a systematic step-down process prior to discharge,
typically described as spanning 4 to 6 months, in which CSC
services were gradually tapered in order to facilitate in-
creasing autonomy and self-reliance as well as adjustment to
a lower level of clinical support. For example, a program
might slowly reduce the frequency of therapy or case man-
agement or taper off certain program components com-
pletely. Virtually all CSC teams remarked on the highly
heterogeneous nature of FEP populations. Transition-
relevant aspects of heterogeneity discussed included the
need for diverse postdischarge services—for example, ser-
vices designed to support both Medicaid and privately in-
sured clients, as well as a mix of residential, higher-intensity,
and lower-intensity services. Many staff noted, for example,
that some clients might need and want only sporadic med-
ication management after discharge, whereas others would
require therapeutically intensive residential or day pro-
grams. In addition, many clinicians emphasized variations in
available family support and social capital as having an im-
pact on discharge planning and client prognosis. Heteroge-
neous responses to treatment affected service duration.
Providers at multiple sites described a subset of clients with
transient or highly treatment-responsive symptoms who
could be effectively discharged after as little as 6 months,
whereas others, even after 3 or 4 years, continued to expe-
rience debilitating symptoms or functional limitations that
required intensive ongoing care.
Clinician discharge experiences and concerns. Most program
staff expressed at least some concerns regarding post-
discharge services and client trajectories. These concerns
were place specific and involved strengths and weaknesses
of programming in their region. Staff from several programs
provided anecdotes of clients who had been doing very well
when they left the program only to relapse. Staff at one
program described having concerns with clients’well-being
and access to services after conducting an informal effort to
contact several clients after discharge:
We did kind of an informal calling back to say like, “Hey, how
are you doing? What’s happening?”and almost nobody had
continued in outpatient care. It’s a handful, maybe two or
three [out of 20 successfully contacted]. And those were the
ones with more active family members. They expressed
several things. One, that none of the programs they went to
were ever like [CSC program] and they wanted to come back
to [CSC]. . . . And more than 50% have already dropped out of
the care that they had been connected to: they couldn’t get
the appointments. So, the desire to get care was there, but
they were dissatisfied with what they were able to get.
Table 2 summarizes other specific areas of concern, often
based on cases in which the program had been alerted to
postdischarge outcomes for selected clients.
Although concerns of various kinds were common, with
many teams expressing an overall preference for a service
period significantly longer than 2 years, others emphasized
the importance of keeping CSC programs transitional in
order to prevent potentially harmful “engulfment”in a
patient role. Three sites reduced their service length for
this reason. Other staff, speaking in this vein, emphasized
TABLE 1. Policies regarding planned or maximum program length at 36 coordinated specialty care programs
Programs
Program length Description and context N %
2-year target with flexibility to extend on a case-by-
case basis
Program target is 2 years, but the program is able to extend the
length of service for clients in need of extended services
16 44
Fixed 2-year service limit, very limited ability to extend Providers’ability to extend services is very proscribed 4 11
Expectation that clients will average 2 years in the
program; no fixed limit
General expectation is that most clients will require 2 years, but
this is not framed as a “target”or “goal,”and there is no upper
limit on services
38
Maximum 3-year service period Program staff described the program as of 3 years in duration,
or they identified 3 years as the upper limit
411
Program serves clients beyond 3 years Program staff reported an expectation that services may last
more than 3 years, without specifying an exact target
26
5-year service period Regional guidance clearly specifies that services should be
provided for up to 5 years
411
Indefinite service period; no upper limit on service
eligibility
Program is new or has not yet developed a discharge policy, or
staff reported both no upper limit and no expectations or
target for service duration
38
490 ps.psychiatryonline.org Psychiatric Services 71:5, May 2020
CSC DISCHARGE, TRANSITION, AND STEP-DOWN POLICIES AND PRACTICES
differences between ongoing long-term medication man-
agement (which might be desirable or necessary in the long-
term) versus therapy. For example, one staff member noted,
“I don’t think therapy should be lifelong. It should be one of
your goals, but to set you in that direction. With this pro-
gram, [CSC], let’s make sure you’re well set in dealing with
your symptoms. . . . Set a foundation for those goals and let
you go on your way.”
Client Themes
Client themes were grouped into four high-level domains:
client-provider discharge planning, client discharge aware-
ness, perceived readiness for discharge, and concerns and
feelings about discharge. Table 3 summarizes higher-level
themes within each domain as well as lower-level codes
under each theme, including example quotations. Table 4
provides the number of interviews in which each domain
was mentioned and the frequency with which specific codes
were discussed, with a further breakdown by length of time
spent in CSC services at the time of the index interview.
Overall, client reports of team communication regarding
program time limits and discharge planning were quite
varied, as were feelings regarding readiness for discharge
and associated concerns. Even among those already served
for 2 or more years or approaching discharge, a substantial
minority reported fears and discomfort—for example, feeling
unprepared or distressed—and concerns about the implica-
tions of losing valued supports and structure. One partici-
pant, for example, compared current CSC staffing to
projected future services: “Any doctors [in standard
TABLE 2. Programs (N=36) in which clinicians expressed concerns about policies and practices related to discharge and transition,
with example quotations
Programs
Concern N % Example quotation
A 2-year service time frame is inadequate 9 25 “Two years is not enough for a lot of people to develop the insight
that they need to be able to be independent and understand that
they will need some kind of ongoing treatment.”
Area services not recovery oriented 7 19 “For step-up services postdischarge, we can send clients to [an
assertive community treatment or an intensive case
management] team, [but] they are very depressing, and they feel
like the opposite of recovery. To the participant, they feel like a
step in the wrong direction. Our participants never stay with
those programs, I feel like, nor would I want them to, because
they’re sort of like a holding place.”
Disengagement or discontinuation of
treatment or medication after discharge
514“Someone could be in this program functioning beautifully . . . but
then once they leave . . . they lose it. Suddenly they think they
don’t need meds anymore . . . and no one’s there to catch them. .
..We’ve had a lot of really heartbreaking cases like that.”
Difficulty of transition to status quo services
after initial experience of high-quality CSC
411“The quality of treatment in [our city], and I would imagine in a lot
of these large urban areas, is just not good. And so, it’s not good
by itself, and then it’s really not good when you’ve had such an
amazing program like this wrapped around you for so long. You
know you’re going somewhere that’s not good. You feel it as
soon as you walk in the door, the smells, the paint job, the
deterioration of the facilities, the staff are grumpy and not
interested.”
Shortage of and limited access to psychiatrists 4 11 “The other piece is just in terms of resources, going back even
internally into our agency, so going back to adult services, there
can often be a shortage in psychiatry.”
Cost of care, particularly for privately insured
(but not wealthy) young adults
411“For a 19-year-old having to pay that much money on medication,
that’s a lot . . . [plus] copays for therapy, and . . . go[ing] from
coming in whenever [they] need and want to, and getting lots of
support, and not paying copays, to private insurance copays.”
Access to clozapine and long-acting
injectables
38“And a lot of people are on clozapine ...orattheinjection clinic.
So, if that’ll have to change in addition to who they were seeing,
it would just be a lot much more complex to coordinate and to
find places that have those similar services.”
Access to psychiatrists able or willing to
prescribe antipsychotics
222“It’s a super big challenge getting a primary care or a private
psychiatrist to continue medication. Those types of medications
are really just specific to community mental health centers,
primarily. That’s where the bulk of those types of physicians are.
To get someone with Medicaid connected to a private
psychiatrist in a community that’s going to provide an
antipsychotic is pretty unlikely. There’s a very low availability of
those kinds of doctors. That’s where our clients get stuck.”
Psychiatric Services 71:5, May 2020 ps.psychiatryonline.org 491
JONES ET AL.
TABLE 3. Themes and lower-level codes related to discharge and transition identified during interviews with clients at 34 coordinated
specialty care programs, by domain
Theme and code Example quotation
Client-provider discharge planning
Discussion of discharge plan
Plan discussed “What’s nice about [discharge] is [staff] and I are talking about it. We are addressing it. What
are our future long-term goals. . . ? So yeah, I mean, we’re addressing the outcomes and
future now, which is good instead of just saying, ‘Oh, 2 years is done. You’re on your
own.’It’s not beating around the bush or anything.”
Plan not discussed Interviewer: “And have you talked at all about not being in the program, because you’re
going away to school?”Client: “We haven’t talked about what’s going to happen after I
go to school and [have to leave the program].”
Discharge awareness
Awareness of discharge policies regarding
time limit
Unaware or didn’t know of any service
limit or related policy
“[How long I can stay is] a good question because I have no idea. I was thinking about that
myself. I have no idea how long this is going to continue for. I’m not really sure how that
works.”
Aware of specific service limit “It’s a 2-year program.”
Aware and believes there is not a limit “No. There’s not [a time limit]. I think as long as it’s helpful. I mean, it’s not like my diagnosis
is going away anytime soon. So, I’ll probably be in the program for the foreseeable
future.”
Perceived readiness for discharge
Ready for discharge
Feels confident, prepared, ready “Honestly, I feel like this was a very good foundation. So, I feel like now that I’ve been really
educated in many ways, that I feel like I can do it on my own.”
Not ready for discharge
Doesn’t feel ready, does not want to be
discharged
“Yeah, I’m actually being told that I’m done with the program. I’ve completed the program
and that a different program is going to have to take over. So, I’m a little stressed out
about that. How can I have completed and I’m not fully recovered? . . . I haven’t been
assisted with that [other services beyond the program]. I’ve only been asked questions.”
Concerns and feelings about discharge
Positive feelings
Fine, okay, content, good “It’s just like I’ll be done with it, but I won’t be scared because I’ll be facing it still with my
family. I’ll have family and loved ones. And I’ll be better at handling situations that stress
me because of [the program].”
Happy, excited, proud, hopeful “I think I’d be proud of myself for not only doing all that, but keeping my s**t together for
that long. Because that would be a change, yeah. I think I would just be proud of myself,
and I think I’d be slightly relieved to know that maybe this is a new chapter of my life
that’s starting now.”
Grateful to program “My doctor told me that I’m going to graduate from the program in about another 3 to
4 months and I’ll be happy that I’m graduating, but a little bit sad because . . . it’sa
transition. It is. But I’m very grateful [to the program], and I can’t express it enough.”
Negative feelings
Sad, distressed, anxious “[I feel] very, very bad. I feel very bad because I’m not going to have the people and I’m not
going to have the resources. So very bad.”
Will miss the program; discharge viewed
as a loss
“I would think I would lose like a place that I used to go to like if I couldn’t come here, I
think I’d lost a place I couldn’t come to no mor. . . . I think I would feel like it was a loss.”
Ambivalent feelings
Sad or will miss it, but also sees moving
on as a positive step
“It’d be a little sad, ’cause I feel like this is my new community. But all things go, and all
things change, so it’ll be like finding a new shell.”
Uneasy or unsure; may or may not turn
out well
“Sometimes I do feel like I’m ready to move on, but then I don’t feel like I’m ready
to move on.”
Vague feelings
Unsure how he or she feels Interviewer: “What do you think it’ll be like when you’re not in the program anymore?”
Client: “I don’t know. I honestly don’t know.”
continued
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CSC DISCHARGE, TRANSITION, AND STEP-DOWN POLICIES AND PRACTICES
treatment] . . . they’re more, I don’t know, they see their
patient. Here they have a lot of resources like occupational
therapy and all that. And there it [will be] more just like
talking to the doctor for 20 minutes and then going home.”
Both of the clients who were interviewed after discharge
were currently being served in a specialized early psychosis
extension program, and both planned to remain in services
for several more years (after having already received 2 or
more years of initial CSC).
Although loss of program structure clearly undergirded
many clients’discomfort, attachment to particular clinicians—
and the distressing prospect of losing these relationships—
were frequently mentioned: “I told them that I didn’tlike
the fact that I wasn’t going to be able to reach out to them
anymoreaftertheprogram....Ididn’tlikethefactthat
after my time here, like after the 2-year mark, I can’t reach
out to [team members] because of confidentiality rea-
sons. . . . I don’t like that.”Many clients also appeared to
view discharge from CSC as entailing the permanent loss of
access to close therapeutic relationships, whether because of
cost, access, or standards of care.
Almost half (43%) of the 30 clients who were explicitly
asked about provider communications regarding future dis-
charge reported that they were unaware of discharge policies
and had not discussed discharge with providers, representing
ten of the 36 evaluation sites. Among these clients, a quarter
had already been served for more than a year and 38% for
2 years or more. In nearly all cases, providers working in the
programs in which these clients were served described early
and proactive discussion about discharge.
Other instances of discordant perspectives between
providers and clients were also present. Clinicians, for ex-
ample, noted instances in which clients might feel prepared
for discharge but in fact were not or, conversely, feel un-
prepared when, from the providers’point of view, they were
ready. One of the providers involved in the cohort follow-up
effort described above noted, “[Some former clients] said
they were fine, and now I’m seeing them in the home and
they are not fine. . . . They’re saying, ‘Everything’s great, I’m
great, I’m doing wonderful. I just started a business.’And
then their parents are like, ‘Yeah, they made that business
up. It’s not a real thing’”
DISCUSSION
Main Findings
These findings underscore the tremendous variability of
discharge practices and policies across the study sample,
including a wide range of program lengths (between 2 and
5 years), and an array of discharge strategies and internal
capacity for continuity of care. Only two of the 36 sampled
programs provided targeted postdischarge extension or
step-down services, and only one was described as having
regular, clinically oriented follow-up to ensure (or assess)
the success of the transition. Concerns about discharge and
the accessibility and quality of postdischarge services were
widespread among clinicians, and a significant proportion of
clients expressed apprehension or sadness about discharge,
including clients already served for more than 2 years or at the
point of discharge. Data also highlight the heterogeneity of
client needs and experiences, with implications for ongoing
improvement and refinement of CSC and post-CSC services.
Clinical Implications and Future Directions
The overarching goals of early detection and early in-
tervention include a fundamental redirection of the histor-
ically poor prognosis of individuals with early psychotic
disorders (35–37) and the transformation of initial systems of
care (38). Follow-up research (8, 10–14) and associated step-
down and extension trials (15–17) have raised important
concerns about the durability of the initial advantages of
CSC over conventional treatment and the best strategies for
sustaining improved long-term outcomes. Although many
practice guidelines and performance-monitoring efforts
include at least some guidance regarding transition (39–42)—
in some cases providing genuinely substantive advice (39)—
empirical substantiation of best practices remains scarce
(43). Our findings underscore the absence of a unified na-
tional strategy for CSC transition in the United States and,
presumably, other countries with distributed CSC services.
TABLE 3, continued
Theme and code Example quotation
Specific areas of concern
Postdischarge service availability in
client’s native language
“I’m going to miss it because of the help I’ve received here. And, I don’t know how it’s
going to be in the next program. Here they have the therapy in Spanish.”
Loss of supports still perceived as needed “What if I need the support or something from them? Plus, I don’t just look at them as
work, I look at them like somebody I can depend on or something. Even though I’m
trying to be independent, like I can depend on them or something.”
Loss of structure “Right now, I’d rather not have to [discharge]. I’d like to continue the program. I’m
somebody that likes just to keep it the way it is, the schedule and everything. I mean, it
helps me just to be able to come here and be able to talk to people and stuff like that. So,
I’m somebody that would vote to stay indefinitely if need be.”
Inability to handle future stressors
without the program
“Just because, like, I don’t think I’ll ever be off my medication, because when the episodes
happen, I can’t tell if it’s real or not. And I come from a very religious family, and so when
stuff happens if I didn’t have this program, I don’t know what I would do.”
Psychiatric Services 71:5, May 2020 ps.psychiatryonline.org 493
JONES ET AL.
Our findings also highlight the role of transition and post-
discharge services and the importance of incorporating ex-
plicit service quality metrics related to discharge into future
follow-up studies (43).
Overall, more research on transition and discharge is
essential, ideally including comparative effectiveness studies
designed to discern which of the many strategies discussed
in our interviews (and the broader literature [22–24])
should guide clinical policy, including the development or
refinement of fidelity tools. Ideally, in this context, practice-
oriented research initiatives would also make an explicit
commitment to unpacking the implications of national, re-
gional, and client-level heterogeneity and how best to craft
and finance models that preserve the initial benefits of
CSC programs while also titrating supports to foster in-
dependence. Key considerations include local non-CSC
service availability and financing and, at the client level,
age (youth versus adult), degree of disability, and relative
socioeconomic disadvantage.
Discrepancies between client and provider perceptions
regarding communication and program policies related to
discharge tentatively suggest that even in cases in which CSC
TABLE 4. Frequency with which themes and lower-level codes related to discharge and transition were mentioned during interviews
with clients in coordinated specialty care, by domain and time in the program
Months in program
Domain
Theme or
code mentioned
b
Discharged
or at
Domain, theme, and code mentioned
a
N%0–12 13–23 ‡24 discharge
Client-provider discharge planning 30 5 7 12 6
Discussion of discharge plan
Plan discussed 17 57 0 4 7 6
Plan not discussed 13 43 5 3 5 0
Awareness of discharge policies regarding
time limit
67 26 16 19 6
Unaware or didn’t know of any service limit
or related policy
15 22 7 3 5 0
Aware of an existing limit or discharge policy 52 78 19 13 14 6
Aware of specific service limit 27 52 9 11 6 1
Aware and believes there is not a limit 25 48 10 2 8 5
Discharge readiness 31 7 6 13 5
Ready for discharge
Feels confident, prepared, ready 14 45 3 3 6 2
Not ready for discharge
Doesn’t feel ready, does not want to be
discharged
17 55 4 3 7 3
Concerns and feelings about discharge 47
Positive feelings 17 36 9 1 3 4
Fine, okay, content, good 5 29 3 0 0 2
Happy, excited, proud, hopeful 6 35 3 1 1 1
Grateful to program 6 35 3 0 2 1
Negative feelings 15 32 4 3 4 4
Sad, distressed, anxious 8 53 2 1 3 2
Will miss the program; discharge viewed
as a loss
747221 2
Ambivalent feelings 15 32 3 4 6 2
Sad or will miss it, but also sees moving on
as a positive step
960323 1
Uneasy or unsure; may or may not turn
out well
640023 1
Vague feelings; unsure how he or she feels 8 17 6 1 0 1
Specific areas of concern 20 43 8 5 4 3
Postdischarge service availability in client’s
native language
2102000
Loss of supports still perceived as needed 8 40 2 3 2 1
Loss of structure 4 20 2 1 0 1
Inability to handle future stressors without
the program
630212 1
a
N of interviews (N=82) in which the domain was mentioned.
b
Percentages for themes are based on total mentions for the overriding domain, and percentages for codes are based on total mentions of the overriding
theme, with the exception of percentages for codes in the domain of discharge readiness and client-provider discharge planning, which are based on total
mentions of the domain.
494 ps.psychiatryonline.org Psychiatric Services 71:5, May 2020
CSC DISCHARGE, TRANSITION, AND STEP-DOWN POLICIES AND PRACTICES
programs are able to articulate well-developed policies and
practices (in interviews), program clients may remain con-
fused or unclear about what to expect. Future research and
program development efforts would thus ideally include a
strong focus on understanding clients’subjective experience
not only of discharge itself but also their advance knowledge
of and preparation for discharge. Integration of participatory
methods may be critical. Differences between provider and
client perspectives—especially insofar as they may affect
program-level decisions to extend care or move forward with
discharge—also raise important questions with respect
to shared decision making and client self-determination,
which feature as key components of CSC programs (32).
Who, we might ask, for example, should ultimately drive
decisions regarding the timing of discharge?
A second important issue is the extent to which ongoing
improvements to CSC programs—within a standard 2- to
3-year treatment window—could potentially affect long-
term outcomes rather than (or in addition to) the extension
of services or development of postdischarge step-downs.
Although we lack follow-up outcomes data, potential ap-
proaches in the published literature include ramped-up
supported education and employment services (18, 44) and
CSC modifications designed to improve outcomes for high-
risk subgroups, including youths and young adults experi-
encing or at risk of homelessness (45) and those identified
early in CSC as likely to disengage from services (46). Con-
versely, we might argue that CSC represents a level of quality
that should in fact characterize mental health services in
general, as underscored by both staff and client concerns
regarding the values and offerings of postdischarge services.
Finally, as evidenced by both clinician and client inter-
views, the tension between helpful structure and support
and a potentially detrimental dependency on services can be
challenging to navigate. For example, as we described, a
large number of clients alluded to the value of therapeutic
relationships and their desire to continue rather than move
on from these relationships. Philosophical and ethical ten-
sions surrounding the trade-offs and impact of long-term
versus short-term, time-limited therapy have been a subject
of debate and disagreement for many years (47–49), albeit
with contemporary insurance policies strongly favoring (if
not requiring) time-limited therapeutic interventions (50).
Pronounced differences between clients in the level of on-
going disability or distress—and the time needed to lay the
foundation for recovery—further compound the challenges
of crafting policies and supports capable of meeting diverse
short-term as well as longer-term needs. An alternative
treatment model, such as is used in the Housing First model
of supported housing (51, 52), might continuously titrate
services to an individual’s wants and needs for an unlimited
period rather than transitioning the client to alternative
services. This would require staffing models different from
those that are currently used, and these models would have
to strive to help clients achieve as much independence from
services as possible. Again, research concerning these issues
would ideally be grounded in a careful consideration of
multiple stakeholder preferences and perspectives (53–55)
andorientedtowardtheinvestigationofmechanisms
whereby interventions can facilitate long-term healing as
well as short-term effectiveness (56–59).
Limitations
Major strengths of the analyses presented here include the
number of programs and states included in the evaluation
sample, and the projects’large multistakeholder sample.
Nevertheless, questions and discussion about discharge and
transition constituted a relatively small piece of a compre-
hensive and multifaceted evaluation. In any given interview,
transition-specific discussion may have spanned as little as
5–10 minutes, falling short of the depth of coverage that
would have been enabled by a research project more ex-
clusively focused on the topic of discharge and transition.
Furthermore, depth of discussion varied considerably across
interviews, and a significant proportion of interviews did not
include discussion of important thematic domains. Although
the number of client participants (N=82) was high overall,
interviews included only one to four clients per site, who
were selected by program staff, raising questions about
potential selection bias. Similarly, the sites selected do
not necessarily represent the much larger population of U.S.
CSC services, and the overarching motivation for the study
(federally sponsored evaluation of CSC services) may have
biased provider narratives. Future efforts to unpack client
experiences and priorities would ideally use careful sam-
pling strategies to capture the range of experiences likely
present even among current or former clients within the
same program and would also ensure adequate representa-
tion of participants with varying levels of disability, pre-
morbid accomplishments, socioeconomic backgrounds, and
amount of family support.
The MHBG 10% Set-Aside Study and the data reported
here also did not include family or caregiver perspectives.
Given the critical role that families often play in supporting
loved ones with psychosis (60, 61), future efforts would
ideally fully integrate family perspectives and priorities with
respect to discharge policies (and communication of those
policies) as well as transition and postdischarge supports.
Another critical but unrepresented group were clients who
opted to withdraw or disengage from CSC services (62, 63).
From a population health perspective, the ultimate success
of CSC depends not only on sustaining the gains of those
who opt to remain in CSC programs for their full duration
but also on working to ensure the sustained well-being of
those who disengage from CSC programs in their current
form.
CONCLUSIONS
Internationally, concerns regarding the relative loss of ini-
tial treatment advantages of early intervention services
are widespread. As our research documents, U.S. clinicians,
Psychiatric Services 71:5, May 2020 ps.psychiatryonline.org 495
JONES ET AL.
both academic and community-based, share these concerns,
as—in more indirect ways—do many CSC clients. Although
programs have developed a range of strategies for support-
ing clients during and after discharge, implementation varies
considerably, and research capable of guiding best practices
is lacking. Moving forward, multistakeholder-informed
intervention and applied services research on discharge,
transition, and step-down should be prioritized.
AUTHOR AND ARTICLE INFORMATION
Department of Psychiatry and Behavioral Neurosciences (Jones) and
Department of Psychology (Gius), University of South Florida, Tampa;
Westat, Inc., Rockville, Maryland (Daley, George, Rosenblatt); National
Association of State Mental Health Program Directors, Alexandria, Vir-
ginia (Shern). Send correspondence to Dr. Jones (genevra@usf.edu). The
first two authors contributed equally to this article.
Research reported here was supported by the Substance Abuse and
Mental Health Services Administration and the National Institute of
Mental Health (task order HHSS283201200011I/HHSS28342008T, ref-
erence 283-12-1108).
Dr. Jones reports serving on an advisory board for Mindstrong Health.
The other authors report no financial relationships with commercial
interests.
Received October 16, 2019; revision received December 11, 2019;
accepted January 16, 2020; published online March 19, 2020.
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