Health Technology Intervention After Hospitalization for Schizophrenia: Service Utilization and User Satisfaction

Schizophrenia is characteristically chronic and relapsing, and data suggest that relapses reduce a patient’s chance of future treatment response (1,2). Therefore, interventions immediately after hospitalization are needed, with the aims to improve outcomes and reduce health care cost. Technology-based intervention studies for people with schizophrenia have produced promising results (3,4); however, patient engagement with technological interventions may require the support of trained personnel (5,6).

The Health Technology Program (HTP) addresses the combined goals of improving care and reducing cost by integrating the use of selected technologies that provide flexible delivery of evidence-based treatments that include guided support of mental health professionals. Mental health technology coaches (MHTCs) were chosen to be part of this treatment in order to deliver a manual-supported relapse prevention program, promote program adherence to the evidence-based technologies, and respond to the patient’s need for guidance on the use of these technologies. The primary aim of this study was to provide empirical findings concerning HTP acceptance by examining patients’ frequency of contacts with MHTCs, overall program satisfaction, and preferences for and satisfaction with the digital tools.

Methods

The first 200 of the targeted 400 patients enrolled in the Improving Care and Reducing Cost (ICRC) study between April 2013 and August 2014 are evaluated in this report. Altogether, 117 (59%) of these patients were men, 95 (48%) were white, 62 (31%) were black or African American, 22 (11%) were Hispanic or Latino, eight (4%) were Asian, two (1%) were American Indian or Alaska Native, and 11 (6%) were of mixed race-ethnicity. The mean age of the participants was 34.6±10.6, and 100 (50%) had a high school diploma or below. [An online supplement to this report includes complete demographic characteristics of the sample.] Study procedures were approved by appropriate institutional review boards, and all participants provided written, informed consent.

Inclusion criteria were meeting the clinical diagnosis of schizophrenia, schizoaffective disorder, or psychotic disorder not otherwise specified; being 18–60 years old; currently psychiatrically hospitalized or having been hospitalized within the past 60 days; ability to participate in research assessments in English; and ability to provide informed consent. The only exclusion criterion was having a serious general medical condition that would make the patient unsuitable for the study.

HTP includes five specific components. First, contacts with the MHTC are guided by developing and refining a relapse prevention plan (7), which includes identification of relapse triggers and the implementation of preventive strategies as described by Mueser and Gingerich (8). The preventive strategies in this program were partially based on the digital tools. Second, an interactive smartphone illness self-management system, known as FOCUS, provides coping strategy training and brief interventions designed to support medication adherence, mood regulation, sleep, social functioning, and coping with auditory hallucinations (9,10). Third, a Daily Support Web site offers Web-based resources to support persons with schizophrenia and their family members or others based on empirically validated approaches to family psychoeducation (4,11). Fourth, Cognitive-Behavioral Therapy Skills for Psychosis (W-CBTSp) consists of two Web-based, self-administered, self-paced CBT education sessions about psychosis, “Coping with Voices” and “Coping with Paranoia” (12). The fifth component offered as part of HTP is evidence-based pharmacological treatment, which will be addressed in a separate report.

Program components were provided to patients by using a shared decision-making approach to assess need and preference as part of a structured engagement process (8). MHTCs received weekly supervision from the sites’ program directors. Each had at least a bachelor’s degree and one year of general experience working at mental health centers. Most were research assistants or had a similar position. The MHTCs also received biweekly supervision from the study team regarding technology-specific issues and implementation of the relapse prevention plan.

The program time frame was the six-month period beginning within 60 days of hospital discharge. At the beginning of the intervention, the MHTC initiated the relapse prevention planning process (13) and determined with the patient which technology components of the ICRC program the patient would use. A smartphone with FOCUS was given to all patients; we reasoned that every patient was likely to have medication adherence issues that FOCUS could address. If we determined that the patient and his or her supporters could benefit from either the Daily Support Web site or W-CBTSp and didn’t have a personal computer, the patient received a personal laptop. During the treatment phase, most patients were able to use all components of the HTP on the basis of their needs, including ongoing work with the MHTC. In addition to having scheduled meetings with the MHTC, patients could leave messages for the MHTC, who would respond during standard working hours according to availability.

The MHTCs documented within the contact log all contacts made with each patient. We used a 13-item self-report survey that was completed by participants at the end of the six-month study. Tables including participant flow, complete contact log, differences between the various digital tools in perceived usability and helpfulness, and moderating effects are presented in the online supplement.

Results

Overall, 93% of enrolled patients completed the six-month program, and 89% completed the program review. The average number of contacts with MHTCs was 28.2±2.0, lasting a mean of 38.3±14.2 minutes in a six-month period, resulting, on average, in more than one 39-minute contact per week. The most common contact location was the outpatient clinic, where 36% (N=10) of contacts took place, followed by phone calls and text messages, which accounted together for 35% (N=9.9) of contacts. In total, 24% (N=6.8) of the contacts took place in the patient’s home or in the community. The most common type of contact was case management, which was discussed in 52% (N=14.6) of contacts. The relapse prevention plan was discussed in 44% (N=12.5) of contacts, and the digital tools were discussed in 45% (N=12.6) of contacts. Overall, 174 (87%) participants indicated that they used at least one digital tool during the study, with 170 (85%) participants indicating that they used FOCUS, 112 (56%) indicating that they used the Daily Support site, and 118 (59%) indicating that they used W-CBTSp. Only 1% τo 16% of patients found the digital tool they used unusable or unhelpful (see online supplement). Overall, 127 participants (72%) were very satisfied and 43 (24%) were somewhat satisfied with the intervention.

Discussion

This report demonstrated very high utilization of, acceptance of, and satisfaction with a coach-coordinated, technology-delivered relapse prevention program. Four features of this program may have been particularly key to these results. First, a technology coach provided in-person training, support, and easy access to technical assistance for the digital tools, likely contributing to the use of the digital tools and to the low dropout rates of the program. Second, participants’ high usability and helpfulness ratings imply that the design features were likely successful. Third, HTP incorporated evidence-based intervention strategies: relapse prevention planning, cognitive-behavioral symptom management strategies, and family psychoeducation strategies, all addressing the symptoms and distress that patients with schizophrenia commonly experience. Fourth, HTP was delivered with a flexible, mobile, technology-informed approach. Most contacts between the technology provider and patient were not in the clinic, and over a third of contacts occurred via technology (phone, text, and e-mail). Analysis of the content of the MHTCs’ interactions with patients demonstrated an important point regarding the needs of recently discharged patients with schizophrenia. They utilized support and guidance around relapse prevention planning in half of the visits, but they also had high case management needs for assistance with housing, benefits, and so forth; thus interventions to reduce relapse must have these dual capacities.

The study had several limitations that should be considered. First, it is important to note that although the program showed that MHTCs are capable of providing persons with schizophrenia with more than case management needs, including relapse prevention planning, which was assisted by the use of the digital tools, the added value of digital tools remains somewhat unclear. Realizing the added value of these tools could be accomplished in a trial that compares different relapse prevention treatment plans, such as one with and one without digital tool utilization. That way, the difference in program acceptance, clinical outcomes, and MHTC contacts could be attributed to the availability of the digital tools. Second, although the results indicate that HTP fulfilled the ICRC study’s first goal of increasing care, they are not yet linked to rehospitalization rates or symptoms to demonstrate achieving the second study goal of reducing costs. Nonetheless, the high satisfaction, usability, and low dropout in HTP demonstrate the strong promise of this approach for helping people with schizophrenia on their recovery path. Third, we used a retrospective and self-report approach to compare the acceptability, usability, and helpfulness of the digital tools. Future research should examine program acceptance and its association with the digital tool preferences using utilization data gathered from each program and using more detailed assessments. This topic will be the subject of a later report after the ICRC study’s completion.

Conclusions

Taken together, data from this study suggest that integrating human support with digital tools is an acceptable and feasible way to engage and treat people with schizophrenia spectrum disorders after psychiatric hospitalization. Outcome and cost-effectiveness studies are needed in order to assess technology-facilitated approaches in mental health care.