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Table of Contents
Year : 2016  |  Volume : 3  |  Issue : 2  |  Page : 146-151

Implementation of integrated care pathways for persons with psychosis in Ontario, Canada: Barriers and opportunities

1 Associate Professor, Queens University, Kingston, Ontario, Canada
2 PGY 4, Queens University, Kingston, Ontario, Canada
3 PGY 1, Queens University, Kingston, Ontario, Canada
4 Consultant Psychiatrist & Director of Research, Southern Health NHS Foundation Trust, Southampton, England

Date of Web Publication6-Jul-2017

Correspondence Address:
Farooq Naeem
Associate Professor, Queens University, 385 Princess Street, Kingston, K7L 1B9, Ontario
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Source of Support: None, Conflict of Interest: None

DOI: 10.5530/ami.2016.2.29

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Currently there is an emphasis on developing Integrated Care pathways for mental health problems. The concept of pathways draws heavily from principles of lean thinking and is therefore based on improving the efficiency of the system to provide quality services to persons with health problems. Development of pathways for schizophrenia, along with depression and dementia is high priority in Ontario, Canada. This is an exciting development, especially as this might trigger radical changes in the health system to improve the care of those with schizophrenia. As the pathways are fully developed in England, we have tried to highlight the issues that can facilitate or hinder the development and implementation of the pathways in Ontario, compared with England. Development of pathways offers unique opportunities, that might lead to substantial improvement in care of persons with psychosis.

Keywords: Psychosis, Pathways, Integrated care, Schizophrenia, England, Canada

How to cite this article:
Naeem F, Asmer S, Munshi T, Wong J, Hasan T, Rathod S. Implementation of integrated care pathways for persons with psychosis in Ontario, Canada: Barriers and opportunities. Acta Med Int 2016;3:146-51

How to cite this URL:
Naeem F, Asmer S, Munshi T, Wong J, Hasan T, Rathod S. Implementation of integrated care pathways for persons with psychosis in Ontario, Canada: Barriers and opportunities. Acta Med Int [serial online] 2016 [cited 2023 Feb 8];3:146-51. Available from: https://www.actamedicainternational.com/text.asp?2016/3/2/146/209778

  Introduction Top

Numerous efforts have been made over the years to develop ways of providing high-quality care to persons with psychosis. The last two decades have witnessed an enormous interest and funding in Early Intervention in Psychosis (EIP) Teams (Anderson, Fuhrer, & Malla, 2010). The EIP teams were formed on the basis of research findings that prolonged duration of untreated psychosis (DUP) leads to poor outcomes (Drake, Haley, Akhtar, & Lewis, 2000). The main aim of early intervention teams is to improve access to treatment at the first episode of psychosis in order to improve the overall prognosis. Although these teams are routinely provided in most countries in the developed world for the engagement and treatment of the first-episode psychosis, there is no evidence that they have reduced DUP. It is not understood why this might be the case (Birchwood et al., 2013). Therefore, it is not surprising that people with schizophrenia and other psychoses continue to die earlier than their peers due to physical and mental health problems (Reininghaus et al., 2015).

With time, it has become evident that a more comprehensive approach and a long term strategy is required to improve the care of those with psychosis. This simply means providing care throughout the journey of a person's psychosis, that is recovery focussed, comprehensive, targeted and evidence based. Not surprisingly, there is currently an emphasis on developing and testing Integrated Care Pathways (ICPs) in health that provide seamless care. These pathways map the journey of a person with psychosis through the mental health care system. Evidence-based quality standards and criteria are then pinned to these pathways, that are delivered throughout the journey of the person through the clinical pathways. The bearing of a care pathway is to raise the caliber of care across the continuum by improving risk-adjusted patient outcomes, promoting patient safety, increasing patient satisfaction, and optimizing the economic consumption of resources(Vanhaecht et al., 2006).

Integrated Care Pathways (ICPs) are important because they improve the quality of care and serve to reduce unnecessary variations in patient care and outcomes. They underpin the evolution of care partnerships and empower persons with psychosis and their carers. The ICPs can also be used as a tool to implement and incorporate local and national guidelines into everyday practice, manage clinical risk and meet the requirements of clinical governance. When designing and introducing ICPs, it is important to incorporate them into organizational strategy and choose appropriate topics which will furnish opportunities for betterment (Middleston & Roberts, 2001).

  Pathways to Clinical Care Top

What is an Integrated Care Pathway?

According to the European Pathways Association (EPA) (http://e-p-a.org), “a care pathway is a complex intervention for the mutual decision making and organization of care processes for a well-defined group of persons with psychosis during a well-defined period. The aim of a care pathway is to enhance the quality of care across the continuum by improving risk-adjusted patient outcomes, promoting patient safety, increasing patient satisfaction, and optimizing the use of resources”. The EPA further defines the characteristics of Integrated Care Pathways as;

  1. A clear description of the main goals and key components of care based on evidence, best practice, and expectations of those with psychosis, and their features
  2. A strategy to facilitate the communication among the team members and with persons with psychosis and families
  3. There must be a visible strategy to coordinate the care process by coordinating the roles Of different stakeholders, and sequencing their activities
  4. An emphasis on clear documentation, monitoring, and most importantly evaluation of variances and outcomes
  5. The identification (and designation) of the appropriate resources.

Historical Perspectives & Scientific Background

The concept of an integrated care pathway is derived from the field of Health Operations Management (Health OM). It has been described as “the analysis, design, planning and control of all the steps necessary to provide a service to a client” (Vissers & Beech, 2005). The idea of the ICPs was also influenced by the concept of Business Process Redesign (BPR) (Davenport & Short, 1990). The BPR defines a production process or business process as, “ the logic, organization of people, materials, energy, equipment and procedures into work activities designed to produce a specified end result”. Further refinements to these ideas come from the Lean Thinking in Health Care, which emphasize the concept of quality improvement and waste reduction, through process mapping, refinement and constant improvement (Joosten, Bongers, & Janssen, 2009).

Integrated Care Pathways for Psychosis in the UK

The National Institute for Health and Care Excellence (NICE) (www.nice.org.uk) in England, has developed evidence-based clinical guidelines and clinical pathways that have set the quality standards and the criteria for care in psychosis. The NICE quality standards are a “concise sets of prioritized statements designed to drive measurable quality improvements within a particular area of health or care. They are derived from the best available evidence such as NICE guidance and other evidence sources accredited by NICE” (http://www.nice.org.uk/standards-and-indicators). The Clinical pathways are implemented throughout the National Health Service (NHS) in the UK and serve as a tool to deliver the interventions suggested by the clinical guidelines, against the quality standards and the criteria. A comprehensive network of organizations at the national and the local level support these tasks. Most notably, the clinical governance units in hospitals play a vital role in implementing criteria that are set nationally. However, the clinical pathways and guidelines described by NICE do not prescribe timeframes around access and interventions. This leaves the criteria in the pathways open to interpretation creating potential for variation in care.

For the first time in mental health, ICPs for psychosis have been developed in the UK that prescribe time frames around access and interventions and are being evaluated. (Rathod, Griffiths, Kingdon, Tiplady, & Jones, 2015). The pathway, TRIumPH: Treatment and Recovery In PsycHosis, prescribes time frames around clinical interventions and service delivery and aims to reduce the impact of disease and promote recovery by ensuring that every individual gets the best evidenced based care at the right time and in the right place. The evaluation of these pathways will help us in better understanding the DUP, tackle the barriers in the delivery of care, and help in the reduction in variation in care. Further information can be obtained from: http://wessexahsn.org.uk/projects/59/triumph-treatment-and-recovery-in-psychosis

In developing these pathways, a multi-pronged approach has been used, using i) research and data, ii) co-production with individuals and carers, and iii) engagement with clinicians and other stakeholders including commissioners, primary care, and third sector organizations. In developing an understanding of the key issues and local need, the organizers gathered individual, carer, and wider stakeholder feedback through a series of co-production workshops. This allowed individuals to describe and document important experiences, both positive and negative, in relation to the care they had previously received. The approach has used a robust methodology and the pathways are compliant with NICE guidelines. [Figure 1], shows a typical routine referral pathways for psychosis Printed with permission from the psychosis pathway steering group and Wessex AHSN.
Figure 1: Routine referral pathways for psychosis

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How are the Triumph Pathways being Evaluated?

The evaluation is performed using a mixed methods approach. It consists of both data collection for quantitative analysis of different parts of the pathways, as well as qualitative interviews and focus groups with staff, persons with psychosis and their carers.

The qualitative work is done in order to assess feasibility and acceptability of the pathway to persons with psychosis, carers and staff, and to explore the barriers to implementation with staff. Satisfaction with the pathways and wellbeing survey can be conducted as semi-structured interviews or surveys. Quantitative outcome measures include; process implementation outcomes (e.g., time to access and interventions, physical health monitoring), service outcomes (e.g., admissions, length of stay etc), and social and performance outcomes (e.g., support for vocation and employment.)

Advantages and Disadvantages of Pathways

Understandably the concept has gathered a lot of attention. There are both advantages and disadvantages in implementing clinical Integrated Care Pathways. Schrijvers et al (2012) have discussed these in details (Schrijvers, van Hoorn, & Huiskes, 2012). It has been suggested that the Integrated Care Pathways have the following advantages;

  1. An improvement in quality of care in persons with psychosis leading to better outcomes and more patient and carer satisfaction
  2. The pathways can be used to implement evidence-based guidelines
  3. The use of time frame can have an overall impact on the DUP
  4. They can be an effective tool in cost reduction through the delivery of explicit standards that can be evaluated
  5. A multi-disciplinary approach allows for better co-ordination and collaboration among parts of the system
  6. A reduction in the risk of errors through systematically delivering care
  7. Finally, improved outcomes and involvement of clinicians and frontline workers can lead to increased job satisfaction

However, pathways have been criticised for potential pitfalls and problems. These include;

  1. Less flexibility in delivery of care, and therefore less potential for creativity and individualized services
  2. Providing fixed interventions at fixed points might mean a less research friendly environment
  3. The pathways might lead to an increase in cost secondary to data collection, increased awareness and expectations of persons with psychosis and their carers

  Implementation of Psychosis Pathways in Ontario, Canada Top

Currently there is an emphasis on developing Integrated Care Pathways for those with mental health problems in Ontario, Canada. Among the mental health problems, the focus is on schizophrenia, major depression and dementia. In order to guide optimal care, strong, measurable quality statements have been published. Every quality standard will be accompanied by a plain language summary for persons with health problems and caregivers. These guidelines will become part of broader Quality Based Procedures (QBPs) which are implemented at a provincial level. The Ontario Ministry of Health helps supports adoption of QBPs by providing a core set of tools and supports which can be used by care providers to help measure and improve specific quality markers indicated by the guidelines (MOHLTC, 2016).

Implementation of Integrated Care Pathways for Psychosis in Ontario, Canada: Barriers and opportunities

Based on our discussions with colleagues in Canada and in the UK, and attendance at the local conferences on pathway development in Ontario, we believe that the psychosis pathways and quality standards are mostly derived from the NICE, UK. Three of the authors received their training and worked in the UK, and we therefore are in a position to compare the British health system with the health system in Ontario, Canada. We would like to highlight the following barriers in developing and implementing clinical Integrated Care Pathways in Ontario, Canada.

System Issues

  1. Unlike NHS in UK, the health care delivery mechanisms in Ontario are diverse. This means not just different timelines are being followed, but different guidelines are being implemented. There are no nationally agreed guidelines on a multifaceted approach to a pathways system of healthcare delivery to patients suffering from psychosis. The guidelines that are available for schizophrenia do not allow the reader to comfortably navigate. Some organizations are using NICE while a few are using the US guidelines. This understandably means following a different set of quality standards and criteria.
  2. Pathways are being developed locally. This probably means there are less chances of equality across the province. As different pathways might have a different focus, derived through different quality standards and criteria. A related issue is that pathways are being developed in bigger cities, and they might not be applicable to smaller cities or hospitals in the periphery.
  3. Patient organizations in Canada are not as prominent as they are in the UK. These organizations can help in bringing about positive changes in the health system through lobbying for patients' rights.
  4. Currently the focus of the health system is hospital and inpatient care, not community based. While assertive outreach teams exist, case management is not reasonably funded, and shared care is at its initial stages of development. The pathways are community-based and case management oriented, thus heavily reliant on effective collaboration with primary care physicians.
  5. In terms of infrastructure, the major difference is the lack of a local agent, that can implement and evaluate the pathways. The clinical governance units have played a vital role in the implementation of evidence based guidelines and in delivering quality standards in the UK. These units work closely with the national organizations that conduct clinical audits to ensure compliance.

Clinical Issues

  1. Currently the psychiatrists are paid through a variety of means. A significant number of psychiatrists are on fee for funding services. The way a physician is paid might have some influence over delivery of care. This can influence how pathways are developed, implemented, and evaluated.
  2. The Mental Health Act, Ontario plays a vital role in the care of the persons with psychosis, especially in the community. The mental health law in Canada offers more flexibility, and though this varies provincially, and is less likely to force implementation of care and in some cases modern intervention, and therefore care in the community part of the pathway might be jeopardized.
  3. There is a serious lack of psychological services in the public sector. It is possible that the pathways in Ontario will become a tool for implementing medicine protocols rather than delivery of care using a bio-psycho-social model. The Cognitive Behaviour Therapy for psychosis is a rare commodity, family therapy is hardly available, and Cognitive Remediation is limited to the labs.

On the other hand, the implementation of pathways also offers certain opportunities. These include;

  1. The clinical pathways provide opportunities to streamline processes, people, and parts of the system together, and develop a coherent system of care. This is highly likely to strengthen, organize and bring order to the system of mental health care delivery.
  2. The major benefit of the clinical pathways might be an improvement in the overall level of care, through the delivery of evidence-based, time-framed and patient focused services. We hope that this will also lead to the strengthening of patient and carer organizations.
  3. This also provides opportunities to highlight areas through clinical audits and feedback that can be improved. This can have serious implications in improving care in the community, including the overall emotional and physical well being of the persons with psychosis and community mental health services.
  4. This initiative will offer cost savings that can be used to invest in other areas or areas of need.

  The Way Forward Top

Development of clinical pathways and their evaluation will offer many opportunities in service development and in improving quality of care. There are also some barriers and issues that need to be addressed. The following can be considered for smooth introduction and implementation of pathways;

  1. The first step should be to select evidence-based guidelines and quality standards at a provincial level. These can be slightly modified for local implementation. This will help reduce inequalities in service provision in different parts of Ontario.
  2. Development of clinical pathways cannot improve the health of persons with psychosis, until and unless they are used to deliver evidence based care within a fixed time frame. In order to do this, a system of implementation is required. This can be easily achieved by further strengthening and by adding resources to the current quality improvement committees. Small clinical governance units in hospitals that report to the quality committees and to a provincial level body can be the way forward. Future cost reductions can be a good incentive for this investment.
  3. The process of pathways development and implementation should include persons with psychosis and their carers, both at the provincial and the local level.
  4. Psycho-social interventions for persons with psychosis is the weakest link in possible pathways and this should be strengthened. This can be easily achieved by following the current model of delivery of Low intensity CBT through the IAPT (Improving Access to Psychological Therapies) services in the UK, that are currently delivering low intensity CBT for psychosis.

  Conclusions Top

Applying Integrated Care Pathways in health services may lead to advantages and disadvantages for persons with psychosis and health professionals. For managers and policy-makers this implies that their effort should be focused on maximizing the advantages and minimizing the disadvantages. For researchers this implies that they use the right definitions to describe care pathway within a context of integrated care, disease management and health care innovation. The list of advantages and disadvantages of Integrated Care Pathways in this paper could be used as a checklist in empirical evaluation studies.

  References Top

MOHLTC. (2016, January 31). Quality-Based Procedures. Retrieved January 31, 2016, from http://www.health.gov.on.ca/en/pro/ programs/ecfa/funding/hs_funding_qbp.aspx  Back to cited text no. 1
Anderson, K. K., Fuhrer, R., & Malla, A. K. (2010). The pathways to mental health care of first-episode psychosis patients: a systematic review. Psychological Medicine, 40(10), 1585–1597. http://doi.org/10.1017/S0033291710000371  Back to cited text no. 2
Birchwood, M., Connor, C., Lester, H., Patterson, P., Freemantle, N., Marshall, M., Singh, S. P. (2013). Reducing duration of untreated psychosis: care pathways to early intervention in psychosis services. The British Journal of Psychiatry, 203(1), 58–64. http://doi.org/10.1192/bjp.bp.112.125500  Back to cited text no. 3
Davenport, T. H., & Short, J. E. (1990). The new industrial engineering: information technology and business process redesign (Working Paper). Cambridge, Mass: Center for Information Systems Research, Sloan School of Management, Massachusetts Institute of Technology. Retrieved from http://dspace.mit.edu/handle/1721.1/48613  Back to cited text no. 4
Drake, R. J., Haley, C. J., Akhtar, S., & Lewis, S. W. (2000). Causes and consequences of duration of untreated psychosis in schizophrenia. The British Journal of Psychiatry, 177(6), 511-515. http://doi.org/10.1192/bjp.177.6.511  Back to cited text no. 5
Joosten, T., Bongers, I., & Janssen, R. (2009). Application of lean thinking to health care: issues and observations. International Journal for Quality in Health Care, 21(5), 341-347. http://doi.org/10.1093/intqhc/mzp036  Back to cited text no. 6
Middleston, S., & Roberts, A. (2001). Integrated Care Pathways. Retrieved January 17, 2016, from https://www.elsevier.com/books/integrated-care-pathways/middleton/978-0-7506-4087-9  Back to cited text no. 7
Rathod, S., Griffiths, A., Kingdon, D., Tiplady, B., & Jones, T. (2015). Pathways to recovery: A case for adoption of systematic pathways in psychosis. Imperial College Health Partners. Retrieved from http://imperialcollegehealthpartners.com/wp-content/uploads/2015/06/Pathways-to-recovery-ICHP-and-Wessex.pdf  Back to cited text no. 8
Reininghaus, U., Dutta, R., Dazzan, P., Doody, G. A., Fearon, P., Lappin, J., Jones, P. B. (2015). Mortality in schizophrenia and other psychoses: a 10-year follow-up of the ESOP first-episode cohort. Schizophrenia Bulletin, 41 (3), 664–673. http://doi.org/10.1093/schbul/sbu138  Back to cited text no. 9
Schrijvers, G., van Hoorn, A., & Huiskes, N. (2012). The Care Pathway Concept: concepts and theories: an introduction. International Journal of Integrated Care, 12(6). Retrieved from http://www.ijic.org/index.php/ijic/article/view/URN%3ANBN%3ANL%3AUI%3A10-1-113788  Back to cited text no. 10
Vanhaecht, K., Bollmann, M., Bower, K., Gallagher, C., Gardini, A., Guezo, J., Panella, M. (2006). Prevalence and use of clinical pathways in 23 countries–an international survey by the European Pathway Association. Journal of Integrated Pathways, 10(1), 28–34. http://doi.org/10.1258Zj.jicp.2006.124  Back to cited text no. 11
sVissers, J., & Beech, R. (2005). Health Operations Management: Patient Flow Logistics in Health Care. Routledge.  Back to cited text no. 12


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