Will Electronic Healthcare Records Promote the Use of Advance Directives?

NYAPRS Note: The following study looks at the impact of the use in England of Joint Crisis Plans, which are defined as “a collaborative effort negotiated by the client and the mental health staff to ensure that a client’s preferences are carried out in times of psychological crisis.” It’s unclear whether the  JCPs have the legal impact of psychiatric advance directives used in the US.

In any case, the study suggests that its inability to find improved outcomes from the use of JCPs may well be attributable to the lack of sufficient valuing and follow up of discharge plans negotiated with people leaving hospital.

While advance directives are included in patient records in the US when they are completed, it seems that they are not known to many providers and play a negligible role in how care is delivered.

Electronic healthcare records are central to the implementation of national and state healthcare reform initiatives: the goal is to share access to people’s records and service plans to all approved providers to encourage good coordination and outcomes.

The question will be: will EHRs visibly highlight the presence and encourage the use of advance directives, which are designed to guide providers to give people the care they believe will most help them and be most effective during times of greatest difficulty.


Patient Preferences Largely Overlooked During Psychological Crisis

by Jen Wilson, GoodTherapy.org Correspondent   September 2nd, 2013


When a person is discharged from a psychiatric inpatient facility, the hope is that he or she will receive the necessary outpatient mental health care to avoid future hospitalization. In England, many procedures are in place to assist with this goal, including the Care Programme Approach (CPA), which provides a plan for outpatient mental health care, social services, care workers, and reviews. However, high rates of readmission still occur.


To address this issue, England recently implemented a Joint Crisis Plan (JCP) which is a collaborative effort negotiated by the client and the mental health staff to ensure that a client’s preferences are carried out in times of psychological crisis. The JCP is aimed at preserving the wishes of client when they are unable to make healthcare determinations for themselves. In this regard, a JCP may provide a window of opportunity to address serious mental challenges before they progress to a point of crisis and hospitalization.


To determine if this collaborative approach results in better readmission outcomes among the seriously mentally ill than CPA alone, Professor Graham Thornicroft, PhD, of the Health Service and Population Research Department of the Institute of Psychiatry at King’s College in London recently enrolled 569 participants who had been inpatients at mental health facilities in the previous 24 months. Half of the participants received CPA alone while the other half received JCP and CPA. Outcomes were measured based on future admission, therapeutic relationship, and overall well-being. Thornicroft discovered that although the therapeutic relationships were stronger for the JCP participants, readmission rates were similar in both groups.


The lack of reduced readmission rates was discouraging and could be the result of several factors. First, participants reported that their wishes were not carried out when they reached a crisis point. Second, they did not have dedicated JCP meetings with staff and healthcare workers, but rather had brief JCP discussions during the course of CPA meetings. Further, many times, key mental health workers were absent from JCP meetings and overall, the mental health professionals did not see JCP as specialized but merely as an obligatory adjunct to the CPA.


Finally, “Qualitative analysis found that although some patients had a positive experience of JCP, many described how clinical services struggled to put it into practice,” added Thornicroft. In sum, the results of this study show that the JCPs have the potential to help reduce readmission rates and benefit mental health clients, but their significance must be emphasized and their stipulations more stringently adhered to in order to provide the maximum benefit possible to the client.


Thornicroft, Graham, et al. (2013). Clinical outcomes of joint crisis plans to reduce compulsory treatment for people with psychosis: A randomised controlled trial. The Lancet 381.9878 (2013): 1634-41. ProQuest. Web