Implementation of Psychosis Risk Documentation in Adolescent Behavioral Health Referrals
Julia A. Plumb, BS (a), Kelsey A. Johnson, MPH (b), Kristen A. Woodberry, MSW, PhD (c,d), & Lydia A. Shrier, MD, MPH (a,e)
a. Division of Adolescent/Young Adult Medicine, Boston Children’s Hospital, Boston, MA
b. Massachusetts Psychosis Network for Early Treatment (MAPNET), Beth Israel Deaconess Medical Center, Boston, MA
c. Maine Health Institute of Research, Portland, ME
d. Department of Psychiatry, Tufts University School of Medicine, Boston, MA
e. Department of Pediatrics, Harvard Medical School, Boston, MA
Abstract
Background: Early detection of and intervention in psychosis is associated with improved outcomes for patients with serious mental illness. Routine screening in adolescent/young adult primary care may help to identify psychotic symptoms earlier than current strategies relying on clinician initiative. The present study evaluated the utility of adding psychosis screening items to a behavioral health consult documentation template.
Methods: Psychosis screening items were added to a standardized electronic medical record template used by behavioral health clinicians for same-day consults in an adolescent/young adult medical clinic. Items addressed observation or disclosure of hallucinations, delusions, and family history of psychosis, and whether symptom presence was elicited by direct provider inquiry about psychosis. We conducted a retrospective chart review of consults from November 2019 – November 2020, and summarized completion and endorsement of the psychosis screening items with descriptive statistics.
Results: Data were collected from 418 behavioral health consults, representing 313 patients (78% female; mean age 19.2). Roughly one in four consults (28%; n=116) included any responses to psychosis items; 72% (n=302) had no documentation. Of the 116 consults with documentation, 22% (n=26) were fully completed. Direct provider inquiry about psychosis was reported in 51% (n=59) of consults with psychosis risk documentation. Among consults that reported direct provider inquiry, 20% (n=12) indicated at least one psychosis risk factor, representing 10 unique patients. For three (33%) patients, this was an initial identification of psychosis risk.
Conclusions: Despite inclusion of psychosis screening items on the consult template, most behavioral health consults did not include medical record documentation of psychosis risk assessment. Documentation of direct clinician inquiry into psychosis risk was associated with identification of previously unidentified psychosis risk factors. Additional systematic efforts, including feedback on documentation, are needed to increase psychosis risk screening and early detection during behavioral health consults in adolescent/young adult primary care.