Reports From the Field

Reducing Lost-to-Follow-Up Rates in Patients Discharged from an Early Psychosis Intervention Program



The relapse signature card was used every 2 months in the last 6 months during the period that the improvement project was ongoing. As it was found effective, now we use it every 6 months until 30 months and then every 2 months until conclusion of the 3-year program.

In addition, an appreciation card (Figure 2) was designed that is given to patients who keep their first downstream appointment. The card highlights independence and responsibility for one’s own care.

3. Provide a designated contact person

To ensure a smooth transition to the new service, we provided a designated person to contact for continuity care. Arrangement was made to transfer care to a specific community team of specific doctors and case managers, and their hospital contact details were provided on a card that was given to patients. Of the 8 patients who were transferred, 1 defaulted, 1 went overseas, 1 followed up with a private psychiatrist and the remaining 5 came for their first visit appointments.


We created run charts to monitor the long-term effectiveness of the interventions. After each of the interventions, there were some fluctuations in the default rate. However, once all 3 interventions were implemented 1 December 2012, there was a decrease in the default rate of patients and the target rate of 0% was achieved within 2 months. A total of 131 patients were transferred from 1 December 2012 to 1 May 2015. Two patients defaulted in the first 2 months after all the interventions were instituted, resulting in a default rate of 1.52%, compared with the pre-intervention rate of 25% (Figure 3). We continued to monitor the default rates until 1 May 2015 and maintained our 0% default rate (data not


Figure 3. Run chart showing percentage of patients who failed to attend their first appointment with continuity care following transfer out of the program. Pre-intervention, default rates ranged from 9% to 75%. In the first 2 months after all the interventions were instituted (Dec 1 2012–March 1 2013), 2 patients defaulted, after which the default rate decreased to 0%.


Making 3 small changes in our early psychosis intervention program led to rewarding gains in improving our patients’ follow-up with continuity care and the changes have become part of our standard operating procedure. In reviewing our processes to identify the root causes for loss of patients to follow-up, we found that obtaining the patient’s perspective was invaluable. It was interesting to learn that the word “discharge” might be impacting the way patients thought about follow-up after completion of the early intervention program. The interventions have become part of our standard operating procedure and we continue to audit the results every month to ensure that 0% default is being maintained. We are also looking into improving out psychoeducational materials for patients and caregivers and using more visual and interactive materials.

Corresponding author: Basu Sutapa, MD, Institute of Mental Health, Buangkok Green Medical Park, 10 Buangkok View, Singapore, S539747,

Financial disclosures: None.

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