First Episode Psychosis Fidelity Scale (FEPS-FS) · 4 . General Guidelines . Background . The First Episode Psychosis Services Fidelity Scale (FEPS-FS) assesses the degree to which

First Episode Psychosis Fidelity Scale (FEPS-FS)

Review Manual © Dr. D. Addington

Version 5 (January 15, 2018)

Contents Contents General Guidelines ........................................................................................................................................ 4

Background ............................................................................................................................................... 4

The First Episode Psychosis Service Fidelity Scale (FEPS-FS) .................................................................... 4

FEPS-FS Manual ......................................................................................................................................... 4

Overview of the Scale ............................................................................................................................... 4

Training Fidelity Assessors ........................................................................................................................ 5

The Process used for Fidelity Assessments ............................................................................................... 5

Preparing for a Fidelity Site Visit ............................................................................................................... 5

Data Collection .......................................................................................................................................... 6

Confidentiality and Data Storage .............................................................................................................. 8

How to Rate Items and Triangulate Across Data Sources ......................................................................... 9

After Your Fidelity Site Visit ...................................................................................................................... 9

Component Criteria and Ratings ................................................................................................................. 10

1. Timely Contact with Referred Individual .................................................................................... 10

2. Client and Family Involvement in Assessments .......................................................................... 11

3. Comprehensive Clinical Assessment at Enrollment .................................................................... 11

4. Psychosocial Needs Assessed for Care Plan ................................................................................ 12

5. Individualized Clinical Treatment Plan after initial assessment .................................................. 13

6. Antipsychotic Medication Prescription ....................................................................................... 13

7. Antipsychotic Dosing Within Recommendations ........................................................................ 14

8. Guided Antipsychotic Dose Reduction ........................................................................................ 14

9. Clozapine for Medication Resistant Symptoms .......................................................................... 15

10. Client Psychoeducation ............................................................................................................... 15

11. Family Psychoeducation.............................................................................................................. 16

12. Individual Cognitive Behavior Therapy for Treatment Resistant Positive Symptoms or for Residual Anxiety or Depression ..................................................................................................... 17

13. Individual and / or Group Interventions to Prevent Weight Gain: ............................................. 18

14. Annual Formal Comprehensive Assessment ............................................................................... 18

15. Assigned Psychiatrist ................................................................................................................... 19

16. Assignment of Case Manager ..................................................................................................... 20

17. Motivational Enhancement (ME) or Cognitive Behavioral Therapy (CBT) for Co-Morbid Substance Use Disorder (SUD) ........................................................................................................................ 20

18. Supported Employment .............................................................................................................. 21

First Episode Psychosis Services Fidelity Scale © (FEPS-FS-1.0) Fidelity Review Manual

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19. Active Engagement and Retention ............................................................................................. 21

20. Community Living Skills ............................................................................................................... 22

21. Crisis Intervention Services ......................................................................................................... 22

22. Participant/Provider Ratio .......................................................................................................... 23

23. Practicing Team Leader ............................................................................................................... 23

24. Psychiatrist Role on Team ........................................................................................................... 24

25. Multidisciplinary Team ................................................................................................................ 24

26. Duration of First Episode Psychosis (FEP) Program services provided to client ......................... 25

27. Weekly Multi-Disciplinary Team Meetings ................................................................................. 26

28. Targeted Health/Social Service/Community Groups (public education) .................................... 26

29. Communication Protocol between Inpatients, Clients, Unit and FIRST EPISODE PSYCHOSIS Service ............................................................................................................................................ 27

30. Explicit Admission Criteria .......................................................................................................... 27

31. Population Served ....................................................................................................................... 28

Appendix A: Preparing for a Fidelity Visit .................................................................................................. 29

Appendix B: Client Record Data Extraction Template ............................................................................... 34

Appendix C: Client interview Guide 38 Appendix D: Family Interview Guide .......................................................................................................... 43

Appendix E: Staff Interview Guide ............................................................................................................. 47

Appendix F: Meeting Observation Guide 63 Appendix G: Final Report Template 64 Appendix I: Medication Dosing Guidelines ................................................................................................ 77


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General Guidelines Background The First Episode Psychosis Services Fidelity Scale (FEPS-FS) assesses the degree to which programs deliver evidence-based practices. Program fidelity refers to the extent to which delivery of an intervention adheres to the protocol of an evidence-based program model. Fidelity scales provide a list of objective criteria by which a program is judged to adhere to a reference standard for the intervention. For further information on the use of the scale, the manual or training please contact Dr. Donald Addington at [email protected] The First Episode Psychosis Service Fidelity Scale (FEPS-FS) The FEPS-FS is a scale designed to assess the degree to which a program delivers evidence-based services. It comprises 31 components and a rating guide for each component. The scale was developed using formal knowledge synthesis processes, including systematic reviews, international expert consensus and pilot testing in two countries. The scale is designed to assess fidelity across differing health systems and different program models. This is achieved first by focusing on the services identified from research as essential and second by a focus on the services received by the client. It is not designed to be a substitute for more detailed operating guidelines developed by country specific or health system specific health systems. (Addington DE et al Psychiatric Services 2013; May 1; 64(5): 452-7. Addington DE et al Psychiatric Services 2016 Sep 1; 67(9):1023-5.) FEPS-FS Manual The FEPS-FS review manual provides a guide for scoring the FEPS-FS. The aim is to increase reliability (consistency) of ratings across different assessors. The manual provides the following:

• A definition and rationale for each component in the Fidelity scale • A list of data sources to inform the ratings for each component • Decision rules that will help score each component correctly • Site visit data collecting tools:

o interview guides o health record abstraction guide o Team meeting observation guide

• Final report template • Site fidelity visit preparation guide

Overview of the Scale The FEPS-FS contains 31 items. Each item on the scale is rated on a 5-point scale ranging from 1 ("Not implemented") to 5 ("Fully implemented"). The standards used for establishing the anchors for the "fully-implemented" ratings were determined through a variety of expert sources. At this point the scale has been tested for feasibility and reliability in 6 programs, 4 in the US and two in Canada. The scale

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assesses both the services received by program clients and how the team works together to engage and retain clients and deliver coordinated evidence-based care. Services Delivered and Staff Roles Staffing patterns, professional designations and individual roles vary significantly from one organization to another and across health care jurisdictions and countries. To address this, the FEPS-FS ratings are dependent on the services received by the clients, rather than professional designation of the person who delivers the service. In practice, assessors need to adapt questions to fit with the staffing pattern of the program being reviewed. For example, CBT, might be delivered by a psychologist or a trained counsellor who is a social worker by profession. Case management may be provided by a mental health professional who is called a case manager or care coordinator or by someone called a counsellor or recovery coach, who may have additional roles such as CBT therapy or individual resiliency training. Training Fidelity Assessors The fidelity assessments should be conducted by trained assessors. Training usually includes a two-day training program followed by a monitored site visit and at least two teleconferences to review ratings of consensus ratings of at least. The raters need to be trained and familiar with the scale and the rating manual. The Process used for Fidelity Assessments The fidelity assessment is based on information derived from several sources. The final evaluation is decided by the fidelity assessor or assessment team and is based on the best available information from all sources. Ratings are easier when multiple sources of information support the same rating. Sources of information include:

• Administrative data such as annual admissions and discharges, staffing information such as the staff Full Time Equivalents spent with first episode psychosis clients and job descriptions. Admission and discharge criteria, population served, program brochures, client and family information materials, curricula for groups such as family or client psychoeducation.

• Health Records. Several items can be best rated based upon a random selection of 10 health records. This information is most relevant for clinical information that applies to all individual served by the program. For example, items covered in assessments and dosage of medications.

• Individual site assessment. This can be done either through a site visit with in person interviews or by telephone interviews.

Preparing for a Fidelity Site Visit The fidelity assessment visit consists of a one or two day in-person visit. Fidelity visits require advanced preparation by all the participants to ensure that the assessors have time to meet with different program stakeholders and receive the information they need to make the ratings. Role for the assessors:

• Review the fidelity manual, scale, and data collection tools in advance of the site visit • Review any documents sent by the site in advance (see data source #1 below for more detail).


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• Complete relevant training on ethical evaluation practices and privacy regulations relevant for the specific program being evaluated and research regulations if the evaluation is part of a formal research study.

• Communicate with the central coordinating unit to schedule the assessment date and organize logistics (hotel, travel etc.).

• Ensure all necessary paperwork related to privacy/ confidentiality is completed (requirements will vary from program to program).

• Note: It is helpful for the assessors to meet in advance of the site assessment to introduce themselves, discuss initial impressions from advanced materials and confirm roles/approach for site visit. This can be done by phone or in person immediately before the site visit.

Role for the program:

• Create schedule for site visit, line up client, family and staff interviews, pull client health records and send assessors any important documents/reports (See Appendix A: Preparing for a Fidelity Visit- for full instructions for the site).

• Ensure all necessary internal approvals (administrative, ethics) are in place and required paperwork has been completed by the assessors.

• Communicate with the central team to schedule the assessment date. Role for central team:

• Liaise with the site and the assessors to organize and schedule the site visits. • Support ethics processes.

The most successful fidelity assessments are those in which there is a shared goal among the assessors and the program site to understand how the program is progressing and delivering evidence-based practices. Data Collection The assessor team will need to review 5 different data sources (see below). Some can be reviewed in advance, but most will be reviewed during the site visit. A schedule for the site visit will be prepared in advance by the site to ensure the days run smoothly (see Appendix A: Preparing for a Fidelity Visit). The data collection tools (all can be found in the appendices), can either be printed and completed by hand on site or the assessors can bring a password protected laptop and complete the tools electronically.

1. Existing documents and administrative data To minimize the burden of the in-person visit, documents including administrative data including: • Staff titles and full time equivalent of their commitment to the first episode psychosis

program. • Numbers of annual admissions, discharges and current program case load. • Percentage of new clients seen for in person visit within two weeks of referral. • Number of educational/ promotional presentations to community services in last year. • Admission criteria including diagnostic inclusion and exclusion criteria. • Service catchment area boundaries if applicable. • Population in the catchment area.


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• The proportion of all client remaining in the program two years after they are admitted. • The number of current clients on clozapine. Details can be found in Appendix A: Preparing for a Fidelity Visit. These documents can be reviewed before the site visit if possible or provided and reviewed during the site visit. NOTE: Only aggregate, de-identified data should be shared in advance.

2. Review of 10 client health records

The health record review will require approximately 3 hours. The central team will work with each site to develop a randomization process to select the records for review. More detail on selecting client records can be found in Appendix A: Preparing for a Fidelity Visit. A staff member must present to orient assessors to the health record and answer any questions that may arise. Any program requirements to support privacy or access from both an ethical and logistical perspective should also be confirmed ahead of time. The Client Record Data Extraction Template (Appendix B) can be used to extract the relevant data from the client records. After the first 1-2 health records are done as a group, health records may be divided among the assessors for efficiency, though ongoing communication is needed to ensure consistency across the assessors.

3. Interviews with clients and families

The programs will recruit clients and families in advance to meet with the assessors (ideally 2-3 clients and 2-3 family members). It is the responsibility of the assessors to ensure that when it is a research project, appropriate informed consent is received at the beginning of each interview. Depending on what works best logistically, clients and families can provide feedback in individual interviews or as a group. Typically, a group format works best if clients are already familiar with each other and used to meeting in a group setting. Unless specifically requested by the clients, program staff should not be in the room during the client interviews. See Appendix C and D for the Client and Family Interview Guides. Detailed notes should be kept during the interviews to support the final fidelity ratings; no audio or video recording devices will be used. A recommended strategy is to assign one assessor to ask questions and another to take notes.

NOTE: No identifying information (e.g., names of staff, clients or families) should be included in assessor notes. Notes also should not include any comments on individual work performance.

4. Interviews with staff

A range of program staff should be interviewed during the fidelity assessment. At all programs, it will be important to interview the program manager, 1-2 case managers/case coordinators, and the psychiatrist. Depending on the team composition it may be helpful to also interview a nurse, social worker, family worker, or any other specialized staff who provide client care. These interviews will be organized in advance by the program. Interviews should be conducted individually unless more than one staff member in a role is being interviewed. People in positions of authority such as the manager or director should always be interviewed separately.


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The specific configuration of meetings with staff will depend on the team composition and functions. See Appendix E for the Staff Interview Guide. We have provided a single interview guide and suggested selected questions suggested for individual staff. An assessor may develop separate interview documents for each staff interview tailored to the specific role of staff in each program. It is recommended that the interview with the site lead should be done at the beginning of the day to clarify the roles of each staff member who will be interviewed and to determine which questions make sense to ask them. The whole interview guide does not need to be used for each interview.

It is the responsibility of the assessors to ensure informed consent is received at the beginning of each interview when the scale is being used for a formal research study. Detailed notes should be kept during the interviews to support the final fidelity ratings. NOTE: No identifying information (e.g., names of staff, clients or families) should be included in assessor notes. Notes also should not include any comments on individual work performance.

5. Team meeting observation

A team meeting should be observed to better understand team dynamics and multi-disciplinary involvement in client care. Assessors do not need to attend the full meeting, approximately 30 minutes should be sufficient. See Appendix G for a Meeting Observation Guide. It is the responsibility of the assessors to collect any necessary consent at the beginning of the meeting. If anyone does not feel comfortable consenting, then the meeting observation cannot take place. The site may opt to use client first names only during the meeting to help protect confidentiality. NOTE: No identifying information (e.g., names of staff, clients or families) should be included in assessor notes. Notes also should not include any comments on individual work performance.

Confidentiality and Data Storage It is important to ensure that proper confidentiality protocols are in place for each site visit and that any data collected is stored in an appropriate manner. Prior to, or at the beginning of the site visit, all assessors must sign the necessary confidentiality forms. These vary depending on the Data collected during the site visit and will include: notes from the client, family and staff interviews, notes from the staff meeting, and the completed Client Record Data Extraction Template as well as any documents or reports shared by the site. The information collected should not include any names or references to individual clients, family members or staff or personal health information. No client records or identifiable information should leave the site. The information will be kept in a secure location by the assessor (locked cabinet/office if on paper or in a password protected file if electronic) until the final fidelity report has been produced. The assessors should then follow appropriate protocols for destroying or retaining data depending on the nature of the evaluation.


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How to Rate Items and Triangulate Across Data Sources It is the task of the assessors to review and synthesize all data collected to determine the score for each item on the scale and complete the final report. How to rate items:

• Ratings should be made based on the scale as it is written. Any concern that the rating does not accurately reflect program practice should be explained in the comments section of the final report.

• The scale ratings are based on current behavior and activities, not planned, or intended behavior.

• For multi-site programs, if service delivery differs across program sites- rate according to the higher preforming program and then describe the discrepancy in the comments.

• If a period is not specified, then the rating can be based on service delivered at any point during the period of care.

Which data source to use:

• In the next section of the manual all the relevant data sources are listed for each item. All the listed data sources for each item can be used to complete the comments section of the report but we have included instructions on which data source is most commonly the best source for you to identify the rating for that item.

• Wherever possible, program administrative data or client health records should be used to determine the final item rating.

• In general, if care related to an item that is delivered to all clients and is typically documented in the health record, then the health record is used as the data source. In this case, if the item is not documented in an individual health record, we assume it did not happen. It is of course possible that it did occur and simply wasn’t documented. This possibility can be discussed in the comments but should not impact the rating.

• If an item is NOT routinely documented in the health record, an alternative data source (e.g., staff interviews) can be used to support the rating. If this is a possibility, interviews will be listed as the appropriate data source for that item. For example, if family support is not documented in the client health record the health record cannot be used as a data source for this item.

• ALL data sources may provide important contextual information that should be included in the comments section of the final report (though it will not necessarily impact the rating). For example, if the rating for an item is low and the policy review indicates that no procedures are in place to support the item, this may be a practice improvement area to flag. On the other hand, if the rating is low and the processes seem appropriate, it may be a documentation issue, and this could be flagged.

After Your Fidelity Site Visit If possible, time should be set aside at the end of the visit for the assessors to discuss and assign preliminary ratings on the fidelity scale. If preliminary ratings cannot be assigned during the site visit, assessors should meet within 3 days of the site visit to assign ratings. It is critical that rating discussions are had while the information is still fresh.


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After the site visit a consensus rating meeting may be scheduled including the assessors and a fidelity expert if available. The assessors will present their ratings and rationale, obtain feedback from the expert, discuss any differences, and agree on a final consensus rating. The fidelity expert will ensure scoring decisions are in line with the intended use of the scale. The assessors will prepare the fidelity report and send to the program within 1 month of the consensus rating meeting. The Final Report Template can be found in Appendix H. The report will include:

• A high-level overview of findings, highlighting program strengths and opportunities for improvement

• Item fidelity scores • Data sources used to determine each score • Any contradictions between data sources • Any additional relevant contextual information that might explain score (e.g., low rates of

clozapine prescribed because of high rate of mood disorder diagnosis in program) • Any recommendations for QI opportunities or promising/ innovative practices to highlight • Specific additional information requested per item (will be clearly specified in template) • Additional assessor comments (e.g., was this item difficult to rate? Do you feel the rating is

valuable/ reflects program practice? etc.) The report should be informative, factual, and constructive. Once finalized the report should be shared back to the key program contact who can disseminate it within the program as appropriate. Please make sure to copy the central coordinator when sending out the final report. The final report should be sent as a PDF. The site will have two weeks after receiving the report to provide a written response which will be appended to the end of a final version of the report. Component Criteria and Ratings Individual Items: 1. Timely Contact with Referred Individual

Definition: Clients should receive an in-person appointment within two weeks of referral to the program. The time starts on the date that the referral is received at the program and ends when the client is seen. The two weeks means ten working days. To meet criteria, appointments must be face to face and must include some element of treatment. Treatment can include any activities that begin the engagement of the client and the process of recovery. This can include the first intake appointment where initial assessment, education and the engagement process are begun. The rating is based on appointments attended, not appointments scheduled or offered. Rationale: Clients who experience a first episode of psychosis require urgent or emergent care. Treatment should be initiated within two weeks of referral. Clear intake and admissions procedures support receipt of a timely initial assessment and treatment. Item Scoring:

• Data source to use for rating: Administrative data or health record review or (if program can pull all initial appointment data- the full data set can be used to assign the rating, rather than the health record review).


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• Item response coding: If 80% or more clients receive a face to face appointment within two weeks, code the item as ‘5’. NOTE: if a client is hospitalized after referral, thereby preventing them from attending a first appointment within 2 weeks, they should be excluded from this calculation (i.e., treatment is considered to have started when the client is hospitalized).

Comments: • Additional data sources to support comments:

o Interviews with program manager, case manager or intake coordinator o Interview with clients and families o Documented program policy and procedure

2. Client and Family Involvement in Assessments

Definition: Service engages family in initial client assessment to improve the quality of the assessment, and to engage both in the treatment program. It can happen that the client is initially seen alone. In these cases, if the family is seen within a month of the initial individual meeting this can be counted as part of the initial assessment. Even if the client does not consent to share information with the family, the family contribute information for the initial assessment even though the clinician cannot share the client’s information. Rationale: The engagement of individuals and families as partners in the assessment process and care improves the overall reliability of the assessment and may foster therapeutic alliance (e.g., helping choose targets for intervention). Item Scoring:

• Data source to use for rating: Health record review or administrative data. • Item response coding: If 80% or more families are seen during initial assessment or within a

month of that meeting, code the item as ‘5’. Comments:

• Additional data sources to support comments: o Interviews with program manager, case manager, clinicians responsible for initial

assessments o Interviews with family members o Program policies and procedures for intake / assessment

3. Comprehensive Clinical Assessment at Enrollment

Definition: Initial assessment includes assessment of the following: i. Time course of symptoms change in functioning and substance use (assessing whether there

was change in functioning correlated with substance use changes or other changes) ii. Recent changes in behavior iii. Risk assessment/harm to self/others iv. Mental status exam v. Psychiatric history vi. Premorbid functioning vii. Co-morbid medical illness


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viii. Co-morbid substance use ix. Family History

Rationale: Comprehensive assessments provide essential information for diagnosis, treatment decisions and care planning. Item Scoring:

• Data source to use for rating: Health record review or administrative data. • Item response coding: If all 9 items above are assessed at enrollment for 80% or more of

clients, code the item as ‘5’. NOTE: In-depth assessment (e.g., use of validated screeners) not necessary if it is clear the issue was raised during assessment.

Comments:

• Additional data sources to support comments: o Interviews with program manager and case manager o Interviews with clients and family members o Policy and procedure manuals, assessment templates (if available)

• Specific information to include: o % of clinical assessments with 6-8 items completed o % of clinical assessments with less than 6 items completed

4. Psychosocial Needs Assessed for Care Plan

Definition: Programs should create a plan for each client that considers and addresses their psychosocial needs. The assessment that informs the care plan, treatment plan, or recovery plan should include the following:

i. Housing ii. Employment iii. Education iv. Social support v. Finance vi. Basic living skills vii. Registration with Family Physician viii. Social skills ix. Family Support x. Past trauma xi. Legal

Rationale: Addressing psychosocial needs such as housing, finances, and other social needs support recovery in the community. In some programs the care plan only, a record the actionable needs identified by the client, however the assessment on which this is made is should be comprehensive. For example, a client may be unemployed but have no interest in work. A rating on this item can be easily supported if structured data gathering tools are used such as an electronic record that requires each field be completed. Item Scoring:

• Data source to use for rating: Health record review


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• Item response coding: If all 11 psychosocial needs of clients are included in 80% of care plans, code the item as ‘5’.

Comments:

• Additional data sources to support comments: o Relevant policy or protocol o Interviews with the program manager and case manager o Interviews with clients and family members

5. Individualized Clinical Treatment Plan after initial assessment

Definition: It is important that treatment plans/ care plans are individualized and reflect both client and family preference. Evidence that client preference was considered may include documentation of a conversation with clients about their preference, the client’s signature on the plan, or a completed client self-report needs assessment. Rationale: The clinical presentation and impact of psychosis is variable, and it is important that treatment is individualized. Item Scoring:

• Data source to use for rating: Health record review is the most reliable source. • Item response coding: If 80% or more clients have an individualized treatment plan that

reflects client preference, code the item as ‘5’. Comments:

• Additional data sources to support comments: o Interviews with program manager and case manager o Interviews with clients and family members o Program policy/ procedures

6. Antipsychotic Medication Prescription

Definition: After diagnostic assessment confirms psychosis and the need for pharmacotherapy, antipsychotic medication is prescribed. Rationale: Antipsychotic medication is an evidence-based core intervention for clients with a first episode of psychosis used to treat symptoms of psychosis and reduce relapse rates. Item Scoring:

• Data source to use for rating: Health record review or administrative data. • Item response coding: If 80% or more clients receive a prescription for antipsychotic

medication, code the item as ‘5’. Comments:

• Additional data sources to support comments: o Interviews with program manager, case manager and psychiatrist


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o Program policy • Specific information to include:

o Is client preference generally considered? If so, explain how this is done and how disagreements/ refusals are resolved.

7. Antipsychotic Dosing Within Recommendations

Definition: Antipsychotic medication dosing is within government approved guidelines for second-generation antipsychotics and between 300 and 600 Chlorpromazine Equivalents for first-generation antipsychotic medications at six months (See Appendix I for Medication Dosing Guidelines). Rationale: First Episode Psychosis clients tend to respond to lower doses of antipsychotic medications and are more sensitive to side effects than multi-episode clients. At the same time a proportion do not respond to medication at all. This means that it is although it important to use the lowest effective dose the full dose range needs to be used when necessary. Item Scoring:

• Data source to use for rating: Health record review or administrative data. • Item response coding: If after starting pharmacotherapy, 80% or more of eligible clients are

on a dose within the target range, code the item as ‘5’. NOTE: Eligible clients are those being treated with antipsychotic medications for psychosis. Clients who are not on an antipsychotic medication (for any reason, including client refusal) should be excluded from the calculation. Also note that dosages below the recommended guidelines, in addition to those above guidelines, also do not meet criteria for this item.

Comments:

• Additional data sources to support comments: o Interviews with program manager, case manager and psychiatrist o Program policy

• Specific information to include: o What % of clients have dosages below the guidelines at 6 months?

8. Guided Antipsychotic Dose Reduction

Definition: Clients who have had positive symptoms for more than one month and have achieved remission for at least one year are offered guided and monitored reduction of antipsychotic medication possibly to the point of discontinuation. This item does not refer to medication adjustments for client’s comfort/side effects. Rationale: A proportion of clients maintain remission without maintenance pharmacotherapy. We do not have robust predictors of which individuals who have achieved remission can maintain remission without maintenance pharmacotherapy. The safest way of identifying those individuals is through supervised dose reduction. Item Scoring:

• Data source to use for rating: Interviews with psychiatrists.


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• Item response coding: If 80% or more of eligible clients receive guided reduction of antipsychotic medication, code the item as ‘5’.

Comments:

• Additional data sources to support comments: o Program policy

9. Clozapine for Medication Resistant Symptoms

Definition: Use of Clozapine if client does not respond adequately after two trials of antipsychotics (equivalent to 10 mg Haloperidol, and over 3-month period). Rationale: Clozapine is indicated for the treatment of inadequate or non-treatment response to first line antipsychotics. Treatment resistance occurs in approximately 20% of cases with schizophrenia. Item Scoring:

• Data source to use for rating: clozapine monitoring enrollment records, administrative data or interviews (depending on what is available).

• Item response coding: If more than 8% of clients are on Clozapine at 2 years, code the item as ‘5’. NOTE: In some places, programs accept clients with mood disorders or those with an attenuated psychotic syndrome for whom clozapine is not indicated. Assessors should rate the item as per the scale and note in the comments section if you think that a high number of bipolar clients is the reason for a low score. If the program has accurate data on the number of bipolar or other clients not eligible for clozapine an accurate proportion can be calculated *Because this item is only relevant for a subset of clients, percentage calculations cannot be made based on the health records. To calculate: Divide the total number of program clients on Clozapine by the total number of currently enrolled clients.


o Interviews with program manager, case manager and psychiatrist o Program policy

• Specific information to include: o % of clients in program with a mood disorder (vs schizophrenia) o Of those with schizophrenia, what % are on Clozapine?

10. Client Psychoeducation

Definition: Provision of at least 12 episodes (or equivalent) of client psychoeducation. Psychoeducation refers to the provision of support, information, and management strategies related to familial, social, biological, and pharmacological perspectives on illness (a more detailed list of topics that may be addressed through psychoeducation can be found below).


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Psychoeducation can be delivered individually or in a group and may be delivered by any member of the care team. A structured psychoeducation manual may be used, or it may be delivered more informally, embedded as a component of case management. Rationale: Psychoeducation is a way of providing information to clients to both engage them and support autonomy and recovery. Item Scoring:

• Data source to use for rating: Health record review or administrative data (e.g., group attendance).

o May be captured in structured documentation or in topics listed in progress notes, including: developing coping and self-help strategies developing resiliency dealing with the symptoms of psychosis activities of daily living educational/academic supports vocational/employment supports housing supports substance abuse supports support in establishing social relationships or connections peer support income support, when necessary recreational supports

• Item response coding: If 80% or more clients experience the equivalent of 12 episodes of psychoeducation, code the item as ‘5’.

Comments:

• Additional data sources to support comments: o Interviews with program manager and case manager o Interviews with clients and family members o Psychoeducation manual or handouts

• Specific information to include: o Are clients offered group or individual psycho-education? o Is there a formal manual or curriculum that is followed?

11. Family Psychoeducation

Definition: Families should receive the equivalent of at least 8 episodes of psychoeducation. Family psychoeducation offers information on illness, how to recognize signs of relapse, and strategies to decrease tension and stress in family. It can be delivered individually or in a group and may be delivered by an appropriately trained clinician. This rating is easier to confirm if a manual or documented family education program is expressly followed. A formal documentation in the health record of family psychoeducation and the topic addressed is necessary to support interview reports that individual family psychoeducation is delivered during clinician meetings with families or clients and families together. Rationale: Family psychoeducation is a robust contributor to lower relapse rates.


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Item Scoring:

• Data source to use for rating: Interviews and document review. • Item response coding: If 80% or more families receive the equivalent of at least 8 episodes

of family psychoeducation sessions, code the item as ‘5’.


o Interviews with program manager, case manager and family worker (if relevant) o Interviews with family members o Family psychoeducation manual, curriculum or handouts

• Specific information to include: o Are families offered group or individual psycho-education? If they are not offered

groups, are families connected to other families in any other way? Explain o Is there a formal manual or curriculum that is followed?

12. Individual Cognitive Behavior Therapy for treatment resistant positive symptoms or for anxiety or

depression

Definition: At least 12 sessions of individual or group cognitive behaviour therapy (CBT) should be delivered for individuals where indicated. CBT is an evidence-based treatment that is indicated for treatment resistant positive symptoms, anxiety or depression. CBT should be delivered by an appropriately trained professional. The training may have been part of their formal professional training or as continuing professional development (CPD). If it was provided as part of CPD training should have been received by an established, authorized provider of CBT training (general CBT training as well as CBT for psychosis are acceptable). A formal certificate of training provides confirmation of CPD training. Training plus follow up consultation from an expert or ongoing clinical supervision at the local level both support that CBT is received by clients. Confirmation that clinicians have specific training and follow a formal manual when providing CBT such as the RAISE manual also provide confirmation. Rationale: CBT has been widely investigated and has been shown to be effective for symptom management and many other aspects of recovery. Item Scoring:

• Data source to use for rating: Interviews and document review. • Item response coding: If more than 30% of clients receive at least 10 sessions of CBT,

delivered by an appropriately trained professional, code the item as ‘5’. Comments:

• Additional data sources to support comments: o Interviews with program manager and case manager o Interviews with clients and family members o CBT curriculum/ manual and materials

• Specific information to include: o Where was CBT training received? o Were any staff specifically trained in CBT for psychosis?


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13. Individual and / or Group Interventions to Prevent Weight Gain:

Definition: Provision at least 10 sessions of evidence-based programs to prevent weight gain. May include:

• nutritional counseling • cognitive behavioral therapy • exercise program • medication • cooking groups

Rationale: Weight gain is associated with many factors. In addition, the use of antipsychotic medications is associated with weight gain. Item Scoring:

• Data source to use for rating: Interviews and document review. • Item response coding: If more than 30% of clients participated at least 10 formal sessions to

prevent weight gain (nutritional counseling, CBT, or exercise), code the item as ‘5’. To get a rating of ‘3’, the criteria for ‘2’ must be met, plus at least 1 client must receive 10 sessions of a structured weight management program.

Comments:

• Additional data sources to support comments: o Interviews with program manager, case manager and metabolic nurse/ physician (if

relevant) o Interviews with clients and family members o Weight management program manual/ curriculum or materials, templates or

software (e.g., TREAT) • Specific information to include:

o Specify which type of weight management program is being provided

14. Annual Formal Comprehensive Assessment

Definition: All clients should receive an annual or ongoing comprehensive assessment, including: i. Educational, occupational, and social functioning ii. Symptoms iii. Psychosocial needs iv. Risk assessment of harm to self or others v. Substance use vi. Metabolic parameters (weight, glucose, and lipids) vii. Extrapyramidal side effects

Rationale: Individual client circumstances change with time and several diagnoses are time dependent. Annual or ongoing assessments are considered a good clinical practice and provide the opportunity for updating treatment plans, communication with primary care providers and ongoing planning. Item Scoring:


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• Data source to use for rating: Health record review. • Item response coding: If 80% or more clients undergo annual or ongoing assessments that

include all 7 items above, code the item as ‘5’. Comments:

• Additional data sources to support comments: o Interviews with program manager and case manager o Interviews with clients and family members

• Specific information to include: o What % of clients have a formal annual assessment on file? o What % of clients have an ongoing review of 3-6 items? o What % of clients have an ongoing review of <3 items?

15. Assigned Psychiatrist

Definition: Access to psychiatry or other qualified prescriber is an important component of the first episode psychosis treatment model and each client should be able to be seen up to once every two weeks by a psychiatrist. It is important that psychiatrists maintain low caseloads to facilitate this frequency. If psychiatrists are unavailable, other appropriately trained prescribers can take responsibility for pharmacotherapy (appropriately trained means that the licensed prescriber can evaluate symptoms and functioning, is aware of the available antipsychotics, their risks and benefits as well as the indications for other psychopharmacological interventions in psychosis. Moreover, they should be able to monitor and manage the side effects). Rationale: Implementation guidelines specify the need for psychiatrists or other appropriately trained providers to be part of the team. Item Scoring:

• Data source to use for rating: Interviews. • Item response coding: If interviews indicate that psychiatrist works with < 29 clients per 0.2

FTE, code the item as ‘5’.

To calculate: 1. Add up the total psychiatry FTEs available to the program per week 2. Divide the total number of currently registered clients by the total psychiatry FTEs 3. Multiply that number by 0.2

For example, if you have 30 currently registered clients and a 0.1 psychiatrist FTE, your caseload is 60 per 0.2 psychiatry FTE.

Comments:

• Additional data sources to support comments: o Interviews with the manager, case manager, and psychiatrist/prescriber.

• Specific information to include: o How many FTEs of psychiatry do you have available? o How long does it take on average to get an initial appointment for new clients (time

between first face to face appointment to first psychiatry appointment)? o If a client needs to be seen every two weeks by a psychiatrist, is that possible?


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o If a client’s condition changes and they need to be seen rapidly, how quickly can that occur?

16. Assignment of Case Manager

Definition: Client has an assigned case manager (individual may have a different title at different programs) who is a professional qualified clinician in nursing, psychology, social work, or occupational therapy. Case managers (or “care managers”) are staff members on coordinated specialty care teams who assess and address the individual and unique needs of each client, providing direct services or making referrals with follow-up ensuring that individualized needs are addressed. Care managers are part of a team, attend team meetings and coordinate care for clients. Care management responsibilities may include mental health counseling, skills training, financial counseling, housing assistance, substance abuse counseling and treatment, and family counseling. Rationale: Case management is a component of all treatment guidelines Item Scoring:

• Data source to use for rating: Health record review or administrative data. • Item response coding: If 80% or more clients have been assigned a case manager for the

first three years of treatment, code the item as ‘5’. Comments:

• Additional data sources to support comments: o Interviews with manager, and case manager o Interviews with clients and family members

17. Motivational Enhancement (ME) or Cognitive Behavioral Therapy (CBT) for Co-Morbid Substance

Use Disorder (SUD)

Definition: Clients with co-morbid Substance Use Disorders (SUD) receive either 3 sessions of motivational enhancement (ME)/ motivational interviewing (MI) or cognitive behavior therapy (CBT). This can be delivered by a trained clinician as part of a formal SUD specific program or integrated into general care. It can also be delivered through referral to an addiction program. Rationale: Motivational interviewing and CBT are evidence-based approaches to increase readiness to change and reduce substance abuse. It is feasible to train staff in mental health programs to deliver these services. Item Scoring:

• Data source to use for rating: Interviews. • Item response coding: If evidence indicates that 80% or more clients with SUD receive at

least 3 sessions of ME or CBT, code the item as ‘5’. Comments:

• Additional data sources to support comments:


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o Interviews with the program manager, case manager and addiction/CBT specialist (if relevant)

o Interviews with clients and family members o Program policy and procedures, SUD program manual/ materials

18. Supported Employment

Definition: Supported Employment (SE) or Individual Placement and Support (IPS) is provided to clients if interested in participating in competitive paid employment. In contrast with mainstream employment services, SE is an evidence-based intervention targeted at individuals with mental illness and includes additional supports such as rapid placement, on the job support, support negotiating workplace accommodations and an emphasis on client choice. Rationale: Supported employment is an evidence-based program which increases employment rates. Item Scoring:

• Data source to use for rating: Interviews. • Item response coding: If interested clients are provided SE by a SE specialist (of any

professional designation) that is part of the first episode psychosis team, code the item as ‘5’. NOTE: Formal training of SE specialist and certification of the SE program is required for the highest score.

Comments:

• Additional data sources to support comments: o Interviews with the program manager, case manager, SE specialist (if relevant) o Interviews with clients and family members o SE program description or materials

19. Active Engagement and Retention

Definition: Use of proactive outreach services (i.e., client visits in the community) to reduce missed appointments, engage clients with a first episode psychosis, and minimize drop-outs. If there is not a reliable source of administrative data on this item, it should be based on the 10 most recent visits in the health record. Rationale: Active outreach promotes engagement and reduces drop-outs. Item Scoring:

• Data source to use for rating: Administrative data. • Note that there is a disconnect between the practice and the rating. The rating is based on

the outcome of the activity rather than by the activity itself. Comments:

• Additional data sources to support comments: o Program policies/procedures (i.e., are they set up to do community visits)


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o Interviews with the program manager and clinicians o Interviews with clients and families

20. Community Living Skills

Definition: Clients receive training (provided in the community) on community living skills. Only a proportion of clients require community skills training. For those who do, the program works in the community in addition to the office, to develop a range of community living skills (i.e. social activities, using transportation, renting, banking, budgeting, meal planning). Rationale: Skills such as using transportation or recreation resources, managing finances, obtaining health care and social services are best learned in the community. Item Scoring:

• Data source to use for rating: Interviews and document review. • This item does not indicate that the FEPS has to provide the service directly. It can be carried out

by team members, appropriately trained workers on contract from another agency or appropriately trained peer support worker. This item does not indicate that the FEPS has to provide the service directly. It can be carried out by team members, appropriately trained workers on contract from another agency or appropriately trained peer support worker. If the service is delivered through a contract, there must be a formal contract for the service and close clinical coordination with the case manager who must receive reports of the activities undertaken which should be verifiable by document review. • . • Item response coding: If over 80% of eligible clients receive face to face community living

skills instruction in the community, code the item as ‘5’. NOTE: The rating proportion refers to the proportion of individuals requiring the services not the proportion of all clients (therefore the health record review cannot be used to calculate proportions).

Comments:

• Additional data sources to support comments: o Interviews with the program manager and case manager o Job descriptions of staff that suggest a focus on community functioning o Review of policy documents

21. Crisis Intervention Services

Definition: First episode psychosis program delivers crisis services or has links to crisis response services including crisis lines, mobile response teams, and urgent care centre or hospital emergency rooms. Rationale: Crises are a common occurrence in this population and both organizational linkages and individual patients/clients care plans must reflect crisis plans. Item Scoring:

• Data source to use for rating: Interviews and document review.


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• Item response coding: If the first episode psychosis team provides 24-hour, 7 day a week in-person support for crises, code the item as ‘5’. For ‘3’ and ‘4’ linkage can include any mechanism that directs clients to appropriate after hours crisis services.

Comments:

• Additional data sources to support comments: o Interviews with the program manager and case manager o Review of policy documents

Team Items:

22. Participant/Provider Ratio Definition: There is a target ratio of clients to Full Time Equivalent (FTE) clinical staff. Rationale: Optimal ratios have been reported in the range of 15- 20 cases per FTE. Item Scoring:

• Data source to use for rating: Interviews. • Item response coding: If interviews indicate that the caseload ratio is 20:1 or less, code the

item as ‘5’. To calculate: Divide the total number of currently registered clients by the total number of clinical FTEs. Clinical FTEs include all direct care staff except physicians (i.e., any staff members who are not manager, administrative, research/evaluation or physician). This includes any specialized staff who are not case managers (e.g., family support worker, peer support worker, nurse, employment specialist, addiction specialist, psychologist etc.). The purpose of this calculation is to get a number that will be comparable across programs and therefore, it may not reflect the actual caseload carried by individual program case managers. For example, if you have 10 registered clients and 0.5 clinical FTEs, your caseload per FTE ratio is 20.

Comments:

• Additional data sources to support comments: o Interviews with program manager and case manager o Document review o Policy and practice documents

• Specific information to include: o Include actual caseload per case manager on staff

23. Practicing Team Leader

Definition: Program staff receive both administrative leadership and clinical supervision. These roles may be held by the same individual (likely a manager or team leader) or by two different individuals. To get the highest rating, the individual who provides clinical supervision should also provide some direct clinical services in the first episode psychosis program. It is not required that these individuals have master’s level education, but in some services, this is a requirement for this role.


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Rationale: Longitudinal studies of implementing best practices show a significant correlation between the presence of a practicing team leader and program fidelity. Item Scoring:

• Data source to use for rating: Interviews. • Item response coding: If the team leader (or other individual) provides administrative

direction and clinical supervision to all staff as well as providing some direct clinical service; code the item as ‘5’.

Comments:

• Additional data sources to support comments: o Interviews with the program manager and clinicians.

• Specific information to include: o Does the program manager have multiple portfolios (aside from the first episode

psychosis program)? If so what FTE does the manager assign to the program

24. Psychiatrist Role on Team Definition: Psychiatrists are team members who attend team meetings, see clients with other clinicians and are accessible for consultation by team during the work week. Rationale: Program guidelines specify the need to have a psychiatrist as part of the team. Item Scoring:

• Data source to use for rating: Interviews. • Item response coding: If interviews indicate that the psychiatrist attends team meetings,

sees patients with other clinicians, shares team health record and available for consultations with staff, code the item as ‘5’. NOTE: If the psychiatrist doesn’t attend formal team meetings but does work closely with the rest of the team that can be counted. If there are multiple psychiatrists who work with the program and who have difference practices regarding their participation on the team, the rating should be made based on the main psychiatrist (the one with the most time allocated to the program) and discrepancies can be discussed in the comments.

• If a proportion of patients have psychiatrists or prescribers who are not part of the FEPS team, the final score for the program needs to be adjusted as follows. If the role of the psychiatrist on the team merits a 5, but 50% or more patients are seen by a psychiatrist who is not part of the team, then the rating needs to be a 2. If the proportion is between 5 and 49% of patients the rating should be a 3.

Comments:

• Additional data sources to support comments: o Interviews with the program manager, case manager and psychiatrist

25. Multidisciplinary Team

Definition: Includes qualified professionals to provide both case management and specific service components including:


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i. Nursing services ii. Evidence based psychotherapies iii. Evidence based addiction treatments iv. Employment support v. Family Education and Support vi. Social and or community living skills vii. Case Management

Some of these items may be delivered by a staff member paid by another program but can still be included if that staff member is an active participant in the client’s multidisciplinary team. More than 1 function may be provided by the same individual. The focus for rating this item is the services received by the clients rather than the professions of the providers. Rationale: Clients and families benefit from the skills of several professionals, which need to be coordinated to deliver consistent care. Item Scoring:

• Data source to use for rating: Interviews and document review. • Item response coding: If team members provide the seven listed services, code the item as

‘5’. Comments:

• Additional data sources to support comments: o Interviews with program manager and case manager o Document review (program staff role descriptions)

26. Duration of First Episode Psychosis (FEP) Program services provided to client

Definition: The mandate of the program is to serve clients for a specified period. Rationale: Due to the nature of the early course of illness, clients and families often benefit from receiving first episode psychosis services for at least three years. The level of services required varies between individual clients and their families and over time. Item Scoring:

• Data source to use for rating: Interviews and document review. • Item response coding: If the intended duration of the service is 4 or more years, code the

item as ‘5’. For this item, duration is based on the program policy and stated mandate (though length of stay for individual clients may vary).

Comments:

• Additional data sources to support comments: o Interview with program manager and case manager o Program policy documentation review o Program administrative data

• Specific information to include: o What % of clients exceed the program maximum? Why?


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27. Weekly Multi-Disciplinary Team Meetings

Definition: Multidisciplinary team meetings are conducted weekly to provide an opportunity to discuss the following:

i. Case review (new admissions and discharges) ii. Assessment and treatment planning iii. Complex cases iv. Termination of services

Rationale: Regular team meetings are conducted to review the status of FIRST EPISODE PSYCHOSIS clients and foster the communication between staff. Item Scoring:

• Data source to use for rating: Meeting observation and document review (meeting agendas, minutes).

• Item response coding: If the team meetings are conducted weekly, and involve discussion of all four issues, code the item as ‘5’.

Comments:

• Additional data sources to support comments: o Interviews with program manager and case manager o Meeting observation o Document review (meeting agendas)

28. Targeted Health/Social Service / Community Groups (public education)

Definition: Provision of information to first contact professionals, including family physicians, school and post-secondary counseling services, youth social service agencies, community mental health services, police services and hospital emergency rooms and other community organizations. Public education may be provided by any source within the program or network. Rationale: Early identification approaches that involve proactively seeking out clients with early psychosis reduce the duration of untreated psychosis. Enhancing the education, communication and liaison with health and service providers who may identify or treat clients with early psychosis will reduce the duration of untreated psychosis. Item Scoring:

• Data source to use for rating: Interviews and document review. • Item response coding: If community education is provided to service providers more than 12

times a year, code the item as ‘5’. NOTE: This should be based on face to face education (activities such as poster campaigns or mass mail outs should not be counted towards this item). .

Comments:

• Additional data sources to support comments: o Interviews with program manager, case manager, and family worker


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o Public education materials (e.g., slides, handouts, speaking schedule etc.) o Administrative data indicating number of sessions delivered in last year

29. Communication Protocol between Inpatients/clients Unit and first episode psychosis service

Definition: If there is a hospitalization of a client, the staff contacts the inpatient staff to be involved in discharge planning and arranging outpatient follow up within 15 days of discharge. Rationale: Post discharge follow up has been shown to reduce re-hospitalization. Item Scoring:

• Data source to use for rating: Health record review, administrative data or interviews (if hospitalizations are not recorded).

• Item response coding: If 80% or more of first episode psychosis clients admitted to hospital are seen at the first episode psychosis Service for an outpatient appointment within 15 days of hospital discharge, code the item as ‘5’.

Comments:

• Additional data sources to support comments: o Interviews with program manager and case manager o Program policy documentation review o Health record review

• Specific information to include: o What is the typical communication between first episode psychosis staff and

inpatient staff during hospitalization? o Are first episode psychosis staff typically involved in discharge planning?

30. Explicit Admission Criteria

Definition: The service has clearly identified mission to serve specific diagnostic groups and uses measurable and operationally defined criteria to select appropriate referrals. Given that diagnoses may change over time many programs appropriately and explicitly include uncertain cases. Rationale: The program needs explicit criteria to conduct effective evaluations and make comparisons with similar programs. Item Scoring:

• Data source to use for rating: Interviews and document review. • Item response coding: If over 90% of the population served meets the admission criteria,

code the item as ‘5’. If there are no explicit admission criteria, code the item as’ 0’. • Count clients with ambiguous diagnoses who later meet criteria for a non-included diagnosis

as meeting criteria for program entry. Comments:

• Additional data sources to support comments: o Interviews with the manager, case manager and intake coordinator (if relevant) o Review of policy documents

• Specific information to include:


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o Describe the program’s inclusion and exclusion criteria for admission

31. Population Served Definition: The intention of this item is to evaluate the extent to which first episode psychosis programs are meeting population need. In other words, are they serving the number of clients we would expect based on the estimated number of people in their catchment area with a first episode psychosis. For guidance, we have included recommended incidence rates based upon data from an international epidemiological study. If there is data available that describes the precise incidence of new cases in your services area this should be used. Comments:

• Data sources to support comments: o Interviews with the program manager and intake coordinator o Program administrative data on new admissions o Publicly available population stats

• Specific information to include: a. Number of new clients admitted in the past 12 months per 100,000 population age

15-45 b. Number of new clients admitted in the past 12 months per 100,000 population

when the program is not aware of the number in the age range specified. Calculation should be made based on the typical number of unique clients admitted in a 12-month period and the population of the program catchment area. Information on new clients and estimated boundaries of the program catchment area can be obtained from the program. The assessor can then look up the population of the catchment area to calculate the item. To calculate:

i. Gather necessary numbers a. Identify the number of new clients admitted to the program in the past 12 months b. Identify program catchment area boundaries

ii. To calculate item a: a. Look up catchment area population size* b. Divide the number of new clients by the total catchment area population c. Multiply this number by 100,000 d. The result is the number new cases per 100,000 population

iii. To calculate item b: a. Look up catchment area population between age 15-45* b. Divide the number of new clients by the catchment area population age 15-45 c. Multiply this number by 100,000 d. The result is the number new cases per 100,000 population age 15-45

Appendix A: Preparing for a Fidelity Visit

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Appendix A: Preparing for a Fidelity Visit Thank you for participating in this fidelity project. The purpose of this document is to outline the steps required to prepare for the assessment site visit. Please review carefully and keep in mind that preparations will need to begin several weeks in advance of the assessment date. 1. Determine primary contact person

It is important to assign a primary contact person (usually manager/research coordinator) to help organize and prepare for the fidelity assessment. They will either lead or assign someone else to lead the rest of the listed items.

2. Establish process and obtain approvals for ethics/privacy oversight It is important that the fidelity reviews are conducted in an ethical manner that respects and protects the privacy of all clients, families and staff. We will work with you to determine what processes and approvals are needed at your site. The process varies with the purpose of the fidelity assessment, specifically whether it is for research or quality assurance. We will also share with you, materials such as consent form templates/samples, confidentiality agreements (if your organization does not have its own form), and data collection tools. Once the required approvals have been obtained, please send a copy of the approval letter or e-mail.

3. Schedule the fidelity assessment dates

The fidelity assessment includes a 1 - 2-day site visit or telephone interview which requires advance preparation by all participants to ensure they run smoothly. When scheduling your site visit it is important to consider the following factors:

• Time required to prepare (it can take several weeks for the program to get everything ready for the site visit) • Which day of the week is your team meeting? (part of the on-site assessment includes observing a team meeting) • Which day of the week will most program staff (including the psychiatrist) be onsite? (part of the assessment includes interviewing

different staff) • Timeline for expected health information privacy / ethics approval (if approvals have not yet been received)

The fidelity assessment coordinator will work with your primary contact person and the assessors to find a date that works for everyone.


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4. Prepare materials for assessors As part of the assessment, the fidelity assessors will review program materials and administrative data reports. These materials need to be prepared in advance and ideally sent to the assessors at least a week prior to the assessment. This will help save time during the site visit. NOTE: Only aggregate, de-identified data should be shared in advance. Please provide the following: □ Description of the program, including services offered and mandated length (info may be included in program brochure, website, or

other existing materials) □ List of staff identified by their staff title and the FTE that they provide to the program □ Program admission criteria □ Service catchment area boundaries □ Information on client caseload (Number of new admissions over past 12 months, and total number currently enrolled) □ Proportion of clients retained in the program after two years.

If available/relevant, please also provide:

□ Client and family psychoeducational materials, manual/curriculum □ Number of clients in program taking clozapine □ The proportion of clients seen within two weeks of referral □ The proportion of face to face visits that take place in the community vs. in office □ Staff meeting agenda (de-identified)

5. Organize interviews and focus groups with Clients, Families, and Staff

Part of the fidelity review involves interviews (individual or group) with clients, family members, and program staff during the assessor site visit. Ideally the assessors will interview 2-3 clients and 2-3 family members per site, and a variety of site staff (i.e., the program manager, psychiatrist, case managers/coordinators, and other service providers) as makes sense for your program. It is not necessary for every staff member to be interviewed but it is important that the assessors get information about all components of the model so if certain components are delivered by specialty staff (e.g., supported employment specialist, nurse, CBT specialist, etc.), it is important they are interviewed. If an in-person interview is not possible a phone interview should be scheduled.


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It is the program’s responsibility to recruit the clients, families, and staff to meet with the assessors. It should be made clear that participation is voluntary and that a decision to not participate will not affect the service provided by the program or the service provider’s role/employment in the program. Depending on what works best logistically, and what the participants are comfortable with, clients and families can provide feedback to the assessors in individual interviews or in a focus group. Staff can also participate in a focus group format, though people in positions of authority such as the manager or director should always be interviewed separately. The specific configuration of meetings with staff will depend on the team composition and functions. It is the responsibility of the fidelity assessors to ensure that if necessary, each client/family member/staff member signs a consent form before participating in the interview or focus group. The assessors will explain the purpose of the interview, that participants have the right to leave at any time, that their responses will not impact their receipt of services/role and that all their information will be kept confidential. To facilitate this process, the program should send the site-specific consent forms in advance to the assessor team. The signed consent forms will be stored on site in accordance with your local ethics/ privacy protocols.

6. Prepare client health records As part of the fidelity review the assessors will review health records of 10 clients who have been in the program at least 1 year. To support

selecting a random set of 10 records, one of a few processes can be used, depending on the health record systems and health information privacy regulations for quality review and or research: • 10 randomly selected (by administrative staff) paper-based health records of clients who have been enrolled with FEP for over 12

months. • Redacted health record* contents for 10 randomly selected (by your administrative staff) clients who have been enrolled with FEP

for over 12 months. • Access to electronic health records for10 randomly selected (by your administrative staff) clients who have been enrolled with FEP

for over 12 months. Logistics and privacy requirements for sharing health records should have been determined during your ethics review/process. Things to think about:

• Will the assessors need access to computers? • Will they need to be assigned a temporary password? • Will paper health records need to be requested? • Will a room need to be booked to review the health records? • Will the health records need to be de-identified?


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It is usually necessary for a staff member to be present during the health record review to orient the assessors to the health record and to answer any questions that arise. Unless specified in advance, the assessors will not be taking any client health records out of the room and they will not record any identifying/personal health information in any notes that they take.

7. Plan visit schedule

The site visit will occur over the course of 1-2 days. It is the role of the primary contact person to organize the schedule and make sure all the necessary interviews are lined up, rooms booked etc. During the 2-day visit the assessors will: • Interview the Program Manager/ Team Leader (~ 1.0 hours) • Perform health record reviews (~4 hours of assessor time. It could be done in two hours if two records can be assessed at the same time) • Observe a team meeting (~30min) • Interview a psychiatrist (~30 minutes) • Interview case managers as relevant (~ 1.0 hours) • Interview additional staff as relevant - e.g., supported employment specialist, nurse, addition specialist, CBT specialist, etc. (~ 30

minutes) • Interview 2-3 clients and 2-3 family members (~30minutes)

Please develop an agenda for the visit that works for your program and includes all the activities listed above. Additionally, 1-2 hours should be scheduled at the end of day 2 for the assessors to debrief with each other. The site visit schedule should be sent to the assessors two weeks prior to the site visit. See a sample agenda at the end of this document.

8. Confidentiality forms and other permissions Depending on the nature and type of review process, (research or quality assurance), assessors may be required to sign a confidentiality form before starting the assessment. They may also be required to fill out other documentation (e.g., temporary password request, visitor badge etc.). If these documents need to be signed in advance, please ensure they are sent to the assessors to complete with sufficient lead time. Otherwise please ensure they are completed at the start of the site visit.

9. Day of the visit


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Either the primary contact person or another team member will be responsible for guiding and supporting the assessors during the 2-day visit. This includes greeting them, giving them an initial tour of the program, guiding them from interview to interview, introducing them to program staff, and being generally available to answer any questions or provide additional information as needed.

Any questions about this project or how to prepare for a fidelity visit can be directed towards the fidelity coordinator (name and contact details). Sample agenda Note: This is an example only; site schedules will be dependent on the program composition and availability of participants.

Day 1

8:00* - 8:15am Introductions, review agenda, tour of program (as relevant) 8:15 - 9:30am Program manager interview 9:30 am - 12:30pm Health record review. (May be concurrent to other interviews) 10:00 - 10:30 am Psychiatrist interview 10:30 -10:45am Case Manager/ Therapist Interview 11:00 – 11:30 am Supported Employment Specialist 11:30 am - 12:00 pm Client interview 12:00 - 12:45 pm Lunch 12:45 - 1:15 pm Observe Team meeting 1:30 - 2:00 pm Family interview 2:00 - 2:30 pm Observe team meeting 2:30 - 3:00 pm Interview nurse 3:00 – 3:30 pm Interview employment specialist 3:30 - 4:30 pm Health record review (if needed) 4:30 - 5:00 pm Assessor huddle to debrief and review learnings

* Start/finish times may depend on the assessors’ travel arrangements

Appendix B: Client Record Data Extraction Template

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FEPS-FS items Response format Possible evidence 1 2 3 4 5 6 7 8 9 10

1. Client length of time in the program

<1 year Yes or No

Admission information

2. First in-person appointment within 2 weeks

Rate Yes for less than two weeks No for more than 2

3. Patient and family involvement in initial assessment

Yes No

Assessment or notes

4. Comprehensive clinical assessment – All 9 items included in assessment i

Number of criteria among these 9 on the health record

Assessment or progress notes or structured assessment

5. Psychosocial needs assessed for care plan – All 11 items included in care plan ii

Number of criteria among these 9 on the health record

Assessment or progress notes or structured assessment

6. Individualized clinical treatment plan after initial assessment – includes needs, goals, and preferences

Yes No

Evidence of individual preference reflected in plan (e.g., notes or signature on plan)

7. Antipsychotic medication prescribed

Yes No

Indicated in psychiatrist note or copy of prescription

8. Antipsychotic Yes Medication


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dosing is within guidelines

No Daily dose

9. Second antipsychotic medication prescribed

Yes No

Medication Daily dose

10. Client psychoeducation – received 12 episodes by trained clinician (individual or group)

Yes No

Client notes or group attendance

11. Family psychoeducation – received 8 sessions by trained clinician (individual or group)

Yes No

12. Annual or ongoing comprehensive assessment– addresses 7 areas of functioning iii

Yes No

Annual assessments on file OR clear descriptions of review of 1-7 items in progress notes

13. Assigned psychiatrist

Yes No

14. Assigned case manager

Yes No

15. Active engagement and retention – > 40% visits occur in community

# visits in community out of most recent 10 visits

Sample of appointment locations

16. Communication Yes Check any Hospital


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between FEP and inpatient- admitted EPI clients receive outpatient appointment within 15 days of discharge

No NA (not hospitalized)

d/c date with f/u appointment date

i Item 4 should include 9 items: (1) Time course of symptoms, change in functioning and substance abuse (assessing whether there was change in functioning correlated with substance use changes or other changes); (2) Recent changes in behavior; (3) Risk assessment/harm to self or others; (4) Mental status exam; (5) Psychiatric history; (6) Premorbid functioning; (7) Co-morbid medical illness; (8) Co-morbid substance use; (9) Family history. ii Item 5 should include 11 items: (1) Housing; (2) Employment; (3) Education; (4) Social support; (5) Finance; (6) Basic living skills; (7) Register with a Family Physician; (8) Social skills; (9) Family Support; (10) Past trauma; (11) Legal. iii Item 12 should include 7 areas: (1) Educational, occupational, and social functioning; (2) Symptoms; (3) Psychosocial needs; (4) Risk assessment of harm to self or others; (5) Substance use; (6) Metabolic parameters (weight, glucose, and lipids); (7) Extrapyramidal side effects.


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FEPS-FS items Abstractor’s comments 1. Client length of time in the program 2. First in-person appointment within 2 weeks 3. Patient and family involvement in initial assessment 4. Comprehensive clinical assessment – All 9 items

included in assessment iv

5. Psychosocial needs assessed for care plan – All 11 items included in care plan v

6. Individualized clinical treatment plan after initial assessment – includes needs, goals, and preferences

7. Antipsychotic medication prescribed 8. Antipsychotic dosing is within guidelines 9. Second antipsychotic medication prescribed 10. Client psychoeducation – received 12 episodes by

trained clinician (individual or group)

11. Family psychoeducation – received 8 sessions by trained clinician (individual or group)

12. Annual or ongoing comprehensive assessment– addresses 7 areas of functioning vi

13. Assigned case manager 14. Active engagement and retention – > 40% visits occur

in community

15. Communication between FEP and inpatient- admitted EPI clients receive outpatient appointment within 15 days of discharge

iv Item 4 should include 9 items: (1) Time course of symptoms, change in functioning and substance abuse (assessing whether there was change in functioning correlated with substance use changes or other changes); (2) Recent changes in behavior; (3) Risk assessment/harm to self or others; (4) Mental status exam; (5) Psychiatric history; (6) Premorbid functioning; (7) Co-morbid medical illness; (8) Co-morbid substance use; (9) Family history. v Item 5 should include 11 items: (1) Housing; (2) Employment; (3) Education; (4) Social support; (5) Finance; (6) Basic living skills; (7) Register with a Family Physician; (8) Social skills; (9) Family Support; (10) Past trauma; (11) Legal. vi Item 12 should include 7 areas: (1) Educational, occupational, and social functioning; (2) Symptoms; (3) Psychosocial needs; (4) Risk assessment of harm to self or others; (5) Substance use; (6) Metabolic parameters (weight, glucose, and lipids); (7) Extrapyramidal side effects.

Appendix C: Client Interview Guide

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Appendix C: Client Interview Guide Assessor Instructions: Before starting the interview, the assessors should identify 1 team member to ask questions and 1 (or 2) to take notes. The interviews should be conducted as a conversation, using a client centred approach. These questions should be viewed as a guide, and assessors should use their judgement as to which questions are appropriate to ask clients. Questions may be rephrased, omitted/ added or reordered as appropriate to get the information needed to complete the ratings. Unless specifically requested by the clients, program staff members should not be present during the interview. Notes should not include any individual names or personal health information. Notes should pertain to program performance and avoid comments about performance of individual staff. Introduction/ consent Thank you for agreeing to be interviewed as part of the fidelity review. The purpose of this project is to better understand how program services match with the first episode psychosis Standards. To do this, we will be asking some questions about the services that you have received. We expect this interview/ focus group will take about 30- minutes. If it is okay with you, my colleague/s will be taking notes. The results of this project are intended to help improve the quality of services in this program. Before we begin, please review the consent form (if required) and if you feel comfortable going ahead, please sign the bottom. Remember that you can always choose not to answer a question, or you can stop the interview entirely. Your responses will not impact the care you receive and will remain confidential. Overall feedback about how the program is doing will be shared with the program, but no individual names will not be used.


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Background How long have you been involved with the first episode psychosis program? Questions about intake/ assessment process:

Questions Responses 1. Timely Contact with Referred Individual- first face to face contact within 2 weeks • Can you describe your experience getting into the

program? o Did they call you right away? Longer than 3 days? o Did it feel like it took too long to get a first

appointment? More than 2 weeks?

2. Psychosocial Needs Assessed for Care Plan • Beyond the psychosis, did your case manager ask you

about other aspects of your life? (e.g., housing, employment, finances, past trauma etc.)

3. Individualized Clinical Treatment Plan after initial assessment • Did anyone ever ask you about what you wanted? About

your priorities or goals? • Did your input become part of the plan? • Were you ever asked to sign off or approve your

treatment plan?

Questions about medications:

Questions Responses 4. Antipsychotic Medication Prescription • What about medication, were you interested in taking it at

first? • Did you feel you were given some choices? How did that

go?


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5. Guided Antipsychotic Dose Reduction: • Once people are feeling better, they often want to reduce

or stop their meds, how about you? • (If you were feeling fine and had no symptoms for a long

time) Did anyone ever suggest you consider lowering or changing your medication?

Questions about services provided:

Questions Responses 6. Client Psychoeducation • Learning about your illness, about mental health, and

general physical health is an important part of recovery for many people. Did you feel like you received enough education? Would you have liked more?

• How is the teaching done? Just one-on-one, or in groups, or both?

• Were you provided any written info?

7. Cognitive Behavioural Therapy (CBT) • Some programs use Cognitive Behavior Therapy or CBT.

Have you ever heard of this? They talk about thought-stopping, beliefs, feelings, and behaviors, you get homework, etc.

• Did you ever receive CBT? May have been in a group or individually.

8. Interventions to Prevent Weight Gain • Did you ever receive any information or services related to

weight management? o Is your weight recorded regularly? o Does anyone ever talk to you about gaining weight? o Were you offered any programs to help you eat

better or exercise more or other strategies to prevent weight gain?


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o Do you feel like you received enough support around weight management? Do you feel like this is something you can discuss with your worker?

9. Annual Formal Comprehensive Assessment (all 7 items) • After your initial assessments, did anyone talk with you

about your progress, about how your recovery was coming along?

• Did you meet with them for an actual review, or just talk about it during regular appointments?

• Have you ever completed a self-survey of your needs? Do you complete it regularly?

10. Assigned Psychiatrist • Do you see a psychiatrist? Are they part of the program? • Have you been seeing the same psychiatrist here since you

started? • Does it feel like you had to wait a long time before getting

an appointment with the psychiatrist?

11. Assignment of Case Manager • Is there one worker here who is “your worker”? They

might be called a case manager or care coordinator? • Has it been the same person the whole time?

12. Motivational Interviewing (MI) or Cognitive Behavioral Therapy (CBT) for Co-occurring Substance Use Disorder (SUD) • Were you ever offered any help to stop using drugs (if this

was something relevant/ you were interested in) • If so, how was this help provided? (Individually, group?)

13. Supported Employment (SE) • Were you ever asked whether you were interested in

getting a job? If you were, did anyone offer to help you get a job?

• (If yes) Can you describe what type of help was offered?


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14. Active Engagement and Retention (service in the community) • Do you see your worker at the office every time, or

sometimes in other locations? Maybe at the mall or a coffee shop, your home, the gym?

• Do you feel like you have a choice about where you meet your worker?

15. Communication Protocol between Inpatient Unit and FEP Service (outpatient visit within 15 days post discharge) • Since you started this program, have you had to be

admitted to the hospital at all? • Did your worker ever see you during this time? • Do you remember what happened after you left the

hospital? Did your FIRST EPISODE PSYCHOSIS worker contact you?

Additional questions (if time) • What have you found most helpful about this program? • Is there anything that you would like to be different or you

think could be improved? • Is there anything else you would like us to know about this

program?

Appendix D: Family Interview Guide

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Appendix D: Family Interview Guide Assessor Instructions: Before starting the interview, the assessors should identify 1 team member to ask questions and 1 (or 2) to take notes. The interviews should be conducted as a conversation, using a client centred approach. These questions should be viewed as a guide, and assessors should use their judgement as to which questions are appropriate to ask family members. Questions may be rephrased, omitted/ added or reordered as appropriate to get the information needed to complete the ratings. Notes should not include any individual names or personal health information. Notes should pertain to program performance and avoid comments about performance of individual staff. Introduction/consent Thank you for agreeing to be interviewed as part of the fidelity review. The purpose of this project is to better understand how program services match with the FIRST EPISODE PSYCHOSIS Standards. To do this, we will be asking some questions about the services that you received/ your family member have received. We expect this interview/ focus group will take about 30- 60 minutes. If it is okay with you, my colleague(s) will be taking notes. The results of this project are intended to help improve the quality of services in this program. Before we begin, please review the consent form and if you feel comfortable going ahead, please sign the bottom. Remember that you can always choose not to answer a question, or you can stop the interview entirely. Your responses will not impact the care you or your family member receive and will remain confidential. Overall feedback about how the program is doing will be shared with the program, but no individual names will not be used.


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Background How long has your [family member] been involved with the first episode psychosis program? Questions about intake/ assessment process:

Questions Responses 1. Timely Contact with Referred Individual- first face to face contact within 2 weeks • Can you describe the experience your [family member]

had getting into the program? o Did they wait a long for the first appointment? More

than 2 weeks?

2. Family Involvement in Initial Assessments • Were you involved in your [family member’s] initial

assessment process? o If you were unable to participate in the initial

assessment, were you offered the chance to speak to the clinician within the first month?

• Did you have any ongoing meetings with your [family members] care team to review progress?

3. Psychosocial Needs Assessed for Care Plan (all 11 items included) • Beyond the psychosis, did your [family member’s] case

manager ever support them in other areas of their life, such as employment, education, or finances?

4. Individualized Clinical Treatment Plan after initial assessment • Do you feel like your [family member] had a say in their

treatment plan?

Questions about medications:

Questions Responses 5. Antipsychotic Medication Prescription • Was your family member interested in taking medication

at first?


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• Did you feel they were given choices? What did that process look like?

• Did anyone talk to you about medication options? Questions about services provided:

Questions Responses 6. Interventions to Prevent Weight Gain • Did you or your [family member] ever receive any

information related to weight management? o Were they offered any programs to help them eat

better or exercise more or other strategies to prevent weight gain?

7. Assigned Psychiatrist • Has your [family member] been seeing the same

psychiatrist here since they started?

8. Assignment of Case Manager • Was your [family member] assigned a specific worker who

they meet with? (may be called a case manager or care coordinator)

• Has it been the same person the whole time?

9. Motivational Interviewing (MI) or Cognitive Behavioral Therapy (CBT) for Co-occurring Substance Use Disorder (SUD) • Was your [family member] offered any help to stop using

drugs (if this was something relevant for them)?

10. Supported Employment (SE) • Was your [family member] ever asked whether they were

interested in getting a job? Were they ever offered supports to get a job?

• (If yes) Can you describe what type of help was offered?

11. Active Engagement and Retention (service in the community) • Does your [family member] ever receive services in the

community? Maybe at the mall, a coffee shop, at home, or at the gym?


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12. Communication Protocol between Inpatient Unit and FEP Service (outpatient visit within 15 days post discharge) • Since your [family member] started this program, have

they been hospitalized? • Do you know if their case worker ever saw them during

this time? • Did anyone talk to you during your [family members]

hospital admission? • Did they receive an appointment with their case worker

soon after discharge?

13. Family Psychoeducation • Were you ever offered information about psychosis or

what was happening to your family member? May have been individually or in a group?

• Were you ever offered support for your own needs, what you were going through as a family member?

• Were you provided an opportunity to connect with other family members?

Additional questions (if time) • What have you found most helpful about this program? • Is there anything that you would like to be different or you

think could be improved? • Is there anything else you would like us to know about this

program?

Appendix E: Staff Interview Guide

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Appendix E: Staff Interview Guide This interview guide is designed to be used in conjunction with the First Episode Psychosis Fidelity Scale (FEPS-FS) and several documents including:

• the pre-interview preparation guide • the health record audit guide and • FDA approved antipsychotic dosing guidelines • the FEPS-FS rating manual

The suggested questions are designed to cover all aspects of the fidelity assessment but should be supplemented by any questions the rater may have based on the information submitted before the telephone interview. All the questions should be asked to the key informant who should be the program person taking the lead for the fidelity review. This person should be prepared to address all the questions and be knowledgeable about the information submitted prior to the fidelity interview. The same questions can be used for the start of the more targeted interviews with other individuals, but more probing questions need to be asked to explore their perspective and role. Who is interviewed? The team leader completes the whole interview. Interviews with other team members need to be flexible and to reflect their specific role in the particular program The individual responsible for case management is interviewed on items 4, 10, 11, 12, 13, 16, 17, 19 20, 22 The supported employment specialist is interviewed on items 14, 18 The prescriber is interviewed on items 3, 5, 6, 7, 8, 9, 14, 15, 24 Assessor Instructions: This interview guide is intended to be used with the program manager and the case managers/care coordinators. Relevant questions may also be used with other staff (e.g., nurse, employment specialist, CBT specialist, peer support worker, etc.) as appropriate. If you know you will be interviewing other specialty roles, it is helpful to note in advance which questions will be relevant. If you are using this interview guide with multiple individuals, you do not necessarily have to ask questions again once they have already been answered. This same document can be used to take notes for multiple interviews so all your notes per question will be together. If you will be printing out a copy to bring, you may want to make the boxes larger. At the end of the interview guide there is a handout that can be given to the interviewee if helpful. It contains the lists of items for relevant questions, so they can read along with you. Before starting the interview, the assessors should identify 1 team member to ask questions and 1 to take notes. The assessor leading the interview should view these questions as a guide and use their judgement as to which questions are appropriate to ask individual staff. Questions may be rephrased, omitted/ added or reordered as is appropriate to get the information needed to complete the ratings.


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Notes should not include any individual names or personal health information. Notes should pertain to program performance. Please avoid comments about performance of individual staff. Introduction/consent Thank you for agreeing to be interviewed as part of the fidelity review. Before we begin, please review the consent form (if required). I am happy to answer any questions and if you feel comfortable proceeding, please sign the bottom. Remember that you can always choose not to answer specific questions or stop the interview entirely. [Give time for staff to review consent form and answer any questions.] Background Could you tell us about your role in the program, your professional background and how long you have been involved in the program? (This question can be used to help gauge which questions will be appropriate for this individual.)

Questions about intake/ assessments:

Questions Responses 1. Timely Contact with Referred Individual- first face to face contact within 2 weeks • Do you have a policy about how soon you contact a person

by telephone after referral? If yes, what is it? • Do you have a policy about how soon a person is seen at

the clinic after referral? If yes, what is it? • Who does the initial assessments? • Who determines that they meet clinical criteria for

admission to the program? • How do you handle referrals who are not deemed

appropriate?

2. Clients and Family Involvement in Initial Assessments • Do you have a policy of family involvement in the initial

assessment? If yes, what is it?


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• How do communicate the need and benefit of family involvement in the initial assessment prior to the first meeting?

3. Comprehensive Clinical Assessment at Enrollment (all 9 items completed) • Please outline what information is collected at the initial

assessment upon enrollment into the FEP Service. • Change in functioning from stable baseline

□ Time of onset of substance use and frequency of use

□ Recent changes in behavior □ Risk assessment/harm to self or others □ Mental status exam □ Psychiatric history □ Premorbid functioning □ Co-morbid medical illness & substance use □ Family History

• Who reviews the initial assessment after completion? • Where would we find it in the chart? (ask for a blank copy

if you don’t have already)

4. Psychosocial Needs Assessed for Care Plan (all 11 items included) • Do you assess the psychosocial needs of your clients? • Which of the following areas are assessed?

□ Housing □ Employment □ Education □ Social support □ Past trauma □ Basic living skills □ Family Physician □ Social skills


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□ Legal □ Finance

• Do you develop and document care plans for your clients? • If yes “How often do you update these Care Plans? 5. Individualized Clinical Treatment Plan after initial assessment • Do your clients have individualized clinical treatment

plans? • How do you engage clients in developing the plans? • How do you document client involvement in developing

the plans? □ Do the clients sign off on the plan? □ Do the clients receive a copy of the plan? □ Do family members receive a copy of the plan?

• If yes to #5a, what is addressed in the clinical treatment plan?

□ Needs □ Goals □ Preferences □ Pharmacotherapy □ Psychotherapy □ Substance Use □ Mood problem □ Suicide prevention □ Weight management


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Questions about medications: The next four items are related to medications. Staff may or may not be able to answer these questions which is okay as these questions will also be asked of the psychiatrist. If you are concerned about time, this may be an area to consider skipping or leaving until the end if there is time.

Questions Responses 6. Antipsychotic Medication Prescription • What percentage of clients with a first episode psychosis

are offered antipsychotic medications? • Do you provide written materials about antipsychotic

medications? (SEND COPY) • How do you assess side effects of medications? HOW

OFTEN?

7. Antipsychotic Dosing Within Recommendations • What is your policy regarding antipsychotic dosing? • What proportion of antipsychotic prescriptions are within

the recommended government approved dose range (at 6 months)?

• What % of clients are on dosages below the guidelines at 6 months?

• Are there any challenges related to dosing within guidelines?

8. Guided Antipsychotic Dose Reduction • Do you ever recommend that clients start a medication

reduction regime with a view to assessing their need for longer term antipsychotic maintenance pharmacotherapy?

• What are your guidelines for selecting individuals for this recommendation?

• Are those guidelines shared with clients and families? • Can we have a copy of those guidelines? • What percentage of clients are offered this

recommendation?


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9. Clozapine for Medication Resistant Symptoms • Does the program use clozapine when indicated? • How many of your clients who have been in the program

for two years are on Clozapine?


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Questions about services provided:

Questions Responses 10. Client Psychoeducation • Are clients provided with information about the schizophrenia spectrum

disorders? If yes, how? • What language groups live in the community that you serve? • What languages do you provide written materials in? • Do you have a structured psychoeducational curriculum (e.g., Illness

management and recovery curriculum, Wellness, Recovery Action Plan (WRAP) training)? If yes, what is it? ASK FOR A COPY

• Who delivers the curriculum? • Are staff trained in the use of this curriculum? If yes, how are they trained? • How is this curriculum delivered? Are clients engaged in formal group or

individual psychoeducational sessions? What is the format of the sessions? How often are they offered? What are the topics of discussion?

□ Developing coping and self-help strategies □ Developing resiliency □ Dealing with the symptoms of psychosis □ Activities of daily living □ Educational/academic supports □ Vocational/employment supports □ Housing supports □ Substance use □ Establishing social relationships or connections □ Peer support □ Income support

• Do you document whether a client receives this curriculum? If yes, how do you document this?


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11. Family Psychoeducation • How do you deliver information about schizophrenia spectrum disorders to

family and caregivers? • Do you provide written materials in various languages? • Are families engaged in individual or group sessions? • If yes to #11c, please describe the format of the sessions, how often they are

offered, and the topics of discussion? □ Information about the illness, its treatment and management. □ Recognition and prevention of relapse. □ Strategies to reduce family tensions and stress.

• Do you document family and caregiver participation in your sessions? • Do the staff who deliver family education and support have formal training?

If yes, what is it? □ Formal part of their professional training. (Describe) □ Continuing professional development with a formal confirmation

of proficiency. □ Continuing professional development without confirmation of

proficiency. • Do the staff who deliver family education receive supervision? (Describe the

frequency and intensity of the training.)

12. Cognitive Behavioural Therapy (CBT) • Does the program offer Cognitive Behaviour Therapy (CBT) for clients? • Who delivers the CBT? • Do the staff who deliver CBT have formal training in CBT? If yes, what is it?

□ A formal part of their professional training □ Continuing professional development with a formal confirmation of

proficiency □ Continuing professional development without confirmation of

proficiency • What are the indications for which CBT is provided?

□ Anxiety or depression


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□ Residual or medication resistant positive symptoms □ Other indications

• How many sessions are typically given to an individual client? • Do you offer CBT in individual or group formats or both? • Please tell us about the last client to whom you delivered CBT

□ What was the target problem / symptom □ How did you engage the client □ What strategies did you suggest to deal with the problem □ Did you assign a homework task? □ What was the outcome of therapy?

13. Interventions to Prevent Weight Gain • Do you routinely monitor weight? • Do you have guidelines for classifying weight such as the BMI? • What interventions do you offer to prevent weight gain?

□ Nutritional counseling □ Cognitive behavioral therapy □ Exercise □ Medication options

• If yes to #13c, please describe the programs and format of the sessions. o Are these details (BMI, interventions, program intervention) in your

documentation? o How many of your clients participate in weight reduction programs?

14. Annual Formal Comprehensive Assessment (all 7 items) • Do you conduct an annual comprehensive assessment? • Please outline what information is collected at the annual formal assessment.

□ Educational/occupational & social functioning □ Symptoms □ Psychosocial needs □ Risk assessment of harm to self/others □ Substance use


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□ Extrapyramidal side effects □ Metabolic parameters (weight, glucose & lipids)

• Who reviews the assessment after completion? • Where would we find it in the chart? (ask for a blank copy if you don’t have

already) 15. Assigned Psychiatrist • Are clients assigned a psychiatrist/qualified prescriber (excluding family

doctor) upon enrollment into the program? • How frequently can clients be seen by the psychiatrist/qualified prescriber

for urgent problems or to adjust medications early in treatment? • Can individual clients be seen at least every two weeks if clinically indicated? • What is the case load of the psychiatrist/qualified prescriber? • How many FTE of psychiatrist/qualified prescriber time is available for that

case load?

16. Assignment of Case Manager • What proportion of your clients get assigned a staff person who is

responsible for delivering case management services or to a case manager upon enrollment in the FEP Service?

17. Motivational Interviewing (MI) or Cognitive Behavioral Therapy (CBT) for Co-occurring Substance Use Disorder (SUD) • How many of your clients have a substance use disorder? • How do you assess for the presence of a substance use disorder? • How do you document the presence of a substance use disorder? • What types of therapeutic services do you provide to individuals with co-

occurring substance use disorders? □ Motivational Interviewing □ Cognitive behavioral therapy

• What types of therapeutic services do you provide to individuals with co-occurring substance use disorders?

• Do the staff who deliver MI or CBT for psychosis have formal training in those modalities? If yes, what is it? Was it a formal part of their professional training or have they received?

□ A formal part of their professional training


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□ Continuing professional development with a formal confirmation of proficiency

□ Continuing professional development without confirmation of proficiency

• What other services are offered to address co-occurring substance use disorders?

18. Supported Employment (SE) • Do case managers assess and record the work and educational interests of

their clients? If yes, when, and how often? • Do you have a separate role on your team for SE specialist (or is this part of

the job responsibilities for a care manager? • Do you use a career profile or equivalent? (Ask for a copy of form) • What supported employment model do you follow? (Prompts: IPS, SAMHSA

toolkit, RAISE NAVIGATE model, On Track) • What training materials/manuals do you use and what training has your SE

specialist(s) received? (Prompts: IPS Employment Center online course, IPS practice manual, SAMHSA toolkit, RAISE toolkit, On Track.)

• Is your SE specialist attached to an SE team? • Do your SE specialists receive supervision from an experienced SE

supervisor? (What frequency?) • How many clients are on each SE specialist’s caseload? • Do your SE specialists track in-person employer contacts? If yes, what was

the frequency over the last month? • How frequently do your SE specialists attend First Episode Psychosis clinical

treatment team meetings? • After entering the SE program, how soon on average does the job search

start? • Does the SE specialist help clients gain volunteer opportunities or non-

competitive jobs? How many people currently hold those types of positions?

• Does the SE specialist help clients gain internships? If yes, how many clients currently have paid internships? Unpaid internships?


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19. Active Engagement and Retention • Do you have a policy about where case managers meet their clients and

families? If yes, what is it? • What proportion of all client visits are out of the office?

20. Community Living Skills • How do you assess the community living skills of your clients? • Do you provide community-based training in community living skills such as

budgeting, cooking, travelling and banking? • Where would we find documentation in the health record?

21. Crisis Intervention Services • How does your program manage client related crises during and after hours?

□ Formal linkages to out of hours’ services □ Respond to crisis calls during office hours □ Drop-in crisis visits during office hours □ 24-hour phone and in person crisis services

Questions about the team structure:

Questions Responses 22. Participant / Provider Ratio • What is the total FTE of all non-medical clinical staff

assigned to the program? • How many clients are currently enrolled in the program?

23. Practicing Team Leader • Do you (the team leader) provide clinical services to

clients? • What are your academic and professional credentials? • How much time do you spend providing direct supervision

and/or clinical services? • Do you carry a caseload? Do you provide counseling or

other direct services?


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• Do you have other responsibilities at the mental health center outside of this role?

24. Psychiatrist Role on Team • What is the role of the psychiatrist on the team?

□ Attend team meetings □ See patients with another clinician □ Accessible for consultation by team during the

work week □ Records medication, symptoms, side effects, etc.,

in medical record available to who team □ Referral to primary care when indicated

25. Multidisciplinary Team • What services are provided to the clients enrolled in your

program? □ Case Management Services □ Psychiatric services such as, diagnosis, prescribing,

monitoring side effects □ Nursing services including medication

administration, monitoring weight, and Blood Pressure

□ Therapy Services such as client and family psychoeducation, CBT, and therapy for addictions

□ Employment services such as Supported Employment

□ Support for community living skills training □ Other, please describe

26. Duration of First Episode Psychosis (FEP) Program • Is there a time limit on the length of time a person can

receive services here? What is it?

27. Weekly Multi-Disciplinary Team Meetings • Does your program have clinical team meetings?


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• How often are team meetings held? • What issues are discussed during team meetings?

□ Case review, admissions, and discharges □ Assessment and treatment planning and

coordination □ Discussion of complex cases

• Who attends those meetings?

28. Targeted Health/Social Service / Community Groups (public education) • Do you provide education about psychosis and first

episode psychosis services to first contact professionals such as community mental health teams, school and college counsellors, social services agencies, family physicians, emergency rooms?

• How often, where and to who? □ Family physician □ School & post-secondary counseling services □ Police service □ Hospital emergency rooms □ Youth social services agencies □ Community mental health services

29. Communication Protocol between Inpatient Unit and FEP Service (outpatient visit within 15 days post discharge) • What is the programs protocol when a client is

hospitalized? • Does your staff visit clients at the hospital? Do they have

ongoing communication with the hospital staff? Are they notified when someone is admitted or when they are discharged?

• What is the program’s role in the discharge process? • What is the average length of time between discharge

from the hospital and being seen by a program team member?



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• What is the programs protocol when a client is hospitalized?

• Does your staff visit clients at the hospital? Do they have ongoing communication with the hospital staff? Are they notified when someone is admitted or when they are discharged?

• What is the program’s role in the discharge process? • What is the average length of time between discharge

from the hospital and being seen by a program team member?

31. Population Served • How do you determine the size of the population that you

serve? • Does the program compare the FEP annual admission rate

in the population served to the expected incidence in the population served?”

• If yes to #31a, “What is the ratio of annual admission rate to the expected incidence?


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Handout for interviewee 1. Comprehensive Clinical Assessment at Enrollment

□ History of presenting symptoms - Time course of symptoms, change in functioning and substance abuse □ Recent changes in behavior □ Risk assessment/harm to self/others □ Mental status exam □ Psychiatric history □ Premorbid functioning □ Co-morbid medical illness □ Co-morbid substance use □ Family History

2. Psychosocial Needs Assessed for Care Plan

□ Housing □ Family Physician □ Employment □ Social skills □ Education □ Family support □ Social support □ Past trauma □ Finance □ Legal □ Basic living skills

3. Annual Formal Comprehensive Assessment

□ Educational/occupational & social functioning □ Psychosocial needs □ Risk assessment of harm to self/others □ Substance use □ Symptoms □ Extrapyramidal side effects □ Metabolic parameters (weight, glucose & lipids


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4. Crisis Intervention Services □ Telephone crisis support, 8 hours a day, 5 days a week □ In-person crisis support, 8 hours a day, 5 days a week □ In-person crisis support, 24/7 □ Linkage to after-hours crisis services (e.g., crisis lines, urgent care centres, emergency department)

5. Psychiatrist Role on Team

□ Attend team meetings □ Sees clients at the same location as the team □ Accessible for consultation during the work week □ Shares team health records □ See clients with other clinicians


□ Nursing services □ Evidence based psychotherapies □ Evidence based addiction treatments □ Supported Employment □ Family Education and Support □ Social/community living skills


□ Case review □ Assessment and treatment planning □ Complex cases □ Termination of services

Appendix F: Meeting Observation Guide

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Appendix F: Meeting Observation Guide Assessors: _______________________Program: ________________________________Date: _________________________

Source What to look for Item Notes Minutes from previous team meetings

Attendance: Which disciplines? All team members?

24,25

What topics are typically covered?

27 □ Case review (admissions & discharges) □ Assessment and treatment planning □ Discussion of complex cases □ Termination of services

Observation of Team Meeting

Which disciplines are in attendance? All team members?

24,25

Which topics are on the agenda?

27 □ Case review (admissions & discharges) □ Assessment and treatment planning □ Discussion of complex cases □ Termination of services

Evidence of multi-disciplinary involvement in client care? How does the team work together, including the psychiatrist?

24,25

Other comments related to specific fidelity items (e.g., public education, family involvement, provision of CBT etc.)

Appendix G: Final Report Template

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FEPS-FS Fidelity Final Report

Program name: Location:

Date of Assessment: Names of Assessors:

Date of Report:


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Introduction This report includes the findings from a --- day site visit to assess fidelity using the First Episode Psychosis Fidelity Scale (FEPS-FS) at the _______________ Program. Measuring fidelity, or adherence to the model, is important to ensure that the services delivered in xxxxxx programs are consistent, high quality and in alignment with the xxxxx Standards. This fidelity assessment was conducted using the validated First-Episode Psychosis Services Fidelity Scale (Addington 2016). The purpose of fidelity assessments is to better understand the services delivered in xxxx programs. It is expected that ratings will vary widely depending on available resources and what is appropriate in the local context; a rating of 5 may not always be the expectation. This report is an opportunity to reflect and identify areas of strength and promising practices that can be shared with other programs, as well as opportunities for quality improvement. Overall Performance Include a short overall summary of program quality of care in relation to the fidelity scale, including areas of strength, opportunities for improvement and overall impressions.


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Ratings per item The following section provides the score for each of the 31 fidelity items from the First-Episode Psychosis Services Fidelity Scale (FEPS-FS). Each item will receive a score between 1 (indicating a low level of fidelity) to 5 (indicating a high level of fidelity), as well as additional details on how the score was determined, contextual information to explain the score and potential recommendations. Instructions for completion Rating: Insert the final rating using language from the scale (including the number and the text). Comments:

• Specify data source(s) used for rating: What data sources did you use to determine your rating? Usually this will be based on the health record review or administrative data but for some items it will be based on other data sources (e.g., staff interview, policy/ document review).

• Any contradictions between data sources? For example, the health records might show a low rate of family involvement in the initial assessment (which would result in a low score) but interview feedback reported high rates. This contradiction will not impact the score but should be noted. It may also be possible to note an explanation for this contradiction (e.g., may be a documentation issue).

• Any policies/ procedures in place to support this item? • Any additional relevant contextual information that might explain score? For example, low rates of clozapine prescribed may be due to

high rate of mood disorder diagnosis in program. Or perhaps the rate of family psychoeducation is low because the family worker role has remained unfilled for the last 6 months due to hiring challenging. This doesn’t change the score but it is important to note in this section.

• Any recommendations for QI opportunities or promising/ innovative practices to highlight? If possible, it is helpful to identify opportunities for improvement. For example, if the rating for an item is low and the policy review indicates that no procedures are in place to support the item, this may be a practice improvement area to flag. It is also important to highlight successes- particularly if you identify creative or innovative practices that might be of value to share with other programs.

• Specific additional information requested per item: Some items may also have specific additional information that should be included. These will be specifically listed per item.

• Additional comments: This is an opportunity for the assessor to include any additional comments. This includes additional comments related to the services delivered at the site and also comments related to the experience of rating the item. (e.g., was this item difficult to rate? do you feel the rating is valuable/ reflects program practice? etc.)


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Describe data sources used

• Profile of health records reviewed • # of health records for clients in the program less than 1 year: • # of health records for clients in the program between 1-2 years: • # of health records for clients in the program between 2-3 years: • # of health records for clients in the program for more than 3 years: • Staff interviewed (list by role): • # clients interviewed: • # families interviewed: • Staff meeting observed (y/n):

RATING COMMENTS 1. Timely contact with referred individual- First in-person appointment within 2 weeks Specify data source(s) used for rating:

Any contradictions between different data sources? Any policies/ procedures in place to support this item? Any additional relevant contextual information? Any recommendations for QI opportunities/ promising practices? % of clients contacted by phone within 72 hours of receiving the referral Additional comments:

2. Client and family involvement in assessments

Specify data source(s) used for rating: Any contradictions between different data sources? Any policies/ procedures in place to support this item? Any additional relevant contextual information? Any recommendations for QI opportunities/ promising practices? Additional comments:

3. Comprehensive clinical assessment at enrollment

Specify data source(s) used for rating: Any contradictions between different data sources? Any policies/ procedures in place to support this item? Any additional relevant contextual information? Any recommendations for QI opportunities/ promising practices?


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RATING COMMENTS % of clinical assessments with 6-8 items completed: % of clinical assessments with less than 6 items completed: Additional comments:

4. Psychosocial needs assessed for care plan

Specify data source(s) used for rating: Any contradictions between different data sources? Any policies/ procedures in place to support this item? Any additional relevant contextual information? Any recommendations for QI opportunities/ promising practices? % of care plans with 6-10 items addressed: % of care plans with less than 6 items addressed: What % of clients have a completed OCAN in the file? Which are generally completed (Core, Self, Staff)? What % of care plans were completed within the first three months? Additional comments:

5. Individualized clinical treatment plan after initial assessment

Specify data source(s) used for rating: Any contradictions between different data sources? Any policies/ procedures in place to support this item? Any additional relevant contextual information? Any recommendations for QI opportunities/ promising practices? How long on average from first face to face meeting until the care plan is completed? Additional comments:

6. Antipsychotic medication prescription

Specify data source(s) used for rating: Any contradictions between different data sources? Any policies/ procedures in place to support this item? Any additional relevant contextual information? Any recommendations for QI opportunities/ promising practices? Is client preference generally taken into account? If so, explain how this is done and how disagreements/ refusal are resolved. Additional comments:


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RATING COMMENTS 7. Antipsychotic dosing within recommendations

Specify data source(s) used for rating: Any contradictions between different data sources? Any policies/ procedures in place to support this item? Any additional relevant contextual information? Any recommendations for QI opportunities/ promising practices? What % of clients receive initial dosage prescriptions at the low end of the guidelines? What % of clients receive low incremental increases? Additional comments:

8. Guided antipsychotic dose reduction


9. Clozapine for medication resistant symptoms

Specify data source(s) used for rating: Any contradictions between different data sources? Any policies/ procedures in place to support this item? Any additional relevant contextual information? Any recommendations for QI opportunities/ promising practices? # of clients with clozapine prescription (from health records): % of clients in program with a mood disorder (vs schizophrenia): Of those with schizophrenia, what % are on Clozapine? Additional comments:

10. Client Psychoeducation- 12 episodes provided by trained clinician

Specify data source(s) used for rating: Any contradictions between different data sources? Any policies/ procedures in place to support this item? Any additional relevant contextual information? Any recommendations for QI opportunities/ promising practices? Are clients offered group or individual psycho-education?


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RATING COMMENTS Is there a formal manual or curriculum that is followed? Additional comments:

11. Family education and support- 8 episodes provided by trained clinician

Specify data source(s) used for rating: Any contradictions between different data sources? Any policies/ procedures in place to support this item? Any additional relevant contextual information? Any recommendations for QI opportunities/ promising practices? Are families connected to other families in any way? Explain Is there a formal manual or curriculum that is followed? Describe Additional comments:

12. Individual or group cognitive behavior therapy (CBT), for treatment resistant positive symptoms, or for residual anxiety or depression- 10 sessions delivered by trained clinician

Specify data source(s) used for rating: Any contradictions between different data sources? Any policies/ procedures in place to support this item? Any additional relevant contextual information? Any recommendations for QI opportunities/ promising practices? # of clients with evidence in health record review of receiving CBT: Where was CBT training received (if applicable)? Were any staff specifically trained in CBT for psychosis? Additional comments:

13. Individual and / or Group Interventions to Prevent Weight Gain

Specify data source(s) used for rating: Any contradictions between different data sources? Any policies/ procedures in place to support this item? Any additional relevant contextual information? Any recommendations for QI opportunities/ promising practices? # of clients with evidence in health record review of attending weight management program: Specify which type of weight management program is being provided Additional comments:

14. Annual Formal Comprehensive Assessment Specify data source(s) used for rating:


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RATING COMMENTS Any contradictions between different data sources? Any policies/ procedures in place to support this item? Any additional relevant contextual information? Any recommendations for QI opportunities/ promising practices? What % of clients have a formal annual assessment on file? What % of clients have an ongoing review of 3-6 items? What % of clients have an ongoing review of <3 items? Additional comments:

15. Assigned Psychiatrist (psychiatrist caseload)

Specify data source(s) used for rating: Any contradictions between different data sources? Any policies/ procedures in place to support this item? Any additional relevant contextual information? Any recommendations for QI opportunities/ promising practices? How many FTEs of psychiatry do you have available? How long does it take on average to get an initial appointment for new clients (time between first face to face appointment to first psychiatry appointment)? If a client needs to be seen every two weeks by a psychiatrist, is that possible? If a client’s condition changes and they need to be seen rapidly, how quickly can that occur? Additional comments:

16. Assignment of Case Manager

Specify data source(s) used for rating: Any contradictions between different data sources? Any policies/ procedures in place to support this item? Any additional relevant contextual information? Any recommendations for QI opportunities/ promising practices? How many FTEs of psychiatry do you have available? How long does it take on average to get an initial appointment for new clients (time between first face to face appointment to first psychiatry appointment)? If a client needs to be seen every two weeks by a psychiatrist, is that possible? If a client’s condition changes and they need to be seen rapidly, how quickly can that occur? Additional comments:


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17. Motivational Enhancement (ME) or Cognitive Behavioral Therapy (CBT) for Co-Morbid Substance Use Disorder (SUD)

Specify data source(s) used for rating: Any contradictions between different data sources? Any policies/ procedures in place to support this item? Any additional relevant contextual information? Any recommendations for QI opportunities/ promising practices? # of clients with evidence in health record review of receiving MI or CBT for substance use: Additional comments:

18. Supported Employment


19. Active Engagement and Retention

Specify data source(s) used for rating: Any contradictions between different data sources? Any policies/ procedures in place to support this item? Any additional relevant contextual information? Any recommendations for QI opportunities/ promising practices? Are there other proactive outreach activities done by the program? (e.g., appointment reminder, no-show follow up etc.) Additional comments:

20. Community Living Skills


21. Crisis Intervention Services

Specify data source(s) used for rating: Any contradictions between different data sources?


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Any policies/ procedures in place to support this item? Any additional relevant contextual information? Any recommendations for QI opportunities/ promising practices? Additional comments:

22. Participant/Provider Ratio

Specify data source(s) used for rating: Any contradictions between different data sources? Any policies/ procedures in place to support this item? Any additional relevant contextual information? Any recommendations for QI opportunities/ promising practices? What is the actual caseload per case manager? Additional comments:

23. Practicing Team Leader

Specify data source(s) used for rating: Any contradictions between different data sources? Any policies/ procedures in place to support this item? Any additional relevant contextual information? Any recommendations for QI opportunities/ promising practices? Does the team leader or program manager have multiple portfolios (aside from FIRST EPISODE PSYCHOSIS)? What FTE is the program manager? Does the program manager have a background of providing direct services in FIRST EPISODE PSYCHOSIS? Additional comments:

24. Psychiatrist Role on Team



Specify data source(s) used for rating: Any contradictions between different data sources? Any policies/ procedures in place to support this item? Any additional relevant contextual information?


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Any recommendations for QI opportunities/ promising practices? Describe the team members and which roles are funded through the FIRST EPISODE PSYCHOSIS service and which are provided by collaborating partners. Additional comments:

26. Duration of FIRST EPISODE PSYCHOSIS Program

Specify data source(s) used for rating: Any contradictions between different data sources? Any policies/ procedures in place to support this item? Any additional relevant contextual information? Any recommendations for QI opportunities/ promising practices? What % of clients exceed the program maximum? Why? Additional comments:


Specify data source(s) used for rating: Any contradictions between different data sources? Any policies/ procedures in place to support this item? Any additional relevant contextual information? Any recommendations for QI opportunities/ promising practices? Any evidence of multi-disciplinary involvement in client care? How does the team work together, including the psychiatrist? Additional comments:

28. Targeted Health/Social Service / Community Groups (Public education)


29. Communication Protocol between Inpatients/clients Unit and FIRST EPISODE PSYCHOSIS Service (outpatient visit within 15 days post discharge)

Specify data source(s) used for rating: Any contradictions between different data sources? Any policies/ procedures in place to support this item? Any additional relevant contextual information?


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Any recommendations for QI opportunities/ promising practices? What is the typical communication between FIRST EPISODE PSYCHOSIS staff and inpatient staff during hospitalization? Are FIRST EPISODE PSYCHOSIS staff typically involved in discharge planning from inpatient units? Additional comments:


Specify data source(s) used for rating: Any contradictions between different data sources? Any policies/ procedures in place to support this item? Any additional relevant contextual information? Any recommendations for QI opportunities/ promising practices? Describe the program’s inclusion and exclusion criteria for admission. Additional comments:

31. Population Served

Not possible to calculate rating

Number of new clients admitted in the past 12 months per 100,000 population: Number of new clients admitted in the past 12 months per 100,000 population age 15-45: Additional comments:

Appendix I: Medication Dosing Guidelines

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Appendix I: Medication Dosing Guidelines The United States Federal Drug Administration approved dose ranges for antipsychotics in the schizophrenia

Generic Name Proprietary Name Approved dose range Aripiprazole Oral Abilify 10 mg – 30 mg / day Aripiprazole IM LA Abilify Maintaina 300 mg – 400 mg / weeks Asenapine Saphris 10 mg – 20 mg / day Brexpiprazole Exult 2 mg – 4 mg / day Cariprazine Frailer 1.5m – 6 mg / day Chlorpromazine Generics 200 mg – 800 mg / day Clozapine Generic 300 mg – 900 mg / day Fluphenazine Prolamin 2.5 mg – 20 mg / day Fluphenzine decanoate IM LA Moderated 12.5 mg – 50 mg / 2- 3 weeks Haloperidol Haldol 1.5 – 20 mg / day Haloperidol decanoate IM LA Generic 50 mg – 250 mg / 4 weeks Iloperidone Fanarts 6 mg – 12 mg / day Leaside Latuda 40 to mg – 120 mg / day Molindone Moran 20 mg – 200 mg /day Olanzapine Zyprexa 10 mg – 20 mg / day Paliperidone Oral Invega 3 mg – 12 mg / day Paliperidone Palmitate IM LA Invega Sistema 25 mg – 150 mg / weeks Paliperidone Invega Terina 175 mg – 525 mg / 12 weeks Quetiapine Seroquel 150 mg – 800 mg / day Quetiapine XR Seroquel XR 400 mg – 800 mg / day Risperidone Risperdal 2.0 mg – 16.0 mg /day Risperidone IM LA Risperidal Consta 25 mg – 50 mg / 4 weeks Thiothixine Nagana 2 mg – 40 mg / day Trifluoperazine Generic 2 mg – 40 mg / day Ziprasidone Geodon 40 – 160 mg / day

First Episode Psychosis Fidelity Scale (FEPS-FS) · 4 . General Guidelines . Background . The First Episode Psychosis Services Fidelity Scale (FEPS-FS) assesses the degree to which

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