Digitalizing Psychiatric Home Treatment: Participatory Design Study on Essential Digital Features with Patients and Professionals

Digitalizing Psychiatric Home Treatment: Participatory Design Study on Essential Digital Features with Patients and Professionals Authors Full name Title Mail Affiliation (s) ORCID Hannah Mundry [email protected] 1,2 0009-0009-26311249 Toni Starke BSc [email protected] 1,2 0009-0001-29380778 Justin Speck BSc [email protected] 1,2 0009-0009-84715081 Martin Heinze MD martin.heinze@immanuelalbertinen. de 1,2 0000-0003-36451033 Stefan Hochwarter PhD [email protected] 3 0000-0003-2652135X Julian Schwarz MD [email protected] 1,2 0000-0001-73067909 1. Department of Psychiatry and Psychotherapy, Center for Mental Health, Immanuel Hospital Ruedersdorf, Brandenburg Medical School, Ruedersdorf, Germany Ruedersdorf DE 2. Faculty of Health Sciences Brandenburg, Brandenburg Medical School, Neuruppin, Germany Neuruppin DE 3. HEALTH - Institute for Biomedical Research and Technologies, JOANNEUM RESEARCH Forschungsgesellschaft mbH, Graz, Austria Graz, AT Corresponding author(s): Julian Schwarz Department of Psychiatry and Psychotherapy, Center for Mental Health, Immanuel Hospital Rüdersdorf, Brandenburg Medical School Theodor Fontane Seebad 82/83, Rüdersdorf, DE, Germany Email: [email protected] 1 Abstract Background: Home Treatment (HT) is an established alternative to inpatient psychiatric care, enabling the management of acute mental health crises in patients’ home environments. Yet, maintaining treatment intensity and providing group-based interventions comparable to inpatient settings remain challenging, particularly when long travel times reduce visit frequency. Digital health solutions may help overcome structural limitations. Objective: The aim of this study was to explore patient needs and identify essential digital features to support both patients and HT teams. These findings were translated into a mock-up for a mHealth application. Methods: A participatory digital design approach was used involving patients (n = 13), healthcare professionals (n = 6), and software developers (n = 2), all with lived HT experience or ≥2 years of professional HT practice. Across three rounds of discussion groups (6/2023–9/2025; n = 4), participants co-developed ideas, which developers iteratively translated into feasible digital concepts. Transcripts were analysed inductively using structured qualitative content analysis, with findings continuously validated and integrated into an application mock-up. Results: Analysis yielded five overarching functional domains and 18 associated digital features: (1) Coordination and scheduling – calendar, reminders, team overviews, appointment coordination; (2) Information and documentation management – treatment overviews, patient profiles, centralized documentation, data sharing; (3) Self-management – mood diary, reminders, visualisation of mood trajectories, task planning; (4) Communication and remote care – secure messaging, emergency button, configurable notifications, feedback; (5) Peer Exchange – protected peer forums, digital group therapy, regional support directories. Overall, participants emphasised usability, ongoing technical support, and team involvement as critical, while digital literacy and device accessibility emerged as potential barriers. Conclusion: Digital applications can enhance patient-centredness and intensity, complexity, and flexibility of HT by addressing structural constraints. Participatory digital design and structured clinical implementation are essential for sustainable adoption. Future research should examine feasibility, effectiveness, and long-term impact of digitally supported HT models. Keywords: Psychiatric Home Treatment; Telemedicine; Mobile Applications; Patient-Centered Care; User-Centered Design; Self-Management; Participatory Design. 2 Background Internationally, there is a growing effort to provide acute psychiatric crisis care in patients’ home environments rather than in inpatient settings (1–3). Home Treatment (HT) offers several advantages for recovery, as it allows patients’ social networks and personal resources to be more effectively recognized and integrated into care (2,4–6). Over the past decade, community-based psychiatric treatment models have become increasingly differentiated—either by target group, e.g., dementia care, perinatal mental health crises (1,2,7), or by the intensity of treatment provided. Assertive Community Treatment offers long-term, low-threshold, and intermittent outreach care for people living with severe mental illness (SMI) (8); Crisis Resolution Teams often serve a gatekeeping function (3,9); and intensive HT teams provide high-frequency support, with up to several daily treatment contacts (6,8). However, these terms are often used interchangeably in the literature (9). The effectiveness of HT compared with inpatient care is now well established (10): HT has been shown to reduce treatment duration (11), lower readmission rates in the months following discharge and thereby mitigating “revolving-door” effects (8,11,12), and improve patient satisfaction and functional recovery (10,11), while maintaining comparable overall costs (10,13). From the patients’ perspective, the key elements of successful HT include low-threshold accessibility, rapid team responsiveness, and continuity of care to foster trust (2,6,14). Additional success factors are flexible and individualized scheduling of treatment contacts, a broad range of therapeutic interventions, family involvement, and opportunities for peer exchange (6). Despite its demonstrated effectiveness, implementing HT under real-world conditions remains challenging. These best practice definitions are often only partially achieved due to structural barriers such as long travel distances, staff shortages, part-time employment, and limited financial resources (2,6,10,15–17). In light of these structural constraints, digital health technologies may offer a promising avenue to strengthen and expand the reach of HT. Several studies suggest that digital health applications in the context of HT have high potential to augment face-to-face care, making HT more intensive, flexible, and individualized; facilitating more immediate communication between patients and HT teams; and thereby enhancing patient-centeredness (18–20). For example, approaches such as Ecological Momentary Assessment (EMA) and Just-in-Time Adaptive Interventions enable real-time symptom monitoring and response within patients’ natural environments (21,22). HT teams can guide the use of these digital tools during home visits, thereby supporting engagement and adherence (18),(23,24). In addition, alternating between digital and in-person treatment contacts can improve workforce efficiency (25), for instance by reducing travel times, thus enabling higher treatment intensity or even making HT feasible in rural areas (26). Digital peer support and group therapy interventions have already been tested in several studies, demonstrating feasibility and efficacy (27,28). To date, most research on the digital augmentation of HT has remained largely theoretical, focusing on how digital approaches might be integrated into patient-centered HT and exploring the perceived needs and expectations of future users, particularly patients and healthcare professionals (HCPs) (18,29). The aim of this study was to explore patient needs as the primary basis for digital support in psychiatric HT, while also integrating the perspectives of HCPs who would use such tools in practice. The study further sought to identify related essential digital features to support patients and HT teams and to translate them into a user-centred and technically feasible mock-up for a mHealth application. The following research questions were addressed: 3 1. What are the perceived needs, priorities, and essential digital features for supporting psychiatric HT from the perspectives of patients and healthcare professionals? 2. How can these essential digital features be translated into a user-centred and technically feasible mHealth mock-up? Methods Design To address the exploratory research questions in a user-centered and comprehensive manner, a participatory digital design (PDD) approach was applied. PDD refers to the adaptation of participatory design methods (30) to the development of digital technologies, integrating all relevant stakeholders—patients and HCPs—as equal partners throughout all phases of the collaborative design process (31,32). The successful implementation and sustained use of digital health interventions require the inclusion of all user groups during development to ensure that their needs and preferences are adequately represented (31,33–35). This process not only promotes more creative and context-appropriate solutions (36) but also contributes to improved clinical outcomes and successful implementation of digital interventions (37–41). The participatory collaboration took place in the form of design meetings, using digital discussion groups as the primary data collection format (42). To ensure the technical feasibility of the proposed digital concepts, software developers were actively involved in the process. The iterative nature of PDD was combined with structured elements of a modified Delphi approach to maintain a transparent and standardized procedure (43). The process consisted of three iterative rounds: 1. Exploration of needs and digital support options, 2. Communicative validation, structuring and refinement, 3. Development and validation of the mock-up. This study builds upon a previously developed best practice model for intensive HT in Germany, which was created during earlier phases of the research project (6). The model consists of 58 patient-defined criteria for “good” HT. These criteria were integrated into the design process by asking participants to reflect on how these best practice principles could be supported or enhanced through digital solutions. All qualitative data were analyzed using content analysis. The relevance and necessity of the identified essential digital features are demonstrated in the Results section through participant quotations. The study was prepared and reported in accordance with the Standards for Reporting Qualitative Research (SRQR) (44) (see Multimedia Appendix 1). Ethics Approval The study was reviewed and approved by the Ethics Committee of the Brandenburg Medical School Theodor Fontane (approval number E-02–20200715). The respective ethics committees of all participating study centers agreed to this initial approval. Setting The study was conducted in Germany, where the model of inpatient-equivalent psychiatric home treatment (IEHT; “stationsäquivalente psychiatrische Behandlung”) has been implemented. IEHT enables individuals with SMIs to receive multidisciplinary care at home, equivalent in intensity and structure to inpatient treatment (1). As of 2020, approximately 70 hospitals in Germany offered HT. Compared to other international HT models, IEHT provides particularly high treatment intensity by ensuring at least one daily face-to-face contact, usually at the patient’s home (45). 4 The study involved ten IEHT-implementing centers, representing urban (n = 5), rural (n = 1), and mixed urban–rural (n = 4) catchment areas. Participating hospitals were located in Berlin (Vivantes Klinikum Am Urban, Vivantes Klinikum Neukölln, Charité – Universitätsmedizin Berlin), Brandenburg (Department of Psychiatry and Psychotherapy, Immanuel Klinik Rüdersdorf, affiliated with Brandenburg Medical School), Baden-Württemberg (Zentrum für Psychiatrie Südwürttemberg, including the Clinics for Psychiatry and Psychosomatics in Zwiefalten, Weissenau-Ravensburg, and Reutlingen, as well as the University Hospital of Psychiatry and Psychotherapy Tübingen, and the Zentrum für Psychiatrie Reichenau), and Bavaria (Kbo-Isar-Amper-Klinikum, Munich region). Sampling and Recruitment Patients were recruited between 06/202307/2023 from the participating centers via telephone using a contact list of individuals from the prior AKtiV-Study, all of whom had provided written informed consent for recontact. Inclusion criteria for the patient group were: 1. sufficient German language proficiency, 2. at least one completed or ongoing HT treatment episode, and 3. no current acute psychiatric crisis. For the HCP group, the only inclusion criterion was a minimum of two years of professional experience in HT. Because the primary objective was to explore the needs and preferences of patients, twice as many patients as healthcare professionals were recruited in order to amplify the patients’ voices and reduce the typical power imbalance between patients and HCPs in mixed-group research settings (46). Recruitment followed a contrastive, purposeful sampling strategy to ensure maximum variation in experiences and perspectives with HT (47). Accordingly, participants were selected to represent a broad range of characteristics, including varying levels of HT experience, age, gender, migration background, and educational attainment. Recruitment continued until each discussion group included 10 participants. Participants were invited to take part in all three rounds; any cancellations in later rounds were compensated for by additional recruitment. Each participant received a financial compensation of €100 for the first round, €75 for the second, and €100 for the third. All participants received preparatory materials by email or post at least one week prior to each session. The participating software developers (JSp and SH) were members of the research team, both with academic degrees in computer science and experience in digital health informatics and participatory digital design. The discussion groups were moderated by two doctors (HM and JS). Procedure The PDD process was implemented as a three-round modified Delphi design (see Figure 1) (43). Data collection took place between 06/2023 and 09/2025 in iterative online discussion groups (n = 4), each lasting approximately three hours. All sessions were audio-recorded, transcribed verbatim, and anonymized. In addition, the moderators kept field notes. Data were analyzed using the software MAXQDA (VERBI GmbH, Germany). An initial exploratory literature review was conducted to provide an overview of existing digital support tools in the context of psychiatric HT. The review was open and non-systematic, aiming to capture a broad spectrum of potential digital solutions and methodological approaches. Databases such as PubMed and Google Scholar were searched, yielding 20 relevant sources (18,20,23–25,27–29,35,40,48–57). After each data collection round, an interim analysis was conducted, and the findings were used for preparation and design of the subsequent round. This iterative approach enabled the stepwise consolidation and contextual validation of the emerging results. 5 Figure 1: Methodological steps for collecting, preparing, and analyzing qualitative data within the PDD process. Round I: Exploration of Needs and Digital Support Options In the first round, two discussion groups were conducted, involving patients (n = 13), HCPs (n = 5), and members of the research team (HM, JSp, SH, JS). The objective was to identify needs, priorities, and barriers related to digital support in HT. Each discussion group was divided into two parts. In Part 1, a semi-structured discussion guide (58) was developed by the research team based on the overarching research questions (see Multimedia Appendix 2). This guide included open-ended questions exploring both the general necessity of digital support in HT and potential barriers to its use. In Part 2, the research team had previously reviewed and discussed the Best Practice Criteria (6) to assess their potential for digital enhancement. Based on this preparatory work, 40 criteria were preselected (see Multimedia Appendix 3) and distributed across the two discussion groups for targeted exploration of digital support needs for each criterion. Data analysis followed an iterative, inductive approach consistent with the principles of qualitative content analysis (59). In the first coding cycle, all statements referring to digital support in HT were coded and condensed into thematically coherent categories. This was conducted as a consensual coding process within the research team (HM and JS) (59). In a second coding cycle, the categories were further refined, and the essential digital features were extracted. Round II: Communicative Validation, Structuring and Refinement The second round was conducted in 04/2024 with a subset of the participants from Round I (patients = 6; HCPs = 2). The objective was the communicative validation and linguistic refinement of the essential digital features identified by the research team in the previous round. Preliminary results from Round I were provided to participants in advance, either electronically or by post. During the session, participants validated and reformulated the essential digital features and organized them into core functional domains. The discussion group was digitally audio-recorded. New or revised statements were integrated into the existing coding framework and refined linguistically. In addition, concrete suggestions were collected regarding the implementation and design of the HT application. Round III: Development and Validation of the Mock-Up Following Round II, the research team inductively developed a visual mock-up of a potential HT application, translating the participants’ articulated requirements and design preferences into an initial visual prototype. 6 In Round III, this mock-up was iteratively refined in an interactive session. The focus was on intuitive usability, the implementation of previously defined user requirements, and the identification of potential barriers to use. All participants (patients = 2; HCP = 1; software developers = 2) had already taken part in the previous rounds. Participants actively influenced design aspects such as the layout and visual structure of the user interface. Revisions were implemented directly in the mock-up during the session. Field notes were analyzed by HM and JS, and several minor adjustments were made afterward based on these observations. Results Sample Characteristics A total of 21 individuals participated in the study, including 13 patients (see Table 1) and six HCPs representing various professional roles within HT teams (see Table 2). In addition, two software developers from the research team (JSp and SH) were involved. The age of participating patients ranged from 31 to 84 years. All participating patients identified their ethnicity as white. Each patient had prior experience with inpatient psychiatric care before their current HT episode. Five patients lived in urban areas and eight in rural catchment areas across Germany. All participating HCPs were employed in HT teams in different regions of Germany at the time of data collection, with approximately half working in urban and half in rural catchment areas. Table 1: Sociodemographic characteristics of the patients study sample (n=13) a: The values do not always add up to the total n of 13 or 100%, as information from individual participants is missing; b: Multiple entries possible. Parameter na %b Age 25-35 2 15,4 36-45 3 23 46-55 3 23 56-65 3 23 >65 2 15,4 Gender female 11 84,6 male 2 15,4 diverse 0 0 Migration background no 9 69,2 yes 4 30,8 Highest educational level no school-leaving certificate 1 7,7 secondary school certificate 1 7,7 intermediate maturity 7 53,8 A-levels 2 15,4 university degree 2 15,4 Vocational training vocational training 9 69,2 no completed training or other degree 4 30,8 Livelihoodb salary from gainful employment 3 23 partner / family 3 23 citizen's allowance / basic income support 4 30,8 pension 7 53,8 7 Existence of a guardian no 11 64,6 yes 1 7,7 Age at first psychiatric or psychotherapeutic treatment <25 2 15,4 25-35 5 38,5 36-45 4 30,8 > 45 1 7,7 Number of HT episodes before the current episode none 10 76,9 1 2 15,4 >1 1 7,7 Number of inpatient previous psychiatric stays 1-3 9 69,2 >3 4 30,8 Table 2: Sociodemographic characteristics of the HCP study sample (n=6) Parameter n % Age 25-35 1 16,7 36-45 4 66,7 46-55 1 16,7 Gender female 3 50 male 3 50 diverse 0 0 Professional function senior physician 2 33,3 specialist physician 1 16,7 psychotherapist 1 16,7 nursing staff 2 33,3 work experience in HT 2-3 years 1 16,7 3-5 years 5 83,3 work experience in psychiatry 5-10 years 1 16,7 10-15 years 4 66,7 > 15 years 1 16,7 experience with digital tools in HT no 1 16,7 yes 5 83,3 Qualitative Findings The qualitative findings are structured into general observations regarding the accessibility of the proposed HT application, followed by the presentation of the essential digital features (see Figure 2). General Observations and Accessibility of the Application Participants explicitly expressed a desire for digital support in the form of an HT application. One patient described its potential benefits as follows: “A digital program [...] would provide the greatest benefit [for those working in HT] [...]. And ultimately for the patients as well. A) It saves time and allows staff to focus on the essential aspects 8 of HT, and B) it also benefits the patients. [...] I think technology has a big role to play here.” (1.1.3 Pat) At the same time, potential barriers to use were a major concern, particularly for patients. The participants emphasized a lack of prerequisites for use, such as missing devices, limited internet connectivity, or insufficient technical skills. As key conditions for successful implementation, patients highlighted both usability and their own willingness to engage with the technology. These factors could, for instance, be assessed and discussed during the initial admission interview. Essential digital features, such as an emergency contact function, must remain accessible to all patients, even without active use of the app. “I think it’s very important, when we think about digitalization, to keep communication channels between patients [...] and the HT team open. [...] The phone number should remain central, accessible, and low-threshold, so that people can still call.” (6.1.1 Pat) To further reduce barriers to use, participants suggested that HT teams could provide technical devices and actively support patients in using the app during daily visits. Under these conditions, participants saw a high potential for successful adoption of the HT application. In total, participants identified 18 essential digital features, which were grouped into five core functional domains (see Figure 2). The following sections summarize how participants described and justified each of these essential digital features. 9 Figure 3: Mock-Up of the HT support application. 16 Discussion Principle Findings This study identified the essential digital features of a digital application based on the needs and priorities of patients and HCPs and translated them into a technically feasible mock-up. The findings illustrate the requirements that digital applications must meet to effectively support HT. Participants primarily emphasized aspects that could improve the organization of care, enhance the efficiency of workflows and information exchange, and thereby contribute substantially to overall treatment quality. Our findings align with previously reported patient priorities in the context of HT (2,6,14), which, under real-world conditions, are often only partially implemented. At the same time, both patients and HCPs clearly recognized the added value and potential of digital support within HT. Although HCPs were included in the development process, the data predominantly reflect a patient-centered perspective, which is nevertheless consistent with the views of HCPs reported in prior research (18). The results suggest that digital applications can play a key role in supporting patients between home visits and further personalizing HT. Patients particularly emphasized the importance of continuously tracking their symptoms and mood. The inclusion of a mood-tracking journal within the HT application was explicitly requested. This is especially relevant because, as previous research shows, many symptoms emerge primarily in patients’ home or social environments and thus remain undetected during limited-time home visits (22). Continuous digital symptom monitoring, such as through EMA, can enhance patients’ illness insight, self-awareness, and sense of responsibility (22,35)), thereby fostering empowerment within the treatment process. Patients in this study also highlighted the importance of inclusive design and adequate user support for the HT application. Prior research has shown that the combination of digital support with personal guidance—i.e., guided use of digital health applications—leads to improved clinical outcomes (25, 26). HT offers a unique opportunity, as the use can be directly guided by the HT team. Human support has been identified as a key factor for improving engagement and adherence (22,35). HCPs can serve as digitally trained navigators within the HT team, addressing technical issues and fostering digital literacy among patients (23,24,35). This ensures that all service users can benefit equally from digital solutions. At the same time, participants identified several barriers to the use of digital applications. The most prominent obstacles were poor usability, limited digital skills among patients, and a resulting low willingness to use digital tools. Participants also mentioned technical challenges and infrastructural barriers, such as poor internet coverage in rural areas. These findings are consistent with prior studies identifying poor usability, limited user-centered design, and low digital literacy as central factors contributing to low engagement (35). In addition to use-related barriers, HCPs expressed concerns about a potential increase in workload associated with implementing and maintaining the HT application. While digital tools may free up time for direct patient contact through more efficient coordination, this largely depends on how effectively such tools are integrated into existing workflows (48). To date, empirical evidence in this area—particularly in the context of HT—remains limited. Overall, the findings underscore that a targeted and participatory implementation of digital applications in HT has the potential to address major challenges in psychiatric service delivery, enhance patient-centeredness and self-efficacy, and open new avenues for flexible, needs-oriented, and sustainable mental healthcare. 17 Strength and Limitations This study provides a rich qualitative dataset that forms a strong foundation for the development of a digital HT application. A key strength lies in its participatory approach: by actively involving patients and HCPs in the conceptualization and design, acceptability, usability, and implementation potential are substantially increased (40,41). Moreover, the sample covers a wide age range and diverse treatment experiences, enhancing the relevance and transferability of the findings within the German mental healthcare context. However, as recruitment was limited to Germany, the findings may not readily apply to healthcare systems operating under different structural or financial conditions. Because participation was voluntary, self-selection bias toward digitally interested individuals cannot be ruled out. In addition, the findings do not allow conclusions regarding effectiveness or cost-benefit ratios, which should be systematically addressed in future research phases. Implications The development of the HT application is ongoing. In light of this study’s findings—particularly the repeated emphasis on usability, co-design, and continuous support—the participatory approach should be consistently maintained throughout all subsequent development stages. Close collaboration with future service users during prototype development, usability testing, and pilot studies is essential to ensure that the application truly meets users’ needs and real-world contexts. Iterative feedback loops and stepwise refinement can further enhance usability and prepare the ground for sustainable implementation. In addition, economic evaluations—including analyses of development, implementation, and maintenance costs—are critical for assessing the scalability and sustainability of digital HT solutions. Early involvement of data protection and regulatory experts is likewise crucial to ensure compliance and build user trust. In the long term, a participatorily developed and technically integrated digital HT application can make psychiatric HT more patient-centered, flexible, and efficient. This requires that technological innovation is not being developed in isolation but rather understood as an integral part of existing service structures, co-created with all stakeholders involved. Conclusions To the best of our knowledge, this is the first study to explore the integration of digital components into HT from the perspective of future service users. Digital interventions in this context offer substantial opportunities to improve patient satisfaction, clinical outcomes, and the efficiency of care delivery. The combination of digital support and personal guidance by the HT team appears particularly promising for ensuring continuity of care and strengthening patient self-efficacy. A participatory, user-centered design approach is essential to ensure both acceptance and real-world applicability of such interventions. Funding This research was funded by the Ministry of Science, Research and Cultural Affairs of the State of Brandenburg. 18 Conflicts of Interest The authors declare that they have no conflicts of interest. Data Availability The datasets generated and/or analyzed during the current study are not publicly available due to the sensitive and confidential nature of the data, which involve identifiable information of patients. Data are available from the corresponding author on reasonable request and subject to appropriate ethical approvals. Authors’ Contribution All authors contributed to planning, analysis, and the critical interpretation of findings. JS contributed to the study design and supervised the study. HM, JS and SH and JSp were responsible for the data collection. HM and JS conducted the data analysis. HM, TS and JS wrote the draft of the manuscript, modified successive drafts, and prepared all tables and figures. All authors edited and approved the nal version. Acknowledgements We thank all participating patients, healthcare professionals, and collaborating home treatment teams for their time and valuable contributions. We also acknowledge the support of the software developers involved in the co-design process. In addition, we thank Lena Holtz for editorial assistance during manuscript preparation. Ethical Approval This study received ethical approval from the Ethics Committee of the Brandenburg Medical School Theodor Fontane (reference number E-02-20200715). The ethics committees of all participating study centers acknowledged this approval. All participants provided written informed consent prior to participation. Guarantor JS Abbreviations HT - Home treatment SMI - Severe mental illness EMA - ecological momentary assessment HCP - Health care professional PDD - Participatory digital design SRQR - Standards for reporting qualitative research IEHT - inpatient-equivalent psychiatric home treatment 19 Bibliography 1. Baumgardt J, Schwarz J, Bechdolf A, Nikolaidis K, Heinze M, Hamann J, et al. Implementation, efficacy, costs and processes of inpatient equivalent home-treatment in German mental health care (AKtiV): protocol of a mixed-method, participatory, quasi-experimental trial. BMC Psychiatry [Internet]. 2021 Mar 30;21(1):173. 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