A Program to Discharge Individuals with Long Term Psychiatric Hospitalizations

Abstract

Despite a substantial decrease in the number of people confined to state psychiatric hospitals in the last decade, some individuals remain hospitalized who are no longer determined to be a danger to themselves, property or others but for whom discharge has been problematic. The clinical issues that affect the discharge of these individuals generally fall into four categories (Boyer et al. in Barriers to discharge, optimal housing and supportive mental health services for residents with conditional extension pending placement legal status, 2006). The first occurs when hospitalized individuals are resistant to discharge, the second occurs when individuals have persistent non-dangerous psychiatric symptoms and or behavior problems that make discharge difficult. The third and fourth barriers, respectively, involve individuals with major medical co-morbidities and/or co-occurring intellectual disability. This paper describes a program designed to discharge individuals who present with one or more of these unique needs in one state psychiatric hospital in the north eastern United States. “The Special Treatment Cottage” (STC) program was initiated for hospitalized individuals who had been determined ready to be discharged but who remained in the hospital until they were willing or able to tolerate discharge and until appropriate residential services could be found. The STC program involved the development of a specialized therapeutic setting in which clinical discharge barriers would be targeted and the focus of treatment would be on discharge. In the first year of operation the STC program admitted a total of 22 residents with an average length of hospitalization of over 5 years. Fifty percent of the hospitalized individuals (11) were discharge within an average of 7 months of entering the program. The clinical strategies utilized are discussed along with a description of the critical ingredients thought to be responsible for the success of the program. Suggestions for future work in this area are also addressed.

Appendix

Fidelity scale for the STC project	1	2	3	4	5
1. Advocate a. STC residents have an assigned advocate b. Identification of intrinsic motivators/recovery goal c. Identification of discharge (D/C) barriers	< 20% of residents have an identified advocate	20–39% of residents have an advocate	40–69% of residents have an advocate	70–89% of residents have an advocate	= or > 90% of s have an advocate
	< 20% of residents have documentation of their recovery goals	20–39% of residents have documentation of their recovery goals	40–69% of residents have documentation of their recovery goals	70–89% of residents have documentation of their recovery goals	= or > 90% of have documentation of their recovery goals
	< 20% of residents have documentation of their D/C barrier	20–39% of residents have documentation of their D/C barrier	40–69% of residents have documentation of their D/C barrier	70–89% of residents have documentation of their D/C barrier	= or > 90% of have documentation of their D/C barrier
Rational Treatment teams in state hospitals often share caseloads resulting in a potential diffusion of responsibility across the team to develop a therapeutic relationship with the patient and become thoroughly familiar with the person’s background. Though not “score-able” development of the therapeutic relationship is understood to be of central importance Scoring Sub-items a-c are scored independently and the scores are averaged together
2. Assertive discharge a. After 1 month discharge sites are identified for all residents b. Relationships and planned strategies are used during exposure to discharge anxiety	< 20% of residents have a discharge site identified after 1 month	20–39% of residents have a discharge site identified after 1 month	40–69% of residents have a discharge site identified after 1 month	70–89% of residents have a discharge site identified after 1 month	= or > 90% of residents have a discharge site identified after 1 month
	Plans to address potential discharge anxiety are documented for < 20% of s	Plans to address potential discharge anxiety are documented for 20–39% of s	Plans to address potential discharge anxiety are documented for 40–69% of s	Plans to address potential discharge anxiety are documented for 70–89% of s	Plans to address potential discharge anxiety are documented for = or > 90%
Rational Often the skills necessary for a successful discharge are defined by the discharge site. Knowing the expectations of the discharge site early in the program can allow the treatment team to tailor its efforts to prepare for the specific discharge requirement. The stress of discharge after many years of hospitalization can exacerbate latent fears and ambivalence. It can also exacerbate symptoms of mental illness. Anticipating this and proceeding despite this stress was coined “assertive discharge”. Despite this, residents always exercised the right to make the final decision about when and where they would be discharged Scoring “Identified site” does not necessarily mean accepted. Sub-items a-b are scored independently and the scores are averaged together
3. Individualized rehab plan a. Individualized intervention is in the residents chart b. Each resident has documented “replacement behaviors” or skills to learn c. Safety plan is completed	Less than 20% of residents have individualized interventions in their charts or house log	20–39% of residents have individualized interventions in their charts or house log	40–69% of residents have individualized interventions in their charts or house log	70–89% of residents have individualized interventions in their charts or house log	90% or more of residents have individualized interventions in their charts or house log
	< 20% of residents have at least one individualized replacement behavior documented	20–39% of residents have at least one individualized replacement behavior documented	40–69% of residents have at least one individualized replacement behavior documented	70–89% of residents have at least one individualized replacement behavior documented	= or > 90% of residents have at least one individualized replacement behavior documented
	Less than 20% of residents have a safety plan completed and in the chart	20–39% of residents have a safety plan completed and in the chart	40–69% of residents have a safety plan completed and in the chart	70–89% of residents have a safety plan completed and in the chart	90% or more of residents have a safety plan completed and in the chart
Rational Individuals in the hospital for long periods of time often engage in learned behaviors which are adaptive in hospitals but that may not be useful in community settings. Reinforcement of replacement behaviors is, ideally, suggested as opposed to trying to extinguish mal-adaptive behaviors alone Scoring Sub-items a-c are scored independently and the scores are averaged together
4. Stage based acceptance and interventions a. Target behaviors are identified with time to achieve them b. Every effort is made to keep residents in the program	Less than 20% of the residents in the STC have a plan that details the shaping of behavior over time	20–39% of the residents in the STC have a plan that details the shaping of behavior over time	40–69% of the residents in the STC have a plan that details the shaping of behavior over time	70–89% of the residents in the STC have a plan that details the shaping of behavior over time	90% of the residents in the STC have a plan that details the shaping of behavior over time
	Less than 20% of the residents in the STC are successful in staying in the program	20%-39% of the residents in the STC are successful in staying in the program	40%-69% of the residents in the STC are successful in staying in the program	70%-89% of the residents in the STC are successful in staying in the program	90% of the residents in the STC are successful in staying in the program
Rational Psychiatric rehabilitation and behavioral theory identity that individuals generally change slowly over time and may require the reinforcement of successive approximations of target behaviors before behavior change occurs Scoring Sub-items a, b are scored independently and the scores are averaged together
5. Team based interventions a. Team know these plans b. Team works on same skills	Less than 20% of staff know the individualized interventions of the residents	20–39% of staff know the individualized interventions of the residents	40–69% of staff know the individualized interventions of the residents	70–89% of staff know the individualized interventions of the residents	90% of staff know the individualized interventions of the residents
	Less than 20% of resident charts have documentation of teams reinforcement of team based intervention	20–39% of resident charts have documentation of teams reinforcement of team based intervention	40–69% of resident charts have documentation of teams reinforcement of team based intervention	70–89% of resident charts have documentation of teams reinforcement of team based intervention	90% of resident charts have documentation of teams reinforcement of team based intervention
Rational Behavior change is thought to be most reliably accomplished when replacement behaviors are reinforced in numerous environments by numerous individuals Scoring Sub-items a, b care scored independently and the scores are averaged together
6. Weekly supervision a. Team is present b. Reviews minutes c.. Social workers report d. All advocates report e. Interventions are delineated	< 20% of STC team meets weekly	20–39% of STC team meets weekly	40–69% of STC team meets weekly	70–89% of STC team meets weekly	= or > 90% of STC team meets weekly
	None of the sub-steps (b–e) are documented in the STC minutes in 1 month	One of the sub-steps (b–e) are documented in the STC minutes in 1 month	Two of the sub-steps (b–e) are documented in the STC minutes in 1 month	Three of the sub-steps (b–e) are documented in the STC minutes in 1 month	Four of the sub-steps (b–e) are documented in the STC minutes in 1 month
Rational The weekly supervision of psych rehab practitioners is essential to the rigorous application of a program model Scoring The 1st component is scored by looking at the attendance at the supervisory and comparing to the identified STC team Sub-items a–e are scored independently and the scores are averaged together
7. Community exposure trips a. Trips occur every week b. Skills are reinforced during trips c. Patients are exposed to alternative settings (live, work, socialize)	< 20% of weekly trips happen each quarter	20–39% of weekly trips happen each quarter	40–69% of weekly trips happen each quarter	70–89% of weekly trips happen each quarter	= or > 90% of weekly trips happen each quarter
	< 20% of weekly trips have documentation of skills being reinforced “in vivo”	20–39% of weekly trips have documentation of skills being reinforced “in vivo	40–69% of weekly trips have documentation of skills being reinforced “in vivo	70–89% of weekly trips have documentation of skills being reinforced “in vivo	= or > 90% of weekly trips have documentation of skills being reinforced “in vivo
	< 20% of weekly trips happen each quarter offer exposure to living, working or socializing locations	20–39% of weekly trips happen each quarter offer exposure to living, working or socializing locations	40–69% of weekly trips happen each quarter offer exposure to living, working or socializing locations	70–89% of weekly trips happen each quarter offer exposure to living, working or socializing locations	= or > 90% of weekly trips happen each quarter offer exposure to living, working or socializing locations
Rational Community trips serve to expose residents to “alternative environments” where they might live, work, and socialize Scoring Sub-items a–c are scored independently and the scores are averaged together