Admission and Discharge Planning

Abstract

It is essential that staff of an adolescent inpatient psychiatry unit have the capacity and authority to ensure parents and treating community clinicians support the admission, families participate in the treatment, and community clinicians participate in discharge planning and assertive follow up since these are features known to improve clinical outcomes. The chapter outlines, through the use of a hypothetical case example, the processes involved in admission to and discharge from the Walker Unit.

Introduction

The Walker Unit is part of a state-wide CAMHS continuum of care that includes centre based and mobile community based treatment teams, residential and day programs, acute adolescent mental health inpatient units, a young person’s forensic unit and a rehabilitation and sub-acute unit. The Walker Unit also interfaces with other mental health providers including general adult psychiatric services, specialized early psychosis teams, youth mental health services, and private practitioners.

The Admission Journey

Referrals are triaged by senior members of the team. If a young person is likely to benefit from the program an assessment team visits them, their family, and current treating team at the hospital or community centre where the patient is treated with the aim to gather more information to assist with treatment planning in the case the young person is admitted to the Walker Unit. The second step in the admission process consists in inviting the young person and their family for a visit to the Walker Unit for further exploration of the suitability and the commitment to the program. Admission dates are spaced so the unit is only settling in one new patient at a time. The Walker Unit team works collaboratively with the referring agency, the young person, and the family in planning for discharge, finding appropriate accommodation, facilitating access to educational or occupational programs, and arranging treatment with local mental health services.

The following hypothetical case example illustrates the admission journey:

At referral Monica was a 15 year old girl, the second of four siblings, living with her mother, mother’s new partner, her three siblings and 3 year old half-brother in a regional location. Monica presented with recurring medically serious self-harm and unremitting suicidality in the context of dysphoric mood. Her diagnoses were complex post-traumatic-stress-disorder and probable borderline personality disorder. During her primary school years Monica was sexually molested by a neighbour. She was referred by the consultant psychiatrist of an acute adolescent psychiatric inpatient unit for consideration of a transfer to the Walker Unit. Transfer was requested because while self-harm had remitted during two previous hospitalisations, the behaviour had returned after discharge to the community. There was significant functional impairment. Monica had not consistently attended school during the previous two years. She was affiliating with an older delinquent peer group who facilitated substance abuse. In the community Monica had received cognitive behaviour therapy and dialectical behaviour therapy, but her engagement with treatment was indifferent. She had also received adequate trials of fluoxetine, sertraline, and venlafaxine, each augmented with quetiapine. For logistic reasons family therapy had not been attempted, but the parents were described as burned out by Monica’s difficulties, and two of her younger siblings were manifesting anxiety symptoms. The referrer sought a comprehensive diagnostic review.

Following the conversation between the consultant psychiatrists, the ward secretary sent a referral pack to Monica’s current treating team. The contents of the pack are summarized in Box 4.1.

Box 4.1 Walker Unit Referral Pack

To support the referral of {insert name} to the Walker Unit please provide the following information.

• 1. summary letter including formulation and goals of a Walker admission

• 2. risk assessment form

• 3. discharge summaries from inpatient admissions (including reports of investigations such as MRI, EEG, blood results, etc.)

• 4. incident reports during admissions

• 5. psychological therapy reports

• 6. family intervention reports

• 7. any cognitive, speech, language and occupational therapy assessments

• 8. education reports

• 9. nursing care plans and

• 10. reports of referrals to other agencies such as Child Welfare Services

Once the completed referral pack was returned, senior Walker clinicians discussed the case during a weekly Intake meeting to determine if Monica could potentially benefit from an admission to the Walker Unit. One consideration was whether she was truly treatment resistant or if she was better characterised as treatment avoidant. The determination was that best endeavours had been employed to engage Monica in evidence-based psychological therapy in the community, and this had been supported by adequate trials of first and second-line pharmacotherapy. The Intake team decided to proceed to the next stage of admission planning, an assessment meeting undertaken at Monica’s present location (regional acute inpatient unit). As per usual practice the assessment would be undertaken by a consultant psychiatrist, clinical nurse consultant, and an allied health professional.

In preparation for the assessment visit, the clinical nurse consultant contacted the referring team to request that the whole family (including all siblings) attend the meeting. The assessment team travelled to the hospital where Monica was admitted. The assessment team first met with the current treating team to receive an update on progress, to further clarify the objectives of a transfer to Walker, and to clarify any queries arising from the written referral material. They then met Monica and her family to assess motivation and capacity to engage in treatment. Monica expressed ambivalence stating, “What’s the point. I’m going to kill myself when I turn 16 anyway” but also described longer-term educational and career goals. The team explored the family’s understanding of Monica’s difficulties, willingness to support an admission, and engage in regular family sessions. Information was provided about the ward program and the various therapeutic modalities described in other chapters of this book. Particular emphasis was given to the importance of family engagement. This is because experience has taught us that some parents, particularly those who have become burned out, see a Walker admission as primarily an opportunity for respite.

After the assessment meeting, the assessment team discussed the readiness of Monica and her family for an admission to the Walker Unit. Owing to the therapeutic intensity of the Walker treatment program considerations for admitting a young person must include a number of perspectives; the level of clinical dependency of the current cohort, such as supervision for activities of daily living or meal times, the cohort’s capacity to engage in the program or providing individualised activities and the potential for risk behaviours and contagion between cohort members. The team believed Monica and her family were ready and motivated for an episode of care at the Walker Unit and recommended proceeding to the next stage of the admission assessment, a visit by Monica and her family to the ward.

The pre-admission visit afforded the family to ask any questions that had arisen from the first meeting. The team reaffirmed the family goals for an admission and their commitment and capacity to attend weekly family sessions. Monica and her family were given a booklet that outlines the program, including level system and expectations. The family were given a tour of the facility so that they may better understand the environment that Monica may be living in for six months or so. Monica and her family at this point agreed to an admission. In other circumstances, families have sought more time to consider their decision. An admission date was agreed on. Admissions are usually arranged for a Monday or Tuesday, so the patient can be settled in during a period of maximum staffing (Fig. 4.1).

Fig. 4.1

Assessment and pre-admission process

Prior to Monica’s admission date the clinical nurse consultant identified the staff directly providing her treatment; primary nurse team, lead primary nurse, psychiatrist, registrar, individual therapist, family therapists, education team and any specific therapist such as a dietician or speech pathologist. To orient the treating team the clinical nurse consultant drew an admission summary diagram which includes the simplified genogram of the young person and their family; a summary of the presenting problem, diagnoses, number of past admissions, illness characteristics; summary of risks in admission; list of medications; summary of educational history; aims of admission from the individual and family system perspective and suggested care plans required to support the young person and the list of the team (see Fig. 4.2). This summary diagram was emailed to all team members, discussed in the morning report meeting before Monica arrived and displayed in the nursing office the week prior to admission.

Fig. 4.2

Summary diagram of admission information

The assessment team reviewed Monica’s risk history both within hospital and in the community and made recommendations for her care. It was determined that Monica could be managed in the general ward rather than requiring an initial period in the high acuity POD area (see Chap. 2).

Preparation for Discharge

Discharge planning is part of the admission planning process and is considered during the multidisciplinary team formulation and review meetings (see Chap. 5) and the weekly care planning meetings. Identification of discharge location, educational pathway, and support services are prioritised from the start of the admission as these can have implications on the length of stay. The discharge destination may be different to the living arrangement prior to the admission depending on the circumstances of the young person’s mental illness, the capacity of the families to support the needs of the young person and to maintain the safety of the young person and others. Discharge home is preferred, but alternatives such as at a different family member’s home, supported accommodation, out of home care supported by child welfare services or alternative mental health facilities for those with continuing treatment needs (such as e.g., a young person with treatment resistant schizophrenia). For the majority of young people, attendance at a mainstream school is not possible and an access request is made for a place in a School for Specific Purposes (SSP) which typically has higher support levels for students. The process of allocating places in SSPs is done only once per school term by the Department of Education. As such, the possibility of an SSP referral has to be made early in the course of hospitalisation at the Walker Unit so that, if successful, there is adequate time to integrate the patient to the new school setting (see Chap. 7).

Practicing leave at their discharge location, being integrated into school and re-engaging the community support staff who will receive transfer of care back after discharge all form part of the treatment process and transition out of the Walker Unit. Graduated exposure to home and community settings is typically undertaken on weekends, and when a young person returns to the unit reviewing leave periods and understanding challenges and successes is done in family meetings. Problem solving difficulties experienced during leave forms part of continuous planning for the next leave period.

The community team is invited to the final MDT formulation and Care Planning in person or via video conference to be updated on the progress and changes during the admission and to discuss the follow up after discharge. We encourage community teams to visit the young person at home, at their home school, or at the Walker unit ahead of discharge. It is not uncommon for young people who are nearing 18 to be transitioned from the Walker Unit to an adult mental health team or service. In these circumstances, initiating the introductions of case managers to young people is attempted.

The discharge from the Walker Unit involves a farewell event for all young people and their families. The key team members provide a review of the admission and reflect on achievements and changes that have occurred during the admission for the young person and also for the family. The teaching team highlights the learning goals that were reached and awards that were distributed. The treating team also acknowledges the potential challenges ahead post discharge but highlight also the strengths they have shown during their admission. The young person and their parents have then an opportunity to reflect and comment on their experience of the admission.

The Walker team provide a seven day follow up call to all young people and their families to support the transition back to the community. This call offers families and young people to share any concerns or challenges they are experiencing with a familiar clinician, who can support problem solving, or connect with community clinicians and support their needs going forward.

It is not uncommon for former patients and families to make contact with the unit, not only during the initial months following discharge, but also to share milestone experiences such as starting a university course, passing their driving licence, or getting a job. In the event that contact is made with staff, there is a logbook for staff to complete, documenting the details of the contact and its nature. If there is any concern raised during contact such as deteriorating mental health or safety concerns, a staff member will liaise with the discharge community team to ensure that information is shared.