Post discharge services start the day a person is admitted to an inpatient unit. Usually, when people stay for a few days in the hospital, staff focuses mainly on medication issues. Many studies of people suffering from severe mental illnesses show an association between non-adherence to medication and higher rates of hospitalizations. When individuals stop taking their medications as prescribed, their chances of being readmitted to a hospital increase dramatically. There are many reasons that individuals stop taking medications. For some people, medications do not provide as much help as one would hope for. Others have difficulty tolerating the side effects of medications that have been tried. Some people do not take medications for personal reasons or because of stigma attached to using psychotropic medication and to mental illness. Non-adherence to medication often occurs along with individuals’ disengagement from mental health service providers. Ultimately, re-admission to a hospital might be required. Yet the common theme for every person who is admitted to the hospital is that no one wants to be there.
Mental health professionals generally agree to use the biopsychosocial model as a way to explain psychiatric disorders. We acknowledge the influence of biological factors that make people vulnerable to psychiatric illness; that is why we offer medications to help people suffering from psychiatric problems. The psychological part of this model involves the effects that social and environmental factors have on a person’s state of mind. It describes the changes in the person’s behavior and interactions with the outside world. The social aspect refers to the way the environment, (shelter, relationships, work, education, etc.) affects an individual.
When a person is hospitalized one or more of these factors have changed in a negative way. Therefore, it would make sense to explore in depth the three parts of the bio-psychosocial model. However, more often than not, the issue that takes the largest amount of human and financial resources is the biological (medications) one. The reasons for the medication-centered approach are complex and beyond the scope of this article. However, the emphasis on medication has significant ramifications for the consumer’s discharge plans. Although the culminating event that triggers a crisis could be the consumer’s ceasing to take medication, underlying causes of the crisis are often not clear, and therefore might not be adequately addressed. A significant result of not addressing psychosocial needs as aggressively as the biological ones is a breakdown in the communication between providers and consumers. Paradoxically, because of this deterioration in communication, even the medical interventions are less likely to succeed.
With the obvious exception of shelter, the most important component in a discharge plan is having access to medications and a follow up appointment with a psychiatrist. As established earlier, chances are that adjusting medications by itself is not going to make a difference for the person that was just hospitalized for a crisis.
What could be done differently? Many times, the goal of hospitalization is to get the person “clinically stable”. Instead, the system should be centered on recovery. Hospital staff should focus on an individual’s needs beyond medications. We suggest that in addition to safety, the goal of hospitalization should be to help the person regain control of their life. For someone to benefit most from a hospitalization and follow up care there should be a focus on goals from the beginning of the admission process. For this to occur, outpatient programs need to supply information to the hospital team beyond medication and recent progress notes. An individual’s treatment goals should be communicated to the inpatient team so that all interventions proposed at the hospital are in harmony with their life goals.
For those people hospitalized without community-based services in place prior to admission, it is essential for staff to identify, together with the patient, what interventions will make a difference in their future. Staff should refrain from establishing goals for an individual. Furthermore, symptom centered goals should not be a part of a treatment plan. In those situations when people only speak about their symptoms, they should be asked what areas of their life they would like to focus on.
At that point medication takes its rightful place in the overall picture of recovery, as one more tool to regain control of the person’s life. Once the discharge plan is centered on the person and not on the symptoms, other treatment options and rehabilitation interventions can emerge as first tier needs. As a individual identifies their needs, they should be educated about the different services available in their community, such as clubhouses, case management, advocacy and employment programs.
In the hours and days that immediately precede the traumatic trip to the psychiatric emergency room, a person’s experience is usually one of chaos and terror, overwhelming symptoms and a slowly diminishing connection to, and control over, one’s world. It is critical that a person’s sense of control over his life is restored before he leaves the hospital. This is where discharge planning, as collaboration between an individual and hospital staff, can serve as a restorative process for the consumer. It is a process within which an individual should be encouraged to express preferences, deliberate options, question recommendations and make important aftercare choices.
In speaking with a number of members of Services for the UnderServed’s (SUS) Brooklyn Clubhouse, who were referred from inpatient hospital units, many were able to recollect how they felt on those first days that they “reported” to the Clubhouse. Overwhelmingly, the common experience was one of fear. They said that they were “not in good shape”, that they felt “lost”. The staff described them as “distant, isolated and mistrustful”. In response, staff “takes it very slow” offering these new members the opportunity to participate in their choice of the various activities the Clubhouse offers. A senior Clubhouse member is assigned to “stay close by” and orient the new member to what is going on at any given moment, and how he/she could get involved. “We try to find out what they like. We know that there is a lot more to this person than may be apparent initially.” The emphasis is on allowing the new member to “see the clubhouse as a place that they will be respected and feel safe.”
The referral process is another bottleneck in the system. Hospital staff is under intense pressure to discharge patients as soon as possible; this results in referrals to outpatient services that are often based more on administrative needs than consumer preferences. Individuals are often not aware of their options after being discharged from a hospital. The key here is in being given “choices” and “respecting” those choices.
We should consider bringing peers to the inpatient setting to help consumers make educated choices regarding their discharge. Peers can also be involved in the implementation of advance directives. Advance directives (AD) allow an individual to decide in advance how they would like the team to work (and even designate other people to make decisions) when they are unable to do so. Informing the consumer about AD should be part of every outpatient treatment program. Once the person has an AD in place the inpatient team will use that document as a roadmap for treatment and discharge planning.
After a stay on an inpatient unit an individual just needs time and a place to restore their bearing, to reconstitute in order to meet the demands of the community. The transition from inpatient to outpatient is often too abrupt and while all the aftercare referrals might be in place, an individual may need support and assistance to cross over successfully. The SUS Clubhouse is structured to do just that. The belief is that an individual must be offered many ways to take charge of his own recovery. Medication is a part of that recovery, but so are relationships and meaningful activity. As a Clubhouse member you are expected to train, work and ultimately teach others.
Crises are often opportunities to make life changes but if the person believes that their problems are only related to medications, they will not be open to change. They might even become more confused, frustrated, and defiant toward a system they see as imposing its will on them. To help prevent this from happening, we can try to return as much control as possible to the consumer during an inpatient stay. By sharing power and accountability with consumers, we will improve communication and ultimately start to restore trust in the system. Utilizing a person-centered model, we will increase the capacity to make appropriate referrals for outpatient services upon discharge from the hospital and improve the engagement process of the person with available services.
The overall quality of outpatient psychiatric services is sound, but by definition it focuses on treatment. A large percentage of the people referred for outpatient treatment do not return to that site after one visit. One of the main reasons this occurs is that consumers feel they do not get what they need.
A comprehensive discharge plan should include rehabilitation services.
Symptom stability alone is not a goal but more often than not a result of other complementary interventions. By waiting for someone to be symptom free or stable we lose the opportunity to connect a person to the services that would assist in their recovery. When an individual can address their service needs, they will also have better chance to control their symptoms.
After several months of Clubhouse membership at SUS, one member, who had spent several months at a state psychiatric center, stated, “I belong here, and what I do while I’m here matters to me and the people who are also members here.” It is that simple and not at all different from what most people want out of life, to feel valuable and valued.
Pablo Sadler, MD, is the Mental Health Medical Director Bureau of Mental Health, at the New York City Department of Health & Mental Hygiene (NYCDOHMH). Yves J. Ades, PhD, is Senior Vice President, at Services for the Underserved. Robert Goldblatt, LCSW, is Director of Rehabilitation Programs, Bureau of Mental Health, at NYCDOHMH.