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VNSW Mental Health Home Care Program: Transitioning Back Home Following Hospitalization

It is becoming increasingly understood and appreciated just how much healing and comfort extend beyond physical well-being. There is a decided mental well-being component as well, recognized by Visiting Nurse Services in Westchester (VNSW), the White Plains-based home health care agency that several years ago created a program of psychiatric healthcare – in the patient’s home, for maximized comfort and effect. Under this unique program, VNSW’s registered nurses, with advanced psychiatric training, conduct home visits to develop a plan to treat mental health issues in conjunction with medical/surgical needs, and to support community integration for its patients. Adjunct services complementing the mental health component include home health aides, medical/surgical nurses, social workers and relevant rehabilitation therapies. This program has proven to be an important component in the care and mainstreaming of psychiatric patients discharged from hospitals.

It is imperative that individuals with a psychiatric diagnosis being discharged, following either a psychiatric or medical hospitalization, get comprehensive follow-up care in the community. The role of discharge planners in the hospital is crucial. They are the link between the patient and the community and it is very important that they access all available community resources to ensure a smooth transition back home. When the client does not have a proper discharge plan, the patient’s transition back into the community becomes much more difficult.

There are several important aspects of the discharge plan. It is essential that clients return to adequate housing. Depending on the needs of individual clients, this may require extensive planning so that the individual can return to some level of supervised housing. Medical care is another area that requires appropriate planning. To help ensure proper follow-up, it is beneficial that the patient have medical and psychiatric appointments set up prior to, and for a date shortly following, discharge. This will help establish a routine with providers in the community and prevent a delay in further follow-up care and medication refills. There is a significant rate of co-morbidities for psychiatric patients and it is imperative that their medical needs, as well as their psychiatric needs, are addressed.

Often patients are discharged home without a proper psychiatric referral, so a treating psychiatrist is needed in the community to prevent further psychiatric hospitalizations. In addition to an appointment with a psychiatrist, the need for outpatient mental health services relevant to the patient diagnosis should be considered. Frequently, patients benefit from continuing day treatment programs and case management services.

Supportive services are an essential component of the discharge plan. All appropriate community resources should be set up while the patient is in the hospital. Personal care aide services through the Department of Social Services should be in place to begin immediately following discharge so as to avoid a delay in service and ensure that the client has the proper support in the home to assist with activities of daily living.

Medication compliance is a concern for many psychiatric patients. Often individuals are discharged with prescriptions that the patients are left to fill themselves. By contrast, knowing for certain that hospital patients being discharged actually have their medications goes a long way toward minimizing non-compliance. The social worker in the hospital should also work with the patient to clarify how the patient will pay for and obtain needed medication. For example; does the patient need to be connected with a pharmacy that delivers, does he/she need assistance calling in refills, does the individual need assistance managing funds and allocating needed funds towards medication and/or medical supplies? The social worker in the hospital must also explore transportation options available to clients; if they do not have transportation to medical appointments and referrals in the community, compliance will be difficult if not impossible.

Visiting Nurse Services in Westchester’s unique Mental Health Program is frequently part of the discharge plan for psychiatric patients from both medical and psychiatric hospitals. VNSW’s mental health team is the link between the patient and his/her providers in the community. The agency ensures comprehensive psychiatric and medical care, and their nurses meet the clients at their homes immediately following discharge.

VNSW reviews the discharge plan with the patient and assists in setting up a schedule of visits with its nurses in conjunction with the client’s medical and psychiatric appointments. If the client attends a continuing day treatment program, the agency arranges its visits so that the patient can attend all necessary programs. The VNSW teams review all medications prescribed upon discharge and, where needed, sets up medication pre-fill sets and locked medication boxes. The mental health nurse also can monitor medication renewals and assist with obtaining prescription renewals, while monitoring symptoms, mood, medication compliance and safety as appropriate, and acting as educators and advocates for their patients.

In addition to nursing care, VNSW provides a full range of rehabilitative therapies, social work and home health aide services; psychiatric patients receive comprehensive care from a coordinated team of health care professionals versed in, and sensitive to, their complete history and needs, providing a complete package of essential multidisciplinary services to help them, following a hospital discharge, to attain and maintain optimal health and functioning in their communities.

With its dedicated Mental Health Home Care Program, Visiting Nurse Services in Westchester is achieving this objective, emphasizing treatment of the whole person with the agency’s core multidisciplinary approach. For details, visit www.vns.org, call (914) 682-1480 Ext. 648 or e-mail MentalHealth@vns.org.

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