Guest Column

Discharging patients with behavioral disorders

Post-hospital follow-up is an important part

By Madeleine Y. Gomez, PhD
President
PsycHealth Ltd.
Evanston, IL

For professionals working in health care, it is easy to quickly become accustomed to the various presentations and stressors that accompany a patient who requires hospitalization. In fact, our efficient functioning is dependent on this to some degree.

However, this should never allow us to become comfortable or callous to the experience that the patient and his/her family are going through as well as to the importance of delivering care that supports the continuity of treatment and the coordination of care among the treating team.

When coordinating the care of patients with psychiatric disorders, either as a primary or secondary diagnosis, hospital case managers should keep in mind from the beginning that a transition to the community will be more difficult for these patients than for many others. They should take steps to ensure that the patients follow their treatment plan and avoid coming back to the hospital. It is through those efforts and compassion that we affect quality care, alleviate suffering, and support mental health and progress.

A psychiatric hospitalization never is a small matter. The acute symptomatology that precipitates and renders necessary a mental health inpatient admission are of significance. The patient may be capable of self-harm or harm toward others. Similarly, patients may be incapable of taking care of themselves or have suffered an exacerbation of a mental disorder or progression of that disease that meets the medico-legal criteria for inpatient admission. The hospitalization focuses on stabilizing the acute symptoms and comprises only a small portion of the whole and ongoing treatment of the patient.

Services also should be delivered with optimal consideration given to the rights of the patient to be treated within the least restrictive setting to ameliorate or stabilize the presenting problem.1

Ongoing awareness of this framework will lead us to appropriate goals for this level of care and, most importantly, post-discharge recommendations.

For the patient, the mere process of being admitted to the hospital will add stress upon the challenges of the current mental dysfunction requiring treatment in a restrictive setting. If it is a first hospitalization for the individual, the stresses may even be greater than for those who already have gone through the process.

For the family of the patient, there will be stresses as well. If this is an initial engagement with the mental health system, these stresses could be significant and upsetting to all. For those families who have been through the psychiatric hospitalization of a loved one in the past, the response may be one of the following: indifference, attempts at continued support and involvement, or abandonment.

As the hospital treatment team seeks to stabilize the patient for treatment in the next level of care, awareness of the family as a potential resource and support will be integral in the care of the patient. It is estimated that 65% of psychiatrically hospitalized patients will return to their families.2

Families who demonstrate support and are involved will be easier to identify and work with during the process of the hospitalization, but it will likely be useful to attempt to engage distant, indifferent, or abandoning families who may provide positive support in the process and continuing treatment of the patient's disorder. As such, the family is a central resource in continuity and coordination.3

Addressing families' needs

With current and ongoing shrinking health care resources, the family's position, perceptions, and support may be even more important than ever in mental health caregiving today. These familial needs must be addressed.4

Patients should leave the hospital with a clear plan for follow-up care, including appointments with mental health providers who will follow them over the long term.

Since hospitalization is geared toward stabilizing the patient to return to the community, it is possible that the patient may have progressed but does not fully understand the continuing treatment plan or the importance of aftercare. Often, the treatment plan and the follow-up appointments amount to little more than some pieces of paper and a couple of prescriptions in a plastic bag along with other papers generated during the hospital stay.

Although it is not a new concept, the importance of discharge planning from the day of admission cannot be overstated.5 This includes ensuring that the patient has set follow-up appointments with mental health providers so he or she can continue the progress that commenced during the psychiatric hospitalization as well as reducing recidivism and the potential for rapid readmission.

Follow-up appointments for psychiatric medical management as well as psychotherapy are important to support the patient's treatment and stability.

Case managers should educate the patients on the importance of follow-up and help them understand that the role of the hospital stay was to stabilize their condition but does not represent the bulk of the treatment they need.

The importance of medication compliance should similarly be underlined. Whenever possible, include the family in these discussions as they often will have a bird's-eye view of the patient's functioning.

Ideally, patients should sign consent forms during the inpatient stay authorizing release of information needed in order to coordinate between treatment teams as patients transition from an inpatient to an outpatient setting. However, those signatures for informed consent, which will authorize the communication necessary between providers for a unified team effort, also can be gathered at the outpatient follow-up appointment.

Not obtaining the requisite forms for release of information creates barriers to quality coordination of care. While patients do have a right to refuse to sign these releases, case managers have an opportunity during the hospital stay to educate the patients about the importance of the releases for the communication and coordination of the team. If it makes sense to the patient and the confidentiality of the case is reinforced, compliance can often be attained. At the same time, requisition of records can ensue. Requisition of records can be time-consuming and tedious but can result in a wealth of data, which can directly affect treatment planning as well as understanding the patient.

As discharged psychiatric patients often will leave with medication prescriptions for psychotropics, coordination with the primary care physician will be paramount to aid medication coordination and to minimize the potential of cross-medication interactions.

In addition, there are cases where patients' primary care physicians are prescribing a psychotropic medication, which the patient may be abusing or could use to attempt suicide. Communication regarding those interactions and potential pitfalls results in improved quality of care and a more unified treatment plan while reducing the possibility of the patient splitting the treatment team. Similarly, encouraging both patient and family support of the recommended medication regime is integral to the continuing care.

Collaborative care must integrate mental health with primary medical care.6 Despite releases of information, professionals often have a barrage of excuses for not making the time to discuss the case and the planning inherent in the process.

Professionals should make the effort to take advantage of communication any time the release of information has been achieved. Examples are easily found of treatment team members actually working at odds against each other's treatment plan without awareness of the attempts of the other professional. This must be avoided; it is the patient who will suffer the consequences for this lack of coordination of care.

12 steps to discharging mental health patients

If an option for post-acute case management is available and appropriate, hospital case managers should recommend it in their discharge plan and communicate with the case manager who will be working with the patient after discharge. Communi-cation with this individual can help coordinate the efforts, cross-communications, and urgent alerts that are a part of treating cases with post-hospitalization issues and pathologies.

As case managers who coordinate care after discharge for patients with mental disorders, we have found that offering a transitional care visit in the home as well as ongoing home intervention-based therapy has a positive impact on the seven-day follow-up rate as well as the reduction of readmissions.7

Results from the program evaluation demonstrated that behavioral health admission rates in a Medicaid managed care sample decreased an average of 2.5 admissions, a reduction of 86%, following the implementation of home-based services.8

While those interventions require a specialized team of individuals well versed in psychiatric in-home treatment, the positive results are supported by statistics in recent publications and recently have been recognized by URAC, which awarded PsycHealth Ltd. with the Gold Award for Healthcare Management in 2008.

Documentation and transmission of a good history as opposed to a cursory one gathered initially during the hospitalization will form the basis for the best treatment recommendations. This will not only aid the current presentation but also reduce the need for duplicating efforts during subsequent interventions.

A well-known saying in mental health is that "unless you have spoken with more than one person regarding the history, what you have is just a story." This is not to devalue the patient's perceptions of his/her life experiences and feeling but rather to more fully understand, from a variety of perspectives, what that experience has been as clearly as possible. This will be of particular support in approaching patients who are psychotic or delusional as without these data, it can be hard to discern what comprises reality for the patient. Speaking to the family is likely to provide a fuller and potentially clearer picture of the identified patient.

Family also can be of great support as they are often in the position of being able to observe the patient's symptoms and can quickly report whether the patient is doing better, worse, or about the same. They offer a unique and ongoing bird's-eye view of the patient, which can utilized with the patient's report for ongoing recommendations.

The importance of case managers emphasizing support for concurrent psychotherapy cannot be understated. Medications may effectively stabilize brain imbalances, but changing habits and relationships, increasing coping, reducing violence, and choosing healthy practices are more likely to improve through the process of individual psychotherapy as well as family therapy.

Maintaining the same treatment team from the hospital to outpatient treatment should be recommended when it is possible. If this is not possible, it is helpful if the same team is reassigned for subsequent hospitalizations and that the patient is referred to the same outpatient providers after discharge.

This continuity helps to reduce repetitive efforts and putting the patient through the stresses of having to form all new relationships at each level and entry into care.

It should be noted, however, if the patient is not improving, the family is dissatisfied, or the patient requests reassignment, changing treating providers should ensue or be assessed.

Despite ever-shrinking health care resources, it remains incumbent upon health care professionals to provide the best quality of care, especially for those individuals with psychiatric disorders who have had the need for hospitalization. We should be aware of both our feelings and those of the patient and avoid a hardened and unempathetic stance. By doing this and facilitating coordination between professionals, the patient, and the family and endorsing the discharge plan and continuity of ongoing psychiatric care, we can best practice and support those who come to us in need.

(For more information, contact Madeleine Y. Gomez, PhD, president, PsycHealth Ltd., Evanston, IL. E-mail: mygomez@psychealthltd.com.)

References

  1. Gomez MY, Hall M. Reforming managed are certification of services. Care Manag J 2006; 6(2):73-79.
  2. Goldman, H. Mental illness and family burden: A public health perspective. Hosp Community Psychiatry, 1982; 33:557-560.
  3. Hatfield AB. The family as partner in the treatment of mental illness. Hosp Community Psychiatry 1979; 30:338-340.
  4. Solomon P, Beck S, Gordon B. Family members' perspectives on psychiatric hospitalization and Discharge. Community Ment Health J 1988; 24(2):108-117.
  5. Hughes KH, Ashby C. Essential components of short-term psychiatric unit. Perspect Psychiatr Care 1996; 32(1):20-25.
  6. Onate J. Psychiatric consultation in outpatient primary care settings: Should consultation change to collaboration? Prim Psychiatry 2006; 13:641-645.
  7. Gomez MY. Home intervention: An idea whose time has come again. Case in Point June/July 2007; 41-44.
  8. Johns M, Gomez MY, Flaxman, J, et al. Psychotherapeutic home intervention program: Impact on Medicaid readmission rates. Care Manag J 2007; 8(4):179-186.