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Inpatient Hospital Treatment
In the 1980s, inpatient psychiatric care was still a primary mode of treatment for people with mental illness. A typical psychiatric unit emphasized talk therapy, or one-on-one interactions between residents and staff, and milieu ther-apy, meaning the total environment and its effect on the client’s treatment. Individual and group interactions focused on trust, self-disclosure by clients to staff and one another, and active participation in groups. Effective milieu therapy required long lengths of stay because clients with more stable conditions helped to provide structure and support for newly admitted clients with more acute conditions.
By the 1990s, the economics of health care began to change dramatically, and the lengths of stay in hospitals decreased to just a few days. Today, most Americans are insured under some form of managed care. Managed care exerts cost-control measures such as recertification of admissions, utilization review, and case management—all of which have altered inpatient treatment significantly. The growth of managed care has been associated with declining admissions, shorter lengths of stay, reduced reimbursement, and increased acuity of inpatients. There-fore, clients are sicker when they are admitted and do not stay as long in the hospital.
Today, inpatient units must provide rapid assessment, stabilization of symptoms, and discharge planning, and they must accomplish goals quickly. A client-centered multidis-ciplinary approach to a brief stay is essential. Clinicians help clients recognize symptoms, identify coping skills, and choose discharge supports. When the client is safe and stable, the clinicians and the client identify long-term issues for the client to pursue in outpatient therapy.
Some inpatient units have a locked entrance door, requiring staff with keys to let persons in or out of the unit. This situation has both advantages and disadvantages (Haglund, von Knorring, & von Essen, 2006). Nurses identify the advantages of providing protection against the “outside world” in a safe and secure environment as well as the primary disadvantages of making clients feel con-fined or dependent, and emphasizing the staff members’ power over them.
Alwan, Johnstone, and Zolese (2008) found that planned short hospital stays were as effective as longer hospitaliza-tions. Patients spending fewer days in the hospital were more likely to attend post-discharge day programming and more likely to be employed after 2 years than patients with longer hospitalizations. Patients with planned shorter stays did not have more frequent subsequent admissions to the hospital.
The Department of Veterans Affairs (VA) hospital system has piloted a variety of alternatives to inpatient hospital admission that occurs when the client’s condition has worsened or a crisis has developed. Scheduled, inter-mittent hospital stays did not lessen veterans’ days in the hospital, but did improve their self-esteem and feelings of self-control. Another alternative available to veterans, the short-term acute residential treatment (START) program (Hawthorne et al., 2005), is based in San Diego and is available at six facilities, all of which are non-hospital-based residential treatment centers. Over a 2-year period, veterans treated in the START program had the same improvement in symptoms and functioning as those treated at a VA hospital, but were significantly more satis-fied with the services. The cost of treatment in a START program was 65% lower than treatment in the hospital.
Long-stay clients are people with severe and persistent mental illness who continue to require acute care services despite the current emphasis on decreased hospital stays. This population includes clients who were hospitalized before deinstitutionalization and remain hospitalized despite efforts at community placement. It also includes clients who have been hospitalized consistently for long periods despite efforts to minimize their hospital stays. Community placement of clients with problematic behav-iors still meets resistance from the public, creating a bar-rier to successful placement in community settings.
One approach to working with long-stay clients is a “hospital hostel,” a unit within a hospital that is designed to be more homelike and less institutional. Hostel projects have been established that provide access to community facilities and focus on “normal expectations,” such as cooking, cleaning, and doing housework. Clients reported improved functioning, had fewer aggressive episodes, and were more satisfied with their care. Some clients remained in the hostel setting, whereas others were eventually reset-tled in the community. (Bartusch, et al., 2007)
The concept of a “crisis hostel” has been successful in a rural community–based program in Colorado (Knight, 2004). The only criterion for using the service is the client’s perception of being in crisis and needing a more structured environment. Knight believed that if the client does not have to exhibit any certain “symptoms” to gain access to the hostel, he or she is more likely to perceive his or her situation more accurately, feel better about asking for help, and avoid rehospitalization.
Lunsky and colleagues (2006) studied more than 12,000 long-stay clients in the tertiary mental health-care system in Ontario. They found that 1 in 8 clients had a dual diagnosis of a major mental illness and mental retar-dation. These clients required, but did not often receive, a higher level of care with more intensive services and super-vision than clients with a mental illness and normal intel-lectual functioning. As a group, the clients with a dual diagnosis had more severe symptoms, more instances of aggressive behavior, and a greater lack of financial and health-care resources. The authors suggested that reform in the tertiary mental health-care system should address the needs of clients with a dual diagnosis, which often exceed current available services.
Case management, or management of care on a case-by-case basis, is an important concept in both inpatient and community settings. Inpatient case managers are usually nurses or social workers who follow the client from admis-sion to discharge and serve as liaisons between the client and community resources, home care, and third-party pay-ers. In the community, the case manager works with clients on a broad range of issues, from accessing needed medical and psychiatric services to carrying out tasks of daily liv-ing such as using public transportation, managing money, and buying groceries.
An important concept in any inpatient treatment setting is discharge planning. Environmental supports, such as hous-ing and transportation, and access to community resources and services are crucial to successful discharge planning. In fact, the adequacy of discharge plans is a better predictor of how long the person could remain in the community than are clinical indicators such as psychiatric diagnoses.
Impediments to successful discharge planning include alcohol and drug abuse, criminal or violent behavior, non-compliance with medication regimens, and suicidal ide-ation. For example, optimal housing often is not available to people with a recent history of drug or alcohol abuse or criminal behavior. Also, clients who have suicidal ideas or a history of noncompliance with medication regimens may be ineligible for some treatment programs or services. Therefore, clients with these impediments to successful discharge planning may have a marginal discharge plan in place because optimal services or plans are not available to them. Consequently, people discharged with marginal plans are readmitted more quickly and more frequently than those who have better discharge plans.
However, discharge plans cannot be successful if clients do not follow through with the established plan. Clients do not keep follow-up appointments or referrals if they don’t feel connected to the outpatient services or if these services aren’t perceived as helpful or valuable. Attention to psychosocial factors that address the client’s well-being, his or her preference for follow-up services, inclusion of the family, and familiarity with outpatient providers is crit-ical to the success of a discharge plan.
Prince (2006) found that three types of intervention are significant in preventing rehospitalization for individuals with four or more prior inpatient stays. These interven-tions are symptom education, service continuity, and establishment of daily structure. Clients who can recog-nize signs of impending relapse and seek help, participate in outpatient appointments and services, and have a daily plan of activities and responsibilities are least likely to require rehospitalization.
Creating successful discharge plans that offer optimal services and housing is essential if people with mental ill-ness are to be integrated into the community. A holistic approach to reintegrating persons into the community is the best way to prevent repeated hospital admissions and improve quality of life for clients. Community programs after discharge from the hospital should include social services, day treatment, and housing programs, all geared toward survival in the community, compliance with treat-ment recommendations, rehabilitation, and independent living. Assertive community treatment (ACT) programs provide many of the services that are necessary to stop the revolving door of repeated hospital admissions punctuated by unsuccessful attempts at community living.
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