Supporting a Participant Through a Hospitalization Stay: Discharge Planning
Disclosure The information that will be shared within today s training are collective ideas gathered from experience, current research, and best practices to support individuals with complex needs who have been hospitalized due to psychiatric or behavioral challenges. This training is not intended to be an inclusive resource as each participant s situation and needs are unique. It is recommended teams refer to this training as one tool to develop individualized plans. 2
Agenda The 5 W s of Discharge Planning Roles and Responsibilities BAS roles Provider roles Participant and Family roles Strategies to Address Obstacles and Barriers Resources 3
The 5 W s of Discharge Planning 4
What is discharge planning? Medicare says discharge planning is "A process used to decide what a patient needs for a smooth move from one level of care to another. Basics of a discharge plan: Evaluation of the patient by qualified personnel Discussion with the patient or his representative Planning for homecoming or transfer to another care facility Determining if caregiver training or other support is needed Referrals to home care agency and/or appropriate support organizations in the community Arranging for follow-up appointments or tests. 5
Why is Discharge Planning Important? Number of Psychiatric Incidents Fiscal Year 14-15: 17 Fiscal Year: 13-14: 18 Fiscal Year: 12-13: 17 Approximately two-thirds (65%) of the patients failed to attend scheduled or rescheduled initial outpatient mental health appointments after a hospital discharge (Boyer et al., 2000) A good discharge plan will help to minimize the chance of a readmission. It helps to establish continuity of care, hold team members and participant accountable, and to plan for next steps. 6
Who should be involved with discharge planning? Participant Family, Natural Supports, Someone who knows participant well Supports Coordinator Behavioral Specialist, when applicable Counselor, when applicable Social Worker (hospital) Psychiatrist/Psychologist (hospital and outpatient) Additional individuals pertinent to the participant s needs 7
Where Does Discharge Planning Take Place? At the hospital or treatment facility Over the phone Through Email Post Discharge: Participant s home Outpatient facility 8
When Should Discharge Planning Occur? Immediately upon receiving notification that a person has been hospitalized Emergency room visit 201 302 Releases may need to be signed! 9
Roles and Responsibilities 10
Bureau of Autism Services To ensure health and safety of the participant To provide technical assistance, where our experience allows BAS is not the expert! Our experiences and interactions with other systems across the state have evolved the skills of BAS. However, the expectation is that we continue to reach out to those who may have specialized experiences related to the participant s needs, when it is deemed necessary (e.g. ASERT, MH system, substance abuse experts, sexuality consultants) While both the clinical and RO rep are an important part of the team, we refer to the family and providers for input and participation as you know the family best. From the beginning, a conversation should be had to define what specific roles will look like 11
Provider Roles and Responsibilities To communicate with entire team once information is received To file incidents in EIM timely and appropriately To communicate with participant while inpatient (think: Who has the best relationship and rapport with that person) To update the ISP, BSP/CIP as soon as new information is received To submit critical revisions in enough notice for review and approval to occur 12
Participant and Family Roles and Responsibilities Sign releases Participate in team meetings, where appropriate Provide input on plan post-discharge Follow-through on agreed upon plan Notify team members (minimum: SC) when changes are needed or something with plan isn t working 13
Example of Task Assignments BAS Clinical- communicate with social worker at hospital, reach out to ASERT for additional supports, review BSP/CIP, provide technical assistance and training BAS RO- coordinate team calls, reach out to other providers who may be able to support participant, approve/auth services in HCSIS SC- take meeting minutes and disseminate, submit CRs, file incident, BS- update BSP/CIP, develop additional tools to collect data or support treatment recommendations, train team members Other Providers- participate in team calls, be flexible with availability, be ready to provide services as soon as discharged Participant- provide input on treatment recommendations and followthrough with plan, take medications as prescribed Family- communicate with entire team, openly share updates 14
Strategies to Address Obstacles and Barriers 15
Collect Data!!
Brief Critical Time Interventions (Dixon et al., 2000) 17
Participant Refusal to sign releases, communicate with team members Who knows the participant well? Who has the best relationship with that person? Could that person go to hospital and visit in person? Is it possible for the participant to agree to certain aspects of communication? Only certain people can talk to hospital, communication can only happen when participant is present, communication can only happen one time Continue to revisit, without overwhelming participant 18
Lack of follow-through on plan (participant and/or team) Lesson learned for next time- be more proactive Does participant understand what is expected (have them restate the plan in their own words) Ensure all roles and responsibilities are clearly understood (in writing!) Is a point-person providing frequent check-ins to maintain accountability Is a back-up plan established? Focus on one task at a time 19
Providers unable to bill when participant is hospitalized BAS continues to fight this fight and will continue to seek allowances to make this happen Some providers have additional funding available for emergencies or training could some support be provided through this avenue? Email is the easiest way to stay informed of progress without it consuming too much time (bonus: serves as a paper trail to refresh memories) Do you have a supervisor who is able to participate on your behalf who is not directly reliant on being able to bill? Remember- a hospitalization is not forever so the more you are able to participate, the easier the transition back to authorized services 20
No BSS Supporting Participant Is the participant willing to accept BSS now? Even without BSS, strategies can still be developed to help address the need Increase additional services Clinical team s technical assistance (having data helps!). Our expertise is in behavioral analysis 21
Little to No Cooperation with Hospital One person should be responsible for contacting the hospital to understand WHY they are not involved with the team If it is a lack of signed release, see other slide for strategies Contact them daily Confirm preferred method of communication (phone or email) Contact them during times of day that is most preferred Go there in person Contact other individuals within hospital, if you have their information Have questions or information prepared ahead of time 22
Participant does not have a home to return to following the hospitalization Be sure to inform hospital of that situation. Be explicit If family is refusing to allow participant to return home, get that information in writing! Consider exploring out-of-home respite services (30 days max per plan year; needs BAS approval) Explore Temporary Crisis Services (needs BAS approval and oversight) Could participant/family fund temporary housing in the community, with services/supports in place? Hotel, shelters, boarding homes, etc 23
Res Hab was approved while in hospital, but participant has not visited the home or met provider Timing is extremely critical! The sooner conversations can start the better SC, BS, or someone who knows participant well should meet with Res Hab provider (preferably in person) to share info about participant, and sell what they are able to offer to help support them and participant Consider skyping or face-timing with participant if hospital allows Keep in close contact with hospital about pending start date with res hab (sometimes they will work with you to not discharge until start date; helps to minimize transitions) Try, when possible, to transition right from hospital to home 24
Insurance Obstacles (transportation, coverage, denials) Obtain written documentation (explanation of benefits) Get specific name and contact info for insurance rep (instead of just general number) Consider private pay options, if feasible File appeals! 25
Medication Refusals Educate participant on each medication, purpose, side effects, dosage, etc Consider teaching self-monitoring techniques (start in hospital) to monitor mood, behavior (see Biphasic Mood Rating Form shared earlier) Take their concerns seriously. Validate and help participant to articulate concerns to a doctor. Take things one day, week, month at a time Injectable medications are sometimes prescribed for certain meds in certain situations- it can t hurt to ask! 26
Medication runs out before outpatient appointment Outpatient appointments should be made BEFORE leaving the hospital and enough meds should be provided until that appointment is scheduled (assuming the appointment is with a psychiatrist) However, sometimes appointments get changed, which means different approaches are needed Try to stress urgency to be seen sooner rather than later May need to go back to the hospital where meds were first prescribed to get more Most managed cares should have a mobile med unit, however, not all meds are covered and should only be used as a last case resort 27
Outpatient appointment not scheduled right away Someone should advocate for an appointment to be scheduled as soon as possible (with 7 days yields a higher participation rate in outpatient treatment, Dixon et al 2009) to both the hospital and the outpatient facility When that is not possible, provide frequent reminders of upcoming appointment. Someone who knows participant well should accompany him/her to appointment (Dixon et al, 2009) Beginning outpatient services while still inpatient may not only help bridge services, but will also increase motivation to participate after discharge (Boyer et al, 2000). 28
Additional Recommendations Someone who knows participant well should meet them at the hospital the day of discharge or meet them when they return home Obtain copy of discharge paperwork (take a picture if needed). Share with entire team Team should schedule a conference call or meeting within a few days of discharge- to check-in, review the plan, etc Schedule calls/meetings on a regular basis for the first few months, if not longer. When possible, BAS will participate SC should take notes and disseminate via email to entire team 29
Additional Recommendations Empower the participant and help him/her gain back some independence following hospitalization by offering choice, engaging in preferred activities, etc The waiver/acap team should be flexible with their schedules to allow to ample opportunities to communicate Some social workers/case workers are only available first thing in morning or late afternoon If you get any updates over the weekend, send a quick email to the team so you do not forget Keep your phone accessible in case something urgent comes up 30
Resources 31
Boyer, C. A., McAlpine, D. D., Pottick, K. J., & Olfson, M. (2000, October). Identifying risk factors and key strategies in linkage to outpatient psychiatric care. The American Journal of Psychiatry, 157(10), 1592-1598. Dixon, L., Goldberg, R., Iannone, V., Lucksted, A., Brown, C., Kreyenbuhl, J., Fang, L., & Potts, W. (2009, April). Use of critical time intervention to promote continuity of care after psychiatric inpatient hospitalization. Psychiatric Services, 60(4), 451-458. 32
Autism Services, Education, Resources & Training Collaborative (ASERT) ASERT is a statewide initiative funded by the Bureau of Autism Services, Pennsylvania Department of Human Services. ASERT is a unique public and private partnership between BAS and PA universities, hospitals/medical centers and private community providers. It is a key component of our strategy for supporting individuals with autism and their families throughout the Commonwealth. WESTERN REGION CENTRAL REGION EASTERN REGION 33
Pennsylvania s leading source of autismrelated resources and information 34