EIS: Post-hospital stabilization practices

EIS: Post-hospital stabilization practices Contents TOC 1 Level 1 (see formatting palette / styles) Date:

Suggested citation... 3 Overview of inquiry... 3 Emergency hospital services and mental health crises... 3 Shortening hospital stays... 4 Predictors of length of stay and readmission... 4 Discharge planning and aftercare services... 5 Ontario inpatient environmental scan... 5 Overview of crisis beds in Ontario... 6 Post-hospital stabilization models and practices... 7 Comprehensive Psychiatric Emergency Program... 7 Bridges Project, Ottawa... 7 Prevention and recovery care (PARC) services, Australia... 9 Adult step-up step-down mental health services, Australia... 10 Meyer 3 Short Stay services, Johns Hopkins... 12 Halfway hospitals, United Kingdom... 12 Additional considerations... 13 Coordination and training... 13 Stabilization assessment... 13 Report context... 13 Search terms... 14 References... 14 2

Suggested citation Ontario Centre of Excellence for Child and Youth Mental Health (2017, February). Post-hospital stabilization practices. Evidence In-Sight. Retrieved from: http://www.excellenceforchildandyouth.ca/resource-hub/evidence-in-sight-database. Overview of inquiry Due to economic pressure and increased demand for specialized services, the length of psychiatric hospitalization for children and youth have shortened significantly over the past twenty years, with the focus moving from comprehensive evaluation and treatment, to brief intensive intervention (Barwick & Boydell, 2005; Greenham & Bisnaire, 2008). However, while youth may no longer be in acute crisis at discharge, they may also not be ready to return home or to the community. Organizations experiencing this dilemma, along with its ripple effects, are interested in an overview of latest evidence as well as examples of short-term stabilization models to better support youth during this transition. Emergency hospital services and mental health crises For children or youth experiencing a psychiatric emergency, it is important to immediately assess and intervene to secure their safety and address their concerns as well as those of the family and caregivers. General hospital emergency departments, however, are often ill-equipped to properly handle mental health emergencies. They may lack appropriate social workers, mental health staff, behavioural screening tools and knowledge of mental health services. As such, comprehensive assessments and mental health evaluations are not always taking place and are sometimes scheduled for a later date. Yet when crises pass, the child, youth or family may not be fully engaged to resolve the problems and adhere to the aftercare plan (Barwick & Boydell, 2005). Research by Heslop, Elsom and Parker (2002) outlined some of the concerns and needs identified by emergency department staff at Frankston Hospital, in Melbourne, Australia in the assessment and management of psychiatric patients and their continuity of care. During consultations and focus groups, the following issues and challenges were identified: roles and responsibilities across discipline are not clearly defined there are difficulties diagnosing and classifying psychiatric patients in emergency settings, guidelines for care need to consider diversity in presentation and treatment options prompt medical evaluation is important but it can be difficult to establish priorities among different medical specialists when there are both organic and psychiatric illnesses trauma from managing difficult patients can arise out of lack of knowledge for dealing with challenging behaviours, particularly for junior staff nurses were often unaware of specific clinical management pathways already in place for some patients nurses expressed feeling insecure in dealing with problematic situations and avoidance was related to insufficient knowledge, unwanted sense of vulnerability and intimidation by invasive and aggressive behaviours 3

nurses expressed sorrow and frustration and a sense of failure about patients presenting at the emergency department on multiple occasions nurses also discussed difficulties acting as gatekeepers to psychiatric services of the hospital when dealing with individuals who they felt purposely and repeatedly manipulated the system in order to be admitted From this research, the need for specialist psychiatric nurses in emergency departments as identified and a risk assessment tool with clinical guidelines was created as a beginning point for ongoing development of pathways and policies in working with psychiatric clients (Heslop, Elsom & Parker, 2000). Shortening hospital stays Inpatient psychiatric hospitalization is one of the most expensive forms of mental health treatment leading to questions and scrutiny of both its efficiency and efficacy (Stewart, Kam & Baiden, 2014; Balkin & Roland, 2007). Inpatient services are now reserved for youth with only the most severe, acute and complex needs while short-term stay programs are meant to stabilize and facilitate new and existing connections with community services and resources (Greenham & Bisnaire, 2008). In the United States, residential treatment settings provide stays of approximately 30 days or more, with acute care programs having an average stay of five to seven days. These short stays, called crisis residence by The American Academy of Child & Adolescent Psychiatry, provide intervention and treatment under 24-hour supervision (Balkin & Roland, 2007). The key assumption behind shortened stays is that youth and families have access and will access outpatient mental health and related services in the community to ease the transition, maintain continuity of care, build upon the gains made in the hospital and prevent the likelihood of future crises and hospitalizations (Barwick & Boydell, 2005). This however, does not always occur. In many communities, shortened hospitals stays have led to what some term the revolving door of psychiatric care with high rates of readmission. Improvement in client symptoms is often used as the sole indicator of stabilization without consideration for coping strategies and a commitment to follow-up care. Some clients are therefore being discharged into the same situation and environment that brought them to the hospital, in crisis, in the first place (Balkin & Roland, 2007). Many family members and community practitioners claim that people are being discharged when they are still unwell and into possibly unstable living situations. Caregiver advocacy groups are arguing for longer stays, more beds and a greater range of community-based mental health service options (Davis, 2013). Predictors of length of stay and readmission There is growing interest in research to help predict length of stay and readmission among youth with mental health problems. To help address these issues, Stewart, Kam and Baiden (2014) examined demographic, background and psychopathology variables from the Ontario Mental Health Reporting System (OMHRS). According to this large data set, 4

the average length of psychiatric hospitalization was 16.32 days with the best predictor of length being psychiatric diagnosis, particularly schizophrenia, mood disorders, eating disorder and intellectual disability. The study also found that background conditions, such as police involvement, experience living in group homes, history of sexual or physical abuse, and perception of family dysfunction better predicted readmission than length of stay, highlighting how family conditions can impact service use. Chronic and severe psychiatric conditions, such as schizophrenia, were also related to higher readmission rates which reinforces the importance of continued monitoring throughout the lifespan with regular check-ups for individuals with these conditions (Stewart, et al., 2014). Through this data set, it was found that youth who experience multiple admissions are at higher risk for readmission in the future. The authors therefore promote greater and more effective use of respite and trauma-based therapeutic approaches upon discharge. The need for psychiatric step-down agencies and other intermediate services such as psychoeducation and vocational training is also mentioned as a way to enhance community support and help sustain treatment outcomes. Interventions that focus on the family and improving coping through training, counseling and respite are also suggested to reduce the likelihood of readmission (Stewart, et al., 2014). Discharge planning and aftercare services Discharge is acknowledged as being difficult for practitioners to get right. To improve and help standardize the process, some settings have developed policies. In the United Kingdom, for example, effective discharge requires a multidisciplinary approach, including the involvement of parents and caregivers, and planning for discharge that begins right at admission. The National Service Framework for Mental Health in the United Kingdom also states that service users who require hospitalization for any period of time should have a written, agreed upon care plan that describes the care and rehabilitation they will receive, identifies their care coordinators and details the actions to be taken in the case of a future crisis (Barwick & Boydell, 2005). Aftercare services such as medication, community support and outreach, assertive community treatment, case management and psychotherapy have all been shown to reduce readmission rates. There is a lack of information, however, on the lag time between discharge and the use of such services. In the United States, most youth hospitalized for suicidality concerns, depression, conduct disorder or schizophrenia do receive some mental health services postdischarge, but there is little research on which aftercare services users actually follow through with. Low compliance rates also suggest that services offered do not always align with the needs or resources of the youth and their families (Barwick & Boydell, 2005). Ontario inpatient environmental scan In their article, Greenham and Persi (2014), aim to describe the state of Ontario s inpatient settings and services with the hopes of eventually establishing a more permanent provincial information-base to facilitate cross-setting comparisons, benchmarks and standards. At the time of their study there were 183 beds across 27 settings. Beds by Local Health Integration Network (LHIN) districts varied from none to 15 per 100,000. For the two districts without designated mental 5

health beds within a hospital setting, one admitted children and youth to an out-of-hospital setting, and the other used an inpatient setting of a nearby LHIN. Unplanned crises accounted for significantly more admissions compared to planned, elective admissions, i.e. admissions booked in advance, beds reserved by physicians, and wait list admissions. Two settings admitted solely crisis, one solely elective and the remaining 21 admitted both. Suicide risk was the most prevalent problem leading to admission. All settings reported providing stabilization, family assessments, diagnosis and mental health education. All but one provided risk assessment and pharmacology. Less than half reported measuring outcomes routinely for every patient. Symptom change was the most frequently measured outcome, followed by risk reduction, stabilization and functional improvement. The authors conclude by stating that the environmental scan supports the need for both crisis and longer term inpatient treatment (Greenham & Persi, 2014). Overview of crisis beds in Ontario In a general online search for services, the availability of crisis or emergency beds did appear, but often as a means to avoid hospitalization, not step-down from it. Most crisis beds were geared towards homeless individuals or those at risk for homelessness. Additionally, most services were for adults or at least those 16 years and older. Below are some examples of the services found. Toronto The Centre for Addictions and Mental Health (CAMH) offers a Crisis Stabilization Bed service that helps individuals 16 years and older remain in the community and avoid hospitalization. This service is considered a brief reprieve in a safe and secure environment, staffed 24/7 by mental health workers. Accommodation is available for three to seven days, along with supportive counseling, scheduled on-site nursing services, case management, community referrals, relapse prevention planning and follow-up services. http://toronto.cmha.ca/programs_services/safebeds/#.wheqa1urkuk Ottawa The Ottawa Hospital operates short-term crisis support beds for adults experiencing mental health crises who do not require inpatient hospitalization but would benefit from temporary placement in a supportive environment. Beds are located within a number of housing options with the goal of helping individuals begin to resolve their crisis through problem solving, symptom stabilization and links to community supports. Beds are accessed through a crisis line where staff determine if they should send the mobile crisis team to assess the situation and determine suitability. http://www.mentalhealthhelpline.ca/directory/program/6889 Hamilton The Good Shepherd Non-Profit Homes - Barret Centre provides a safe space for individuals needing support in resolving crisis situations. The program employs a recovery oriented service model and is client directed. Telephone support is available 24/7 as well as in-person, non-residential support. The program also provides support for clients transitioning 6

from inpatient programs back to the community, as well as for those leaving custody or who are involved in court diversion programs. http://www.mentalhealthhelpline.ca/directory/program/6909 Whitby Durham Mental Health Services offers short-term crisis support beds. Other crisis supports for those 16 years and older include: 24/7 telephone support, community visits by a mobile team, linkages to other community supports and followup supports. Community mental health workers have specialized training to help individuals in crisis. http://www.mentalhealthhelpline.ca/directory/program/6566 Brantford The Youth Resource Centre offers short-term (up to 10 days) crisis support beds for youth, 16 to 19, requiring housing, support and stabilization. This residential program provides assessment and discharge planning services. http://www.mentalhealthhelpline.ca/directory/program/19050 Post-hospital stabilization models and practices The following section outlines examples of sub-acute care and post-hospital stabilization models and practices found in the literature. Relevant and recent information was limited and most examples found focused on the adult population. The examples outlined below come from the United States, Canada, Australia and the United Kingdom. Comprehensive Psychiatric Emergency Program Barwick and Boydell (2005) describe The Comprehensive Psychiatric Emergency Program in New York City which is located adjacent to a medical emergency department. With this program, a psychiatrist is available 24/7 to evaluate patients and a trauma team approach is taken for extremely agitated or violent patients to quickly evaluate them and get the behaviour under control. After the evaluation is conducted, there are three treatment pathways for the client: they can be sent to the extended observation unit for up to 72 hours, to a mobile crisis unit for follow up, or to a crisis residence bed. A Partial Hospital Program, was also developed to provide six-week, full day intensive treatment from a behavioural and family-focused approach for children and youth with high levels of violence to themselves or others. This program is meant for youth in crisis, presenting to the emergency department who could stabilize with intensive treatment and do not require inpatient admission. For more information, visit: https://www.sjhsyr.org/cpep Bridges Project, Ottawa In Ottawa, the Children s Hospital of Eastern Ontario (CHEO) has shifted services towards crisis stabilization leaving a gap in partial hospitalization, day treatment programs and intensive services post-discharge, particularly for youth ages 16 to 18 with severe mental illness. As a result, a number of unintended effects have been seen including: repeated presentations to emergency departments or contact with mobile crisis units, repeat emergency admissions and 7

readmissions, poor access and long wait times for hospital and community outpatient services and longer says due to difficulties in discharge planning for youth with serious mental illness (Baker et al., n.d.). In response to these issues, the Bridges Project was developed for youth requiring intensive services beyond the immediate crisis. The project is the result of cross sectorial collaboration and Memorandum of Understandings between four main partners: Youth Services Bureau of Ottawa (YSB), CHEO, The Royal Ottawa Health Care Group (The Royal) and Ottawa Public Health. YSB houses the project and is responsible for the day-to-day operation. The project is funded by the Champlain District Local Health Integration Network (LHIN), the Nursing Secretariat and Ottawa Public Health with support from other funders and foundations. Funding is distributed between CHEO, The Royal, and YSB to pay for staff positions (Baker et al., n.d.). Bridges provides youth with complex mental health needs, and their families, a link between the hospital and community by offering short-term (16-week) clinical intervention and skill building. An interdisciplinary team provides a coordinated, integrated and intensive response. The team includes a clinical coordinator, youth and family counsellors, public health nurse, psychiatric registered nurse, occupational therapist, psychologist, psychiatrist, administrative assistant and program volunteers (i.e. yoga and music instructors) (Baker et al., n.d.). Clients include youth between the ages of 13 and 17, who reside within the Champlain LHIN, are experiencing symptoms of complex mental illness and require enhanced services before transitioning to ongoing community-based mental health services. They are referred to the Bridges Project through YSB s Integrated Crisis Response Services/Mobile Team, CHEO or The Royal (Baker et al., n.d.). An evaluation of the program found that between April 2013 and August 2015: 156 clients were referred 127 clients received services the average length in program was 137 days (19.5 weeks) the median length in the program was 132 days (18.6 weeks) approximately 75 percent of clients received several recommendations, including referrals at discharge 56 percent of clients were involved in services post-bridges, including counselling, psychology, psychiatry, intensive parenting support, alternative schooling, specialized program, adult services etc. there were two re-referrals into the program (1.54 percent) 27 percent of clients required hospitalization during their participation in Bridges Identified challenges with this project and its delivery include: clients are complex and can be difficult to serve the lived experience population can be difficult to engage there is limited capacity to manage emergency situations patient flow is an issue patients are often difficult to discharge to community resources 8

there is an uneven coverage of psychiatry it is difficult to integrate research opportunities scheduling issues The full presentation on the Bridges Project can be found at: http://cmho.org/documents/ma4-bridges-presentationfor-cmho-nov-18-final-pdf-version.pdf Prevention and recovery care (PARC) services, Australia In Australia, mental health prevention and recovery care (PARC) services treat people experiencing acute and severe mental health episodes in a community setting. PARC services are short-term, recovery focused and delivered through a clinical and community partnership model. The goal is to provide an accessible, supportive and therapeutic model of sub-acute care (Galloway, Scollo & Thomson, 2016). Care pathways are considered critical for providing support at various stages of mental illness, from acute to sub-acute treatment, to ongoing support and recovery. PARC services are considered a step-up from community-based services for those whose mental illness is increasing in severity and a step-down for those transitioning from inpatient services after an acute psychiatric episode. PARC services are considered part of the continuum of mental health care as they seek to improve the mental health outcomes of people with a severe mental illness who become acutely unwell while preventing avoidable admissions and readmissions to acute inpatient units (Galloway et al., 2016). As of January 2016, there were: 20 adult PARC services with 194 beds and 6 day places, including a women s only service and an extended stay service 3 youth PARC services with 30 beds 2 new adult services under construction to offer an additional 18 beds and 2 day places Youth PARC services are available for those between the ages of 16 and 24 years. Admission is voluntary, but individuals on a community-based treatment order can access services. Treatment practices include: intensive clinical intervention (including bio-psycho based treatment) support and practical assistance to foster independent living and social skills appropriate group-based activities and therapies At the time of the study PARC services were operating below capacity, with only 72 per cent of beds occupied over the five-year study period. For youth PARC services, the average occupancy rate was 67 per cent. Limited information about PARC services for both mental health professionals and consumers was offered as an explanation for the low use rates. The rates are increasing over time, suggesting they will reach recommended occupancy levels in the future (Galloway, et al., 2016). 9

The study found that PARC services are being used as both a step-up and step-down for clients. For the youth PARC services, two thirds of youth PARC clients (67 per cent) were stepping-up from community-based services, and 33 per cent were stepping-down from inpatient services. PARC services aim to provide an average stay of between seven and fourteen days with a maximum stay of 28 days. For youth PARC services, the average stay was found to be 19 days. Discharge from youth PARC services peaked at 14, 21 and 28 days, compared to other youth inpatient mental health services where discharge typically peaks two days after admission (Galloway, et al., 2016). PARC services aim to reduce admissions and readmissions into acute inpatient mental health services. Preliminary findings suggest they have not significantly changed the use of, or length of stay, in inpatient mental health services. The authors recommend further investigation be conducted, as PARC services do provide an important option for consumers based on their community focus and less restrictive practices (Galloway, et al., 2016). Adult step-up step-down mental health services, Australia In Australia, adult step-up step-down mental health services provide short-term sub-acute residential rehabilitation in a home-like environment. These services are designed to take some pressure off inpatient units by offering transitional services for those returning to the community through a more cost-effective model. Across Australia, adult step-up stepdown units are increasingly being developed (Thomas, Rickwood & Bussenschutt, 2015). In 2009, the adult step-up step-down services in Canberra began operating as a five-bed residential unit. For clients experiencing an escalation in symptoms but looking to avoid hospitalization, step-up services were available by referral from a clinical mental health worker. Step-down clients were those believed to benefit from additional supports before returning to the community and were referred by inpatient units at the two major hospitals. To ensure a safe environment for all participants, a risk assessment is performed as part of pre-eligibility screening to assess risk of selfharm, risk to others and risks associated with living in a congregated setting. The unit in Canberra includes two wings, allowing for gender-specific bedrooms and bathrooms. Communal spaces include a large kitchen, dining room, lounge room, sunroom and enclosed outdoor space. The service is fully occupied at all times, with new clients ready to enter the program whenever vacancies allow (Thomas, et al., 2015). Recovery and positive psychology approaches provide the foundation with services focused on promoting well-being, hopefulness, personal empowerment, social connections and self-determination. Clients are able to explore and develop elements of recovery in a safe environment while also accessing evidence-based biological, psychological and social interventions. Through these services, recovery goals are set through collaborative decision-making, social connections are promoted and personal strategies to manage symptoms and foster positive mental health are developed (Thomas, et al., 2015). The adult step-up step-down services are staffed 24/7. Staff include a full-time manager, a mental health specialist nurse who provides clinical support, and two social workers who provide clients with individual support and training. Social workers (called key workers) help clients develop recover plans, self-management skills and daily routines. They also can accompany clients to appointments and actively help them develop community connections. All staff are trained in 10

mental health or social/community work and have an understanding of mental illness and recovery-oriented care. Inhouse trainings are offered and staff attend conferences and other events to continually expand their knowledge of mental health recovery (Thomas, et al., 2015). Step-up step-down programs involves a number of components including: community meetings clients and staff meet every weekday morning for 20 minutes to plan the day s activities, discuss topics of concern, and organize community events psychosocial groups once a week for an hour, staff facilitate peer support/educational sessions based on topics chosen by the clients Optimal Health a structured evidence-based program facilitated by staff to provide clients with knowledge about their illness and help them develop personal self-management strategies. Optimal Health takes place for one hour, twice a week, for four weeks. art/music groups weekly class designed to help clients explore their creative interests personal engagement one-on-one sessions between staff and clients to focus on specific recovery goals, personal illness management, and relapse prevention social outings weekly trips to a local venue chosen by clients to provide experience and develop confidence in accessing local community activities and spaces physical therapies exercise programs based on clients comfort levels and abilities focused rehabilitation assistance with budgeting, public transportation, shopping, developing relationships with local pharmacists, job and housing applications, and government departments to support the clients return to the community daily living activities support and guidance on basic skills such as meal planning, shopping, cooking, cleaning and personal hygiene communal meals twice a week staff and clients participate in meal planning, shopping, food preparation and clean up community linkages with support from staff, clients are encouraged to connect with community groups with common interests, and other community services, resources and supports family support clients are encouraged to maintain connections with family and friends and family is welcome in the program to receive their own support, psychoeducation resources and referrals alcohol and drug counseling staff are trained in this area, and clients with substance abuse problems are referred to suitable residential or community support services during the program and for when they transition out of it transition planning during the first week clients set goals they d like to achieve while in the program and begin to work towards them Both step-up and step-down clients participate in the same activities but from a different perspective. At the beginning, responsibility for treatment lies predominantly with staff and the treatment team, but gradually the client takes on more accountability. Outcomes examined for discharge include clinical symptoms as well as daily functioning. Ideally, upon 11

program exit, the client shows clinical improvements, is well-engaged in appropriate and ongoing clinical and psychosocial supports and is progressing towards their recovery goals (Thomas, et al., 2015). Meyer 3 Short Stay services, Johns Hopkins The Meyer 3 Short Stay services are designed for severely mentally ill patients, admitted from emergency departments and outpatient programs. The mission of the service is to integrate clinical care, teaching and research to best treat psychiatrically ill patients. These services aim to stabilize and return clients to step-down programs in day hospitals, substance abuse programs, or intensive outpatient treatments. Clients are typically between the ages of 18 and 64 with schizophrenia, bipolar illness, substance abuse and other comorbid conditions. Multi-disciplinary treatment using community psychiatry principles is offered to address the psychosocial needs of patients while working with families and other support systems in the community (Johns Hopkins Medicine, n.d.). The treatment team is comprised of a psychiatrist, senior clinical nurses, social workers, occupational therapists, substance abuse counselors and residents. A comprehensive evaluation, physical exam, and medication review is conducted within the first 48 hours. Through these services, patients are diagnosed by the treatment team, acute medical problems are assessed and treated, a treatment plan is developed, and assistance is provided to help patients follow through with the care plan (Johns Hopkins Medicine, n.d.). For a more detailed description of the program, visit: http://www.hopkinsmedicine.org/psychiatry/patient_information/short_stay_unit.html Halfway hospitals, United Kingdom In the United Kingdom, a treatment gap is recognized to exist between hospitals and community services, and there is an understanding that a number of admissions could be avoided and lengths of stay could be reduced if suitable community and residential options were available. Boardman and Hodgson (2000) discuss a number of models, including crisis houses that allow for stays from a few days to a few months with the provision of housing and short-term acute treatment and support services. Hospital hostels were another model featured which offer clinical expertise of hospitals but in a home-like environment. The first hospital hostel was a Victorian house on the grounds of a hospital that opened in 1977. It could accommodate 14 residents in seven double rooms and aimed to provide a non-institutional environment and independence to residents. Subsequent hospital hostels have switched their focus to rehabilitation for patients with severe and chronic illness (Boardman & Hodgson, 2000). The authors discuss a survey of acute beds which called for more sub-acute beds to provide a step-down from acute inpatient wards to the community with the focus on respite and recuperation. There is no universal term for these settings, but in the U.K. they are commonly referred to as community in-patient units or halfway hospitals (Boardman & Hodgson, 2000). Boardman and Hodgson (2000) found halfway hospitals could be effective and increase patient satisfaction but that they are not a viable option for all patients, particularly those without the needed self-care skills or 12

those who do not wish to be transferred. Other issues with halfway hospitals included the limited number of beds compared to the high demand and difficulties with scheduling staff to provide 24/7 supervision and care. According to the authors, residential psychiatric care is slowly evolving and diversifying in the U.K. with more alternatives to traditional hospital based-care being offered. There appears to be a growing realization that a range of local services are needed to support people with severe and long-term mental illness including acute care, rehabilitation, respite, asylum and other therapies. Additional considerations Coordination and training Coordination between emergency and community mental health services is critical yet due to a lack of common language and regular interaction, they do not always communicate effectively. To improve coordination and increase emergency department staff s knowledge of youth mental health services, specific interventions are required. Barwick and Boydell (2005) recommend cross training for both mental health and emergency service staff around pediatric mental health. These authors also suggest a screening tool be developed and used in emergency services to better identify emergency mental health concerns and ensure young people are treated accordingly and provided necessary referrals and follow-up (Barwick & Boydell, 2005). Stabilization assessment Instead of relying solely on symptoms, Balkin and Roland (2007) propose reconceptualising stabilization to involve a three-step goal attainment scale process: 1) client identifies the problem(s) that resulted in hospitalization, 2) client possesses relevant coping skills to the identified problems, 3) client commits to follow-up. The authors believe this goalattainment model can help provide a higher quality of care for youth hospitalized in acute care psychiatric programs and more likely lead to positive outcomes afterwards. This process and tool can provide evidence for practitioners on whether there is a need to continue crisis stabilization or transition towards discharge (Balkin, 2013). Different templates and variations of the scale can be found online. Report context This Evidence In-Sight report involved a non-systematic search and summary of the research and grey literature. These findings are intended to inform the requesting organization, in a timely fashion, rather than providing an exhaustive search or systematic review. This report reflects the literature and evidence available at the time of writing. As new evidence emerges, knowledge on evidence-informed practices can evolve. It may be useful to re-examine and update the evidence over time and/or as new findings emerge. Evidence In-Sight primarily presents research findings, along with consultations with experts where feasible and constructive. Since scientific research represents only one type of evidence, we encourage you to combine these 13

findings with the expertise of practitioners and the experiences of children, youth and families to develop the best evidence-informed practices for your setting. While this report may describe best practices or models of evidence-informed programs, Evidence In-Sight does not include direct recommendations or endorsement of a particular practice or program. Search terms We used the following terms or combination of terms to find literature pertaining to: transition, discharge, stepped care, child and youth mental health, crisis, stabilization, continuum of care, length of stay, hospital, acute, sub-acute care References Baker, P. S., Tataryn, K., Slepanki, C., Leikin, B., Hurtubise, M., & Gandy, H. (n.d.). Inter-agency collaboration: A BRIDGE to success [PowerPoint slides]. Retrieved from: http://cmho.org/documents/ma4-bridges-presentation-for-cmho-nov-18- final-pdf-version.pdf Balkin, R. S. (2013). Validation of the Goal Attainment Scale of Stabilization. Measurement and Evaluation in Counseling and Development, 46(4), 261-269. Balkin, R. S., & Roland, C. B. (2007). Reconceptualizing stabilization for counseling adolescents in brief psychiatric hospitalization: A new model. Journal of Counseling and Development, 85, 64-72. Barwick, M. A., & Boydell, K. M. (2005). A review of acute child and adolescent mental health services. Toronto, ON: Ministry of Children and Youth Services. Retrieved from: www.melaniebarwick.com/dlcmh.php?f=review_of_acute_cmh_services.pdf Boardman, A., & Hodgson, R. (2000). Community in-patient units and halfway hospitals. Advances in Psychiatric Treatment, 6, 120-127. Davis, S., (2013). Community mental health in Canada: Theory, policy, and practice (Revised and Expanded). Vancouver, CA: UBC Press. Galloway, J., Scollo, G., & Thomson, N. (2016). Mental health prevention and recovery care: A clinical and community partnership of sub-acute mental health care. Victoria State Government, Department of Health and Human Services. Retrieved from: https://www2.health.vic.gov.au/api/downloadmedia/%7b70361c50-9740-40a1-a53f- 96493A8A3341%7D Greenham, S. L., & Bisnaire, L. (2008). An outcome evaluation of an inpatient crisis stabilization and assessment program for youth. Residential Treatment for Children and Youth, 25(2), 123-143. 14

Greenham, S. L., & Persi, J. (2014). The state of inpatient psychiatry for youth in Ontario: Results from the ONCAIPS benchmarking survey. Journal of the Canadian Academy of Child and Adolescent Psychiatry, 23(1), 31-37. Johns Hopkins Medicine (n.d.). Short stay inpatient unit. Psychiatry and behavioral sciences [website]. Retrieved from: http://www.hopkinsmedicine.org/psychiatry/patient_information/short_stay_unit.html Stewart, S. L., Kam, C., & Baiden, P. (2014). Predicting length of stay and readmission for psychiatric inpatient youth admitted to adult mental health beds in Ontario, Canada. Child and Adolescent Mental Health, 19(2), 115-121. Thomas, K., Rickwood, D. J., & Bussenschutt, G. (2015). Adult step-up step-down: A sub-acute short-term residential mental health service. The International Journal of Psychosocial Rehabilitation, 19(1), 13-21. Retrieved from: http://www.psychosocial.com/ijpr_19/adult_step-up_thomas.html 15