Expanding Roles: The APRN in the Pediatric Residential Treatment Center Carla Branson MSN, APRN, PMH-CNP and Dawn Glowatz MSN, APRN, PMH-CNP Neither of today s two speakers have any conflicts of interest to disclose. Learning Objectives: I: The participant will be able to identify some of the unique characteristics of the Pediatric Residential Treatment Center. II: The participant will gain an understanding of the population served within a typical Pediatric Residential Treatment Center and the rationale for utilizing trauma informed care. III: The participant will be able to describe some qualities of the multifaceted role of the Psychiatric APRN in CCHMC s Pediatric Residential Treatment Center. Branson, Glowatz 1
General RTC Population -CDC report: 13-20% of all children and adolescents will experience a mental health condition in any given year -NIMH: 20% (or 1 in 5) children either currently or at some point during their life, have had a seriously debilitating mental disorder. -Have had serious safety issues and multiple DSM dx -Approximately 82% have experienced some type of trauma -Failure of response to less restrictive forms of care, sometimes even other RTCs. CCHMC-RTC Three units: one for latency aged children, two for adolescents APRN s on P2E: -Maximum bed capacity: 10 -Female Adolescents -Axis II Traits P2S: -Maximum bed capacity: 12 -Co-ed (but more male) -Extreme behavior related and/or psychosis Population of CCHMC-RTC Fiscal years 7/1/11 thru 6/30/14 on P2E/P2S only Total admissions 146, (60 males, 86 females) Ages 8, 11-17 (totals respectively 2, 5, 6, 12, 25, 34, 39, and 23) 101 paid by Medicaid, remaining 45 either private insurance, self pay, or hospital financial 69 of the 146 in custody of an Ohio County (JFS) 40 had PTSD diagnosis listed, 18 of these had PTSD for primary diagnosis *Data gathered by Natalie Ross, BS, LSW, Division Support Analyst Branson, Glowatz 2
Program Composition -Mainly Social Model: milieu managed by social workers/therapists, MHS -More medical component: -Access to seeing a Psychiatric APRN upon request -Psychiatrist visits two/month -Psychiatric APRN visits one to two times/week -Weekly treatment team meetings -Individual/Group Therapies: CBT and Trauma Focused CBT Art, Music, Equine, Small Animal, Horticultural Speech, Occupational Chaplain s Group and Fernside Grief and Loss - CCHMC RTC Treatment Model Combination which integrates: CBT: Cognitive Behavioral Therapy CARE: Child Adult Relationship Enhancement TFCBT: Trauma Focused Cognitive Behavioral Therapy TIC: Trauma Informed Care -Sources of trauma -ACE Studies -Biological and psychosocial impacts Trauma Informed Care WHAT? -Focus on Complex Trauma -Creation of a safe environment -Re-framing of mental concept of adults -Avoidance of inadvertently re-traumatizing WHY? -Population being served -Chronic/Complex Trauma is at the core of many behavioral and psychological disorders of children and adolescents (Hummer et al.) -Actually treating problem not just symptoms Branson, Glowatz 3
I. SAFETY II. CONNECTIONS III. MANAGING EMOTIONS Three Pillars -1999 Asay and Lambert major study: What leads to positive outcomes in psychotherapy? on average, the qualities of the therapeutic relationship itself accounts for twice as much positive change as the therapeutic techniques that are used (Bath, 2008) CCHMC s RTC Future -Introduction of DBT: Dialectical Behavioral Therapy -Modified DBT for the Intellectually Disabled -New Facilities: new building with total of 4 units, fence around building and outside green space, bike trail within the fenced green space. Branson, Glowatz 4
The Multi-Disciplinary Treatment Team (2S/2E) -Psychiatrists (2) -APRN s (3) -Pediatrician -Social Workers (2) -MHS: Mental Health Specialists -Therapeutic Recreation Specialists -Occupational Therapists -Speech Therapists -School Teachers (2) -Dieticians The Psychiatric APRN Role in the Pediatric RTC -Lack of Research and Empirical Data -Currently determined by Facility/Program -Dynamic-ever changing-continuing to evolve Psychiatric APRN Role within CCHMC-RTC -Allows the utilization and implementation of all of the Standards of Practice for the PMH-APRN: 5C: Consultation (collaborating with all members of interdisciplinary treatment team) 5D: Prescriptive Authority and Treatment (providing and billing for psychopharmacological services) 5E: Provides pharmacological, biological, and integrative therapies (during individual sessions) Branson, Glowatz 5
Standards of Practice Continued: 5F: Milieu therapy (assisting with education of MHS staff in managing milieu, especially when present on unit) 5G: Therapeutic relationship and counseling (most important!!!) 5H: Psychotherapy American Nurses Association, American Psychiatric Nurses Association, International Society of Psychiatric-Mental Health Nurses (2014). Typical Week for Psychiatric APRN: -Three weekly interdisciplinary meetings -Up to two weekly care plan development meetings -Individual Sessions with each patient -Gate keeper for all orders -Care Conferences with outside parties/providers Psychiatric APRN Role within CCHMC-RTC Pros: REWARDING Increased Practice Autonomy Cons: Demanding and time consuming Increased Clinical Opportunities Utilization of the Therapeutic Relationship Challenging Patients Return to same dysfunctional environment Ability to observe improvements over time Branson, Glowatz 6
Summary -Pediatric RTC is a unique practice setting -Serves the most seriously emotionally disturbed pediatric patients -Focuses heavily on complex trauma -Utilizes all of the Standards of Practice for Psychiatric-Mental Health APRN References: Included in today s handouts. Branson, Glowatz 7