Discharge Planning, Part 2/4


Parenting with hope through the hard places by Jennifer Griffis.
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“Here’s the discharge summary. There’s a follow-up appointment for medication management in two weeks. She has an appointment for therapy next week. And here is all of the information on her medication. I just need you to sign here and then I’ll go get her for you.”

After the nurse left the room I turned to my husband, “That’s it? We just take her home now? What do we do if she does this again?”

It was our first discharge experience at a psychiatric hospital. Our daughter, who was six years old, had been there for the past ten days after attempting to kill a sibling and demonstrating some highly concerning thought patterns. We had made the decision to admit her with the hope of finally getting some answers about what was causing the behaviors and how to move forward as a family. But as I walked out of the hospital holding her hand, it felt like all we’d gotten was ten days of respite. I wasn’t sure when, but I knew at some point we’d be back. The question was how long could we survive before it happened again.

The next morning I went to have coffee with a friend. When I got home her behaviors were already beginning a downward spiral. My husband and I spent the afternoon trying desperately to “reset” her, but despite our efforts her behaviors continued to escalate. Eventually we made the decision to head back to our local emergency room for a mental health evaluation. Less than 24 hours after being discharged she was being admitted back into the hospital.

In the medical world it’s called “bounce-back”. In criminal justice it’s called “recidivism”. In the mental health world we hear both terms. It means a person leaves a system and within a defined period of time returns back to the system they just left.

Over the course of the past five years our daughter has experienced three bounce-back admissions to in-patient psychiatric hospitals and had a re-admission to residential treatment after only six months in a community setting. Situations like this are common among children with untreated mental health issues.

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“Bounce-back” admissions and recidivism rates are something that systems track and attempt to avoid. High rates in these areas are not a mark of a healthy system. So why is it common for families of children with a serious emotional disturbance to experience multiple hospitalizations in a short time or to find themselves back in a court room or an treatment center intake room only weeks or months after leaving? Here are a few reasons…

  • Lack of communication in systems. A larger urban hospital may recommend a service that isn’t easily accessible in a smaller community. Or maybe an outpatient clinician’s assessment of a child isn’t easily available to the inpatient therapist. When agencies and organizations fail to effectively communicate with each other, parents are left with the responsibility of piecing together services and providers to support their child’s treatment.
  • Lack of practical crisis planning. Giving a family a crisis number at the time of discharge is not a crisis plan. Neither is writing down a list of coping strategies. Crisis planning goes beyond these ideas and provides practical steps that a family can take when a crisis happens, including the names of professionals who will support them in those moments.
  • Lack of treatment services. Quite often the services a child needs just aren’t accessible. Maybe it’s due to funding challenges, living in a rural location, or not being part of the “right” system. Finding ways to remove the barriers to appropriate services is critical to reducing the chances of readmission.

My state is in the process of transitioning to a more child-centered children’s mental health system. Recently I participated in a discharge meeting that left me feeling amazed and hopeful. As professionals from multiple system partners were discussing the services my daughter would need after discharge from residential treatment, one of them said, “If we don’t have the right level of care available within the community then we should consider delaying discharge while we work to get those services in place. We have to make sure the level of care matches her needs.”

If you’re a parent navigating a system that isn’t yet child-centered in its discharge process there are ways you can help the system move in that direction.

  • Ask questions to help point out the gaps in crisis services. For example, “Is the ER the most appropriate place for me to take my child in crisis, or is it simply the only option?” or “What exactly is going to happen when I call this crisis number?”
  • Share details about the services that are available in your community. Often administrators and clinicians working in other parts of a state or region are not aware of the specific services available, or lacking, within a community. Instead of leaving them to make assumptions about services based on incomplete knowledge, help educate them.
  • Encourage practical discharge conversations soon after admission. While discussing discharge criteria at the moment of admission is good clinical practice, these conversations often leave parents feeling fearful and anxious. A discharge plan helpful to families should include discussions about services needed after discharge, as well as therapeutic and medication goals for the child.

Comprehensive, practical discharge planning is possible when parents have the opportunity to participate in authentic conversations about needed services and supports for their family. This can be a positive step in helping children and families receive the care and support they need within their own communities.

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