Innovations: Child & Adolescent Psychiatry: "Sweet Are the Uses of Adversity": A Transition Program for Children Discharged From an Inpatient Unit

Introduction by the column editor: In the time since this column was submitted and then prepared for publication, disaster struck New Orleans. The excellent program described below was having a great impact in ameliorating the crunch between shrinking state support for inpatient care and the inadequacies of outpatient care. Hurricane Katrina disrupted the entire system, raising questions as to whether the program presentation was still relevant. Clearly the model, including use of some principles of system-of-care reforms, is widely applicable to many around the country and needs to be shared. By sharing it with readers of Psychiatric Services I hope we are recognizing the losses sustained by our colleagues and their patients in New Orleans and also, in a small way, helping to restore the important role that this great city plays in all our lives and the role that its stellar medical training facilities plays in our country's clinical and research community.

Until recently, mental health planners in New Orleans faced the problem of how to respond to a mandated downsizing of the number of public-sector children's inpatient beds to an impossibly low level: ten acute-stay beds, believed by many to be too few given community needs and the realities of the existing continuum of care. It was feared that children would overcrowd emergency departments, that there would be waiting lists for hospital beds, and that existing community services would be further stressed. Efforts to appeal the decision were futile. Solid financial, political, and ideological reasons were given for the cuts, which were said to be needed in order to develop a more comprehensive system of care. When asked whether it made more sense to create community programs first, the leadership of children's public mental health programs agreed but noted that there was no money to do so. The number of beds would need to be reduced first.

The planners were urged to respond quickly with innovative and cost-effective programs that would compensate for the missing and needed beds. Others in leadership roles doubted that the beds were needed and believed that the "community" would take up the slack. The response of our staff ranged from begrudging acceptance to outright anger: "That's easy for them to say. They don't have to actually take care of the kids!"

This column describes the creation and implementation of a program to facilitate the transition of children and adolescents from an inpatient setting to the community.

Looking for a better solution

A planning and implementation group was created to respond to the bed crisis. This group comprised key representatives of the hospital, the community, the region, and the State Office of Mental Health. The group's analysis of existing resources identified a large gap in the continuum between the inpatient unit, with its wide range of resources, and the five traditional mental health centers that provided medication management as well as social work contacts on a weekly to monthly basis.

Previously, the standard response was to keep the children in the hospital long enough so that their needs at discharge approximated what could be provided by the mental health clinics. This strategy, which necessitated longer, costly stays, usually worked. All too often, however, the children, regardless of length of stay, needed more than the clinics could offer. Some of these children qualified for rehabilitation option programs. Those who did not qualify for these programs tended to be discharged to the clinics, which did the best they could with their available resources. If these resources proved inadequate, the child would usually be rehospitalized and the cycle reinitiated.

The logical next step for many of the planners was to create a day hospital program that would be a step-down program for the children's unit. This program would take pressure off the small number of acute beds and create an intermediate program that would fill the existing gap in the continuum between the hospital and the clinics. The major downside to this "logical step" was the fact that a previous day treatment program had failed for a host of reasons, the most significant of which were cost, transportation, and the perceived inability to provide adequate structure for very disruptive children because of varying regulatory standards for such programs. There was a sense that another day hospital program would face similar problems. Others simply did not want another hospital-based program. They wanted more of a community-based program.

The transition program

This dilemma led to the creation of a unique hybrid "transition program" that has effectively bridged the gap between the hospital and the rest of the community. This program involves a team that conducts outreach into the community and acts as a clinical extension of the children's inpatient unit (1,2). The team comprises a half-time social work supervisor, two social workers, and a psychiatric aide. To ensure clinical continuity, the social work supervisor spends half her time as the social work supervisor of the inpatient unit social workers. In this dual capacity, the supervisor monitors all admissions and identifies, from day 1, for patients who might be candidates for early discharge should increased community supports be available. The social work supervisor then assigns members from the transition program to these cases. They work with the hospital clinical team, attend all clinical staffing meetings, and facilitate discharge planning.

As discharge approaches, the entire clinical team, the patient, and the patient's caregivers create an individualized child- and family-focused treatment discharge plan. This plan, which was inspired by similar plans created for local rehabilitation teams, specifically addresses six life areas (mental health; family, social, and natural supports; education; recreational and leisure activities; basic needs, finances, and employment; and physical health) and also includes a specific crisis plan. Some of the system-of-care principles outlined by Stroul and Friedman (2) and the wraparound process (1,3) are included in this program: community-based and integrated care, individualized care tailored to the needs of each child, and family inclusion.

The transition program staff accepts a maximum of 11 clients. The individualized and comprehensive discharge plan serves as the road map for services, which are tailored to the specific needs of the clients and their caregivers. These services may include home visits, school visits, transportation to and from appointments with physicians and other professionals, crisis interventions, ongoing therapy, and case management. Progress is monitored daily by the supervisor and in weekly multidisciplinary clinical staffing meetings of the entire team. In keeping with the concept of transition, the child and family keep the same psychiatrist throughout the transition.

Likewise, even though we always favor the use of community resources over hospital resources, the child can utilize the resources of the hospital if this is clinically warranted. If the child is not yet enrolled in a school in his or her community, he or she can continue attending the specialized hospital-based school. If the child needs pediatric follow-up for medical problems identified during hospitalization, such care can be provided by the hospital's pediatricians. Until the child is under the care of a physician in the community, medication checks and writing of prescriptions can be undertaken by the inpatient unit's child and adolescent psychiatrist.

The transition program thus acts as a true bridge between the resource-rich inpatient unit and the community. Although it was originally envisioned that clients would participate in the transition program for only short periods (two to four weeks), some clients, because of their specific needs, have taken more time. These extensions are usually due to delays in obtaining access to highly sought after community programs created for specific clinical populations—for example, programs for sexual perpetrators and dual diagnosis programs. In a recent case, a patient was in the transition program for a year until a slot opened in a program for persons with developmental disabilities. In most cases, the transition program team becomes less involved with the child and family as community resources become available. Although less involved, the transition program may still provide one or two missing parts of the discharge-transition treatment plan.

Success of the program

Between its initiation in February 2001 and October 2003, the transition program saw 80 clients. Since its initiation, the program has kept data on its functioning, including clinical functioning, improvement and severity ratings, recidivism, aftercare compliance ratings, and satisfaction surveys. This information shows that the program has fulfilled its mission. The ten inpatient beds have proved adequate for community needs. Inpatient lengths of stay for clients who are transferred to the transition program have decreased, readmission rates are low, and, when required, the length of stay for subsequent readmissions is shorter than usual. There are more community referrals, compliance is greater, and family satisfaction is high.

All child and adolescent psychiatry residents are assigned to the transition program as part of their rotation through the child inpatient unit. In addition, the transition program has served as a community-based training laboratory. Several of the program's concepts, forms, and policies have been generalized for use in other programs in the larger mental health delivery system, especially our child and adolescent assertive community treatment teams. It is hoped that the transition program will be a step toward reform in the system of care in New Orleans to one that is truly community based, focused on the individual needs of children and their families, and more integrated with the realities of culture and community experience of families in our city.

Dr. Drell is head of infant, child, and adolescent psychiatry at Louisiana State University Health Sciences Center in New Orleans and clinical director of New Orleans Adolescent Hospital and Community System of Care, 210 State Street, New Orleans, Louisiana 70118 (e-mail, [email protected] or [email protected]). Charles Huffine, M.D., is editor of this column.