Admission to a psychiatric inpatient unit can have varying outcomes for a patient. The success of the admission is determined by the patient’s ability to function after discharge. During the course of treatment, it is important to prepare the patient for life after hospitalization. All members of the team, including family members, residential staff, and the outpatient team in conjunction with the patient himself play a significant role in determining whether or not the transition will be successful. For patients with ASD/DD there are some key components that, if in place at each juncture of this process, will help increase the likelihood of this success.
It is important to have an understanding of the circumstances that resulted in the hospitalization including (but not limited to):
- Behavioral Triggers
- Environmental Triggers (changes in environment)
- Medical Triggers (medication changes; other medical concerns)
Prevention of these triggers in the future can help to decrease the likelihood of readmission to an inpatient unit in the future. In recent years the criteria for admission have become much more stringent; only patients that have psychiatric symptoms that meet specific criteria as outlined by the DSM-5, or whose functioning has deteriorated to a point that they pose a threat to themselves or others, are typically admitted psychiatrically. Accordingly, only those who have severe psychiatric symptoms are admitted.
Coordination of treatment between the patient’s outpatient team and the hospital treatment team is critical to success, allowing for ongoing monitoring of the patient’s treatment and progress and taking into consideration the patient’s strengths and needs.
Patients intellectual, emotional and psychiatric functioning and feelings about the hospitalization will affect their ability to participate in a successful discharge plan. Some people with ASD/DD experience hospitalization as desirable because of the increased attention and structured group activities. Hospitalization can create a sense of belonging and comfort which can result in reinforcement of the behaviors that resulted in the hospitalization. But other patients can experience the hospitalization in a negative manner or as a “punishment.” They could be resentful of family members/caregivers who facilitated the hospitalization, and become uncooperative/unmotivated during their stay, prolonging discharge and adversely affecting what happens following discharge. Regardless, the ultimate goal should be a collaborative process of all parties involved for successful treatment and discharge.
Successful hospitalizations should always include the following:
- Establishing clear treatment plans with concrete goals
- Implementing motivational systems and positive reinforcement for expected behaviors and progress toward treatment goals
- Establishing a positive sense of progress for the individual to facilitate the patient’s participation in the transition planning process
- Creating a collaborative team approach with all treatment providers and family members during and following the hospitalization
Individuals with ASD/DD often require additional supports that inpatient units frequently do not provide. These supports include:
- Visual Supports (pictures, words, symbols)
- Use of concrete, short chunks of language
- Clearly established rules and expectations
- Communication of treatment goals in clear, discrete descriptions
During hospitalization family/caregiver involvement is important. Many hospitals have family therapy and family groups, and attendance in these offerings is recommended. Family and caregiver participation includes the following:
- Teleconferencing into sessions when unable to attend in person
- Obtaining a visit summary following visits
- Periodically checking in with mental health providers
- Write questions down prior to appointments
- Taking notes at appointments
- Request informational handouts
Even with the best psychiatric care, patients can easily become upset with their providers; it is essential that family/caregivers remain objective about the providers being involved in the treatment will allow them to assess the providers themselves. The more informed the family/ caregivers are, the better able they are to participate in the discharge process.
Preparing for Discharge
Early on in the process family/caregivers should start thinking about their role after discharge. It is important to realize that the inpatient treatment team represents a “fresh set of eyes” that can make recommendations to be implemented during admission and continued after discharge. Make sure that discharge instructions are explained thoroughly and ask questions if there is any uncertainty. The patient (or legal guardian) should sign legal releases so inpatient discharge summaries can be forwarded to the outpatient provider(s).
Understandably hospitalization is a stressful process and the discharge can be equally as stressful. Family/caregivers should be aware that there is a choice in who provides outpatient psychiatric care to a patient after discharge. Sometimes it is best to continue with provider(s) that were in place prior to admission, but sometimes it is best to seek more specialized provider(s). Also evaluate the needs of the patient including:
- What level of care does the patient need?
- Are additional resources needed to meet the patient’s needs?
- Will the patient benefit from working with a provider who specializes in specific diagnoses of symptoms (i.e., ASDs, OCD, etc.)?
Viable recommendations for additional supports should be investigated. Appropriate referrals should be sought from the inpatient team and other reliable professional sources. All services should be in place prior to discharge. Contact information for the outpatient treatment team should be established to enable the inpatient team to communicate the discharge plan and facilitate a successful transition. Also, if possible, family/caregivers should accompany the patient to the first appointment as part of the reintegration process. It is important that all be aware that on discharge, patients are usually not “fixed” and are frequently highly vulnerable, making the need for patience, support and involvement in their treatment even more essential.
Sophia Francis-Stewart, MD, is Staff Psychiatrist, Katherine Cody, PsyD, is Senior Staff Psychologist and Natalia Appenzeller, PhD, is Clinical Director at the Fay J. Lindner Center for Autism and Developmental Disabilities. Contributions to this article were also made from Carole Kalvar, Faith Kappenberg,PhD, and Bernice Polinsky.
This article was originally published in the fall 2013 issue of the Asperger Syndrome and High Functioning Autism Association’s (AHA) print publication, On the Spectrum.
Caregiver Tips for Easing the Way After Hospitalization
Work with the individual to create a structured daily routine. Structure is essential to encourage focus and avoid the damaging impact of boredom and isolation. Work with them to start a diary to create structure and routine, with specific times for waking, personal hygiene and grooming rituals, meals, chores, exercise, recreation, and bedtime. Try to keep the time intervals as short as possible. Structured activity keeps the mind focused, preventing brooding and repetitive thinking, encouraging good “mental hygiene,” and preventing a spiral down into inappropriate acting out or depression.
Help the individual put an exercise routine in place. Any exercise program should be approved by their physician but, if possible, some form of vigorous activity should be incorporated into their schedule. This can be as simple as brisk walking and is extremely important for overall health and well-being.
Everyone needs a purpose to feel useful. Work with the individual to better access their strengths and interests. They could develop a better sense of self by assisting an elderly neighbor with chores or taking care of their animal.
Defuse conflicts by learning more effective communication skills. Use short and simple declarative statements to convey expectations. Often, less talk is more effective. Don’t try to “talk down” an agitated person. Don’t tell them to “just calm down” or to “take it easy.” Instead, simply state what is expected and walk away. It takes at least two for a fight and if you make yourself scarce the individual is more likely to regain self-control. Make sure that what you are asking the individual to do is reasonable and within their ability, and then be steadfast in requiring them to meet the expectation. Be clear, firm, and, above all, consistent.
– Contributed by Maureen Holohan, Carole Kalvar, and Eric Schissel