Discharge Planning and Preparation on the Behavioral Health Unit - Recovery Action Plan: We RAP!

Transcription

1 Discharge Planning and Preparation on the Behavioral Health Unit - Recovery Action Plan: We RAP! Program Description The Behavioral Health Unit (BHU) at Harford Memorial Hospital (HMH) is the primary mental health care provider in Harford and Western Cecil Counties. The focus of the BHU is to address the patient in crisis, assist with treatment and stabilization, and promote the safe return of the patient to the community utilizing the patient-centered care approach that is an integral part of the mission and vision of Upper Chesapeake Health. The unit is comprised of 27 beds, male/ female, and ages 18 and older. Both voluntary and involuntary admissions are accepted. Mental Health treatment is delivered utilizing a multi-disciplinary approach which includes Nurses, Psychiatrists, Social Workers, Occupational Therapists, Case Managers, and Patient Care Technicians. Other disciplines, such as Dieticians, Respiratory, Speech and Physical Therapists are included on the Treatment Team as needed based on the patient s unique needs. Outpatient resources offered at HMH include an Intensive Outpatient Program and traditional Outpatient Clinic Services. This promotes a comprehensive service line of After Care available for patients, not only for those discharged from the BHU, but also for the community at large. As the primary mental health service provider we saw a large number of patients with chronic mental health issues who want to be treated close to home. Our challenge was to meet those needs of our patients and better equip them to remain in the community and access outpatient services. We determined that reducing hospital readmissions would be the best measure of success. Process A literature search identified that Nurses, Social Workers and Discharge Planners have been implementing new and innovative approaches to decrease readmissions. One of those approaches was the WRAP program created by Mary Ellen Copeland, PhD. Nurses from the BHU attended the WRAP Around the World Conference presented by the Copeland Center for Wellness and Recovery in Philadelphia in August of The concept of aggressive discharge planning utilizing the Wellness Recovery Action Plan concept ignited the creative juices of the nurses. Using this evidenced-based concept, a Multidisciplinary team began creating a plan that would work to capture the configuration of the BHU patient population including diagnosis, age range, intellectual functioning and the general condition of the unit milieu. The RAP Recovery Action Plan was developed and implemented in November of Solution This Wellness Tool Kit places the emphasis on recovery of illness and preparation for discharge. The Tool Kit consists of educational resources including post discharge Daily Schedule of Activity and Medication, personalized Crisis Plan and Aftercare Plan. The components include follow-up appointments for Mental Health and somatic treatment, Support Groups, phone numbers to use in event of crisis, and of names of Mental Health professionals, and other support systems available for the patient. Upon admission, as appropriate, every patient receives a RAP folder. The folder has a RAP label on the outer cover with a place to record emergency numbers such as the Mobile Crisis Team, and the outpatient Psychiatrist s name. Patients are instructed to attend scheduled RAP Groups and to bring their folder.

2 RAP Group is conducted at least three times weekly. Since the average length of stay is 3-5 days, the majority of patients will attend a RAP Group during their hospitalization. It is open to all patients and all patients are encouraged to attend. The patient opens the Tool Kit with instruction and completes the directed component for that session. The 5 Key Recovery Concepts are reviewed: Hope, Personal Responsibility, Self- Advocacy, Education, and Support. Wellness tools (coping skills) are identified by each patient and recorded. A schedule for each day of the week is completed, anticipating needs upon discharge. Activities such as self-care, appointments, and a medication schedule are incorporated. Also, additional activities to promote daily structure are explored. This detailed plan consists of Emergency Contacts, Emergent Health Needs, Service Providers involved, transportation issues and cultural/spirituality needs. Patients identify: who to notify in event of a crisis, how to manage symptom emergence, issues with medications, concerns with transportation to after care appointments, and even financial barriers. Patients have the opportunity to share resources and suggestions for success with peers. The Group is an interactive process, promoting peer interaction and independence. Several components are reviewed and completed by each patient with assistance from the nursing staff functioning as facilitators. Documentation of RAP Group attendance and level of participation is monitored and documented daily as part of the treatment plan. All patients are encouraged to complete their tools during their admission. Completed tools are reviewed by assigned nursing staff and Social Worker during 1:1 sessions prior to discharge. Measurable Outcomes At the time of initiation of RAP, the average monthly readmission rate was 12.6%. There has been a steady reduction in readmission rates over the past 18 months which correlates to the implementation of the RAP program. Over the past 12 months, the Average Monthly Readmission Rate has been 8.6%, the average for the state of Maryland is 19% (per Value Options). Due to our low readmission rate and other quality achievements, the BHU has been identified as a Value Select Provider (VSP). The VSP recognition is given to a provider for engaging in activities that promote clinical effectiveness and administrative efficiency. This designation makes the BHU eligible for increased referrals, preferred provider distinction and opportunities for education programs through Value Options.

3 Behavioral Health Unit Readmissions Sustainability The RAP Wellness Kit has been completely integrated into the treatment program of the BHU and has been utilized by the Treatment Team since November of Review of the RAP has become a standard part of the treatment plan and providers look to this document for information and direction in care planning. Since November of 2011, over 2100 RAP s have been used with our patients. Copies of completed Crisis Plans are readily available to the Treatment Team, should a readmission occur. The plan is revised and altered to meet the patient s post discharge need. RAP Group is a routinely scheduled Group and all Discharge Planning centers on the RAP. Collaboration RAP is successful on BHU as it incorporates an interdisciplinary approach. All members of the Treatment Team are involved, this includes the Psychiatrist, Social Worker, Occupational Therapist, Case Manager and the Nursing staff in assisting the patient with developing their personalized plan. Active and aggressive discharge planning utilizing the RAP is consistently incorporated into each patient s treatment plan, preparing for a successful discharge. Clinicians collaborate daily in Interdisciplinary Rounds, Nursing Shift Report and Briefs in effort to have a successful discharge plan in place. BHU Leadership, including the Clinical Nurse Manager, Director and Chief of Psychiatry assisted in obtaining form approvals and rollout of education for Team Members, as well as support for project development.

4 Innovation By identifying the needs of the community, receiving mental health services close to home, the BHU has developed a plan to meet those needs and encourage better integration into the community. A distinguishing attribute of the RAP approach is that is promotes patient engagement, involvement, autonomy and responsibility. The program encourages patients to be active participants in the creation of their own discharge plan. Resources BHU RAP (BHU Attachment 1) WRAP Around the World Conference, 2011; Mary Ellen Copeland, PhD WRAP as Evidence-Based Practice, May 2011; webinar with Judith Cook Submitted by: Claire Kidwell, BSN, RN, B-C Clinical Nurse Manager, BHU Contact: Judi Webster, RN, BSN Title: PSO/PI Manager jwebster@uchs.org Phone:

5 RAP Recovery Action Plan This is your RAP Recovery Action Plan and Wellness Tool Kit. This discharge plan has Resources, a Schedule for the Day and your personalized Crisis Plan for you to use when you go home. We will work on this together while you are here. When you are discharged we will keep a copy in your chart so if you are to return we can review and update the plan as needed. This packet will be explained in Group. Your responsibilities are: Bring this packet to Group Complete all portions of the packet that are being discussed in Group Review your personalized Plan with your Nurse and Social Worker during your time here After discharge your responsibilities are: Take your copy of the packet home to continue your recovery Use the packet as a reference for phone numbers, Daily Schedule and keep it with your other discharge papers Key Recovery Concepts These five key concepts will provide the foundation of effective recovery work! Hope Personal Responsibility Self Advocacy Education Support To begin the journey of recovery you need to: 1. Receive Good Medical Care 2. Understand Medication Management Make sure that you understand your medications and the side effects that may happen 3. Understand Symptom Monitoring By knowing your triggers and your symptoms you can for-see a relapse in many cases 4. Create and Use a RAP 5. Develop a Personal Crisis Plan/Suicide Prevention Plan 6. Address Traumatic Issues Make sure that the therapy you are receiving helps you to address past traumatic events and establish a connection with others 7. Develop and Practice a Wellness Lifestyle

6 Wellness Toolbox Some common Wellness Tools for a Wellness Lifestyle are: Eat three healthy meals per day Exercise Play with my dog or pet Write in my journal Make my bed Do something nice for someone else Watch a video that makes me laugh Listen to music See my counselor What are some of your Wellness Tools? My Wellness Tools are:

7 Planning Your Day One of the most stressful things to face once you leave the BHU can be planning your day. What will you do first? How will you stay on track with medications, appointments and compliance? And how will you use the coping skill you have learned while you are here? These are hard questions and we want you to succeed! Why not make a schedule a calendar to remind you of the activities that you can do throughout the day to keep you on your journey of recovery? A schedule is especially helpful when you feel like some early warning signs of relapse are creeping up on you. Reviewing your schedule will also allow your healthcare support team to examine where things started to go wrong and assist you in getting back on track. Take a few minutes to fill out your schedule when you focus and direction. We have included a blank schedule for you on the next page. Here is a sample of how a schedule could look: Time Planned Activity Actual Activity How It Felt Get up, shower, dress As planned Fine 7am - 8am 8am - 9am 9am - 10am Eat, wash dishes Write list, grocery shop Also cleaned bathroom As planned Felt rushed Hard to concentrate Spent much more than planned

8 Time Planned Activity Actual Activity How It Felt 7am - 8am 8am - 9am 9am - 10am 10am - 12pm 12pm - 2pm 2pm - 4pm 4pm - 6pm 6pm - 8pm 8pm - 10pm

9 Crisis Plan Name: Address: Phone#: Birthdate: Gender: Female Male Transgendered Emergency Contact, Name: Emergency Contact, Phone #: Health Needs: Directions to Home: Service Providers: Pets: Children: Cultural Heritage/Spirituality:

10 Describe what crisis looks and feels like to you? What is different in times of crisis than in other times of your life? (Like bad days for instance) Crisis Other times in my life When you ve been in a crisis situation what kinds of support did you seek? What things (people, places, services) were the most helpful? Why? Support What was helpful? Why?

11 What are the most difficult feelings for you to experience? Please check the MOST difficult feelings or add any that you don t see listed: Happy Joy Sad Grief Afraid Angry Rage Anxiety Overwhelmed Boredom Loneliness Emptiness Think about what happens when these feelings get overwhelming. Consider the following: What does it feel like inside your body? What do you need when this happens? What can you do for yourself? What has been helpful before? How do you decide to reach out for support? How do you identify when you need to do something different? Write about that. Think about the people around you when you experience crisis. Are there behaviors or actions you take that might frighten other people? Please describe:

12 How do you feel about these behaviors? What would you like the people around you to understand about this? How would you like them to react? What do you need to hear? Also identify what can make it worse, what you don t want people to do. What do you need to do personally? Write about this. Can you identify things that you re not likely to talk about when you re in crisis, or code words you may use? Are there people in your life who are important to you? (Children, Partner, Friends, Relatives, Clergy, Staff) Think about who they are and who you may want to be in touch with if you are experiencing crisis, or end up getting support other than in your home. List their information here. Name Relationship Phone #

13 Are there people from this list who you would want consulted if there was any question of Next steps when you are in crisis? Name those people. Make sure their contact information is included in the list above. Is there anything else you would like people to know or consider when you re in crisis? Is there anything else you need to remind yourself about when you re in crisis?