DISCHARGE WITH A DIFFERENCE BRIEFING NOTE

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Gervais Poole
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1 Evaluating the transition of long-stay, complex yet stable geriatric psychiatry patients from hospital to long-term care BRIEFING NOTE ISSUE As our health care system evolves, alternatives to long-term hospitalization of complex yet stable geriatric psychiatry patients need to be explored and evaluated. Research suggests that elderly individuals with psychiatric illness who have had a long hospital stay but are stable can be successfully transitioned to the community with ongoing support (1,2). Further, client satisfaction is high among those who have transitioned to the community (1,2). In caring for elderly populations, planning both before and after a move from a hospital setting to the community (3) can minimize the possible negative effects of relocation. Planning strategies based on effective communication, family involvement and continuity of care (4) from an interdisciplinary team are key components to success. Interdisciplinary models of mental health care delivery, which blend consultation with training and education, are also effective in a long-term care home (LTCH) environment (5). BACKGROUND In September of 2003, the Ministry of Health and Long-Term Care (MOHLTC) funded the development and evaluation of a Transitional Discharge Model (relocation of long-stay, complex yet stable geriatric psychiatry patients from tertiary care to a LTCH). The model, developed through a partnership between Regional Mental Health Care London (RMHC L) and McGarrell Place (MP) 1, included an enhanced environment (a special care unit (SCU) within the LTCH) and access to a tertiary care based Discharge Liaison Team (DLT) and a consulting psychiatrist (see Figure 1). The DLT (four registered nurses, three registered practical nurses) provides 24/7 on-call patient, family and staff support and links the SCU staff to resources at RMHC L. Figure 1: Transitional Discharge Model Long-stay, Complex yet Stable Geriatric Psychiatry Patients Community Care Access Centre (CCAC) On site Long-term Care Home Placement Case Manager RMHC-L Multidisciplinary Team of Specialized Resources Consulting Psychiatrist Discharge Liaison Team (RNs and RPNs) Assessment Treatment Discharge Planning Transition, stabilization and support for patient, family and long term care home McGarrell Place Special Care Unit Enhanced, permanent funding Individualized care plans Note: RN: Registered Nurse; RPN: Registered Practical Nurse 1 At the time of the evaluation, Versa-Care Lambeth, located in London, Ontario, had been selected by the MOHLTC as the SCU site. In November of 2006, Versa-Care Lambeth was rebuilt in another location under the name McGarrell Place.

2 EVALUATION The evaluation strategy, approved by the Health Services Research Ethics Board at The University of Western Ontario, employed mixed methods. Quantitative Data Collection Data were abstracted from patient charts from RMHC L and from the LTCH resident charts (see Table 1). Qualitative Data Collection Qualitative data were collected through: Key informant interviews with individuals who were involved either directly or indirectly with the development of the Transitional Discharge Model; and Focus group interviews with DLT and SCU staff as well as SCU residents and their family members. Table 1: Information Collected Information from RMHC-L Patient Charts Demographic information Activities of daily living Diagnosis Re-admissions to RMHC-L Information from LTCH Resident Charts # of calls to DLT # of calls to the attending physician for medication and/or aggressive behaviour # of trips to the emergency room # and types of medication # of employee incidents involving residents Note: RMHC L: Regional Mental Health Care-London; DLT: Discharge Liaison Team RESULTS Characteristics of Those Transitioned to the Special Care Unit From November 15, 2004 to November 30, 2005, 23 people were transitioned to the SCU (one patient died from a medical condition shortly after being admitted). Among the 23, 61% were female, 57% had schizophrenia, 30% had dementia, 61% were unable to dress or groom themselves (see Table 2) and one had a 40-year history at RMHC L (the last 26 years were consecutive). Residents, family members and staff satisfaction Overall, residents, family members and staff were satisfied with the transition process. Resident quality of life was higher in the SCU than in the tertiary care hospital. Further, SCU staff, over time, demonstrated an increased capacity to care for geriatric psychiatry populations. SCU staff are very accommodating and go above and beyond the call of duty in caring for the residents in the SCU. DLT Staff We had one [resident] who when she first came to us she couldn t converse with anyone now she socializes and goes to all activities. SCU Staff Staff on the SCU are very skilled and experienced in managing challenging behaviours as a result of learning and communication with the DLT at RMHC-L. MP Administrator The positive relationships and collaborative spirit among providers has facilitated access to different parts of the health care system which wasn t always the case. Key Informant Interviewee 2

3 Table 2: Characteristics of Those Transitioned to the SCU Characteristic Sex - Male - Female Dementia^ Depression^ Schizophrenia^ Admissions to RMHC-L more than 1 Age (years) - < % with Characteristic (count) 30.4% (7) 69.6% (16) 26.1% (6) 73.9% (17) 56.5% (13) 43.5% 34.8% (8) 65.2% (15) 4.3% (1) 21.7% (5) 56.6% (13) 17.4% (4) DISCHARGE WITH A DIFFERENCE Characteristic Feeding* Bathing* Dressing* Grooming* Toileting* Mobility* % with Characteristic (count) 87.0% (20) 13.0% (3) 17.4% (4) 82.6% (19) 43.5% (10) 56.5% (13) 73.9% (17) 26.1% (6) Note: RMHC L: Regional Mental Health Care-London; *: Able: Two categories: Totally independent & some assistance; Unable: Two categories: Totally dependent & constant assistance: ^: if listed as Psychiatric Diagnosis on Discharge Liaison Team assessment. Success Factors and Challenges Both success factors and challenges were identified (see Table 3). Table 3: Success Factors and Challenges Factors Key to Model Success Challenges Collaborative provider partnerships Communication and information sharing On-site Community Care Access Centre Long- Term Care Placement Case Manager Availability of a consulting psychiatrist Access to RMHC L resources by SCU staff Readiness, willingness and desire of MP staff to work on the SCU SCU enhanced and permanent staffing Enhanced education provided for SCU staff Individualized approaches to care in SCU SCU access to DLT support 24/7 DLT and MP staff turnover Evolving DLT roles and responsibilities Some psychotropic drugs not covered by Ontario Drug Benefit for long-term care homes Occasional short notice of patient relocation to SCU SCU residents family concerns about ability of a LTCH to care for their relative after a long-term hospitalization MP residents family members concerns about locating geriatric psychiatry patients in home Maintenance of SCU resident focused activities Note: SCU: Special Care Unit, MP: McGarrell Place; DLT: Discharge Liaison Team; RMHC L: Regional Mental Health Care London 3

4 RECOMMENDATIONS 1. Continued support of relocation of stable geriatric psychiatry patients within Southwestern Ontario through the work of the DLT (24/7 liaison with LTCH staff) 2. Maintenance of the existing SCU 3. Continued support for the psychosocial rehabilitation needs of patients with persistent mental illness in the SCU 4. Future development of other SCUs in other LTCHs CONCLUSIONS In 2006, the Standing Senate Committee on Social Affairs, Science and Technology recommended that alternatives to hospitalization of seniors with mental illness be more widely available (6). This evaluation indicates that alternatives to long-stay hospitalization are currently available and that long-stay, complex yet stable geriatric psychiatry patients can be successfully integrated into LTCHs with the appropriate supports. Seniors are living longer and the number of individuals between 65 and 85 will almost double in the next 20 years (7) as will the number of seniors presenting with mental illness. Elderly people with long-term, complex yet stable mental illness deserve the opportunity to live in the community. The results of this evaluation demonstrate that long-stay, complex yet stable geriatric psychiatry patients can be successfully integrated into the community with the appropriate supports and that a Transitional Discharge Model is an innovative way of supporting the relocation of geriatric psychiatry patients. Guided by the principles of mental health reform, this model builds upon the resiliency of older adults and values their individual preferences, needs, assets and rights to autonomy. This is a wonderful alternative to the hospital [ ] 100 times better Family Member It is an intelligent move. It works. It is very practical for the families and is a nicer environment to be in than the hospital environment Family Member 4

5 Manuella Giuliano, Research Associate Research and Evaluation Specialized Geriatric Services Jennifer Speziale, Coordinator Discharge Liaison Team Dr. Kiran Rabheru Brad Davey Shelley McCorkell Joan Woodley Lynn Mellows Michael Walters Authors Dr. Iris Gutmanis, Director Research and Evaluation Specialized Geriatric Services Contributing Authors DISCHARGE WITH A DIFFERENCE Bonnie Kotnik, Director Geriatric Psychiatry Program Dr. Lisa VanBussel, Psychiatrist Physician Leader, Geriatric Psychiatry Program For further information contact Dr. Iris Gutmanis (519) , extension Bonnie Kotnik (519) , extension Acknowledgements For his vision and clinical leadership Former Program Manager, Southwest Region, MOHLTC Former Program Consultant, MOHLTC Former Administrator, Versa-Care Lambeth Administrator, McGarrell Place Long-Term Care Home Former Program Consultant, MOHLTC Thank you to Specialized Geriatric Services, St. Joseph s Health Care, London A special thank you to all staff, residents and their family members of Winderemere Way at McGarrell Place who participated in the evaluation Finally, a sincere thank you to the MOHLTC for supporting the evaluation of the project References 1. Newton, L., Rosen, A., Tennant, C., Hobbs, C., Lapsley, H.M., Tribe, K. (2004). Deinstitutionalization for long-term mental illness: an ethnographic study. Australian and New Zealand Journal of Psychiatry, 34: Hobbs, C., Newton, L., Tenant, C., Rosen, A., Tribe, K. (2002). Deinstitutionalization for long-term mental illness: a 6-year evaluation. Australian and New Zealand Journal of Psychiatry, 36: Castle, N. (2001). Relocation of the elderly. Medical Care Research and Review, 58:3, Walker, C., Hogstel, M.O., Cox Curry, L. (2007). Hospital discharge of older adults: how nurses can ease the transition. American Journal of Nursing, 107:6, Bartels, S.J., Moak, G.S., Dums, A.R. (2002). Models of mental health services in nursing homes: a review of the literature. Psychiatric Services, 53:11, The Honourable Michael J.L. Kirby, The Honourable Wilbert Joseph Keon (2006). Out of the shadows at last: highlights and recommendations. The Standing Senate Committee on Social Affairs, Science and Technology. 7. The Daily. (2007, February 27). A portrait of seniors. Statistics Canada. Accessed on May of 2007 from 5

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