Discharge Planning Case Study
Discharge planning is an essential activity in the preparation of consumers for the transition from hospital to home settings. The efficiency of the process for patients living with mental health problems can influence the number of future rehospitalizations in acute-care facilities as well as their quality of life in the community (Nurjannah et al., 2014). This paper will address the discharge planning process for a 48-year old patient called Margaret who had been treated for an anxiety disorder at a local hospital. According to the history, she had been referred for assessment by her general physician due to a history of withdrawal and agitation which had developed recently. She had then been admitted to the mental health unit of the local hospital one week previously. On admission, she was accompanied by her partner. Her general physician had been treating her for an anxiety disorder over the preceding 6 months. The paper will focus on the issues of concern in relation to the patient, formation of a collaborative relationship with the patient, demographic information required for successful transition care planning and justification of the manner in which the demographic information would be utilized to facilitate successful transition to the community.
The issues of concern in relation to this patient include preparation of the patient/carer for discharge, effective documentation and communication, social support, and medication management. Australian guidelines on discharge planning for patients admitted with acute mental conditions are equivocal on the importance of preparation of patients/carers for discharge from admission (Mental Health Branch, 2005). The guidelines recommend that patients\carers should be actively involved in care planning and realistic expectations of length of inpatient stay communicated throughout the care process (Mental Health Division, 2009). This recommendation is influenced by increased pressures on acute care services as well as the need to provide comprehensive care to patients (Mental Health Division, 2009). For instance, the nurses in this case want to prepare for weekend admissions. Whilst emphasizing the importance of utilization of acute care services for acute exacerbations of mental illnesses, the guidelines also caution against premature discharge. They recommend that patients be assessed comprehensively by the multidisciplinary care team to determine their readiness for discharge (Mental Health Division, n. d.). The team caring for the patient is in agreement that Margaret is ready for discharge.
Another important consideration in discharge planning for this patient is social support. Care guidelines emphasize on the importance of assessing the social supports available to patients prior to discharge (Mental Health Commission, 2009). Social support networks encompass family members, friends, church members, workmates amongst others. Prolonged hospitalization can reduce a patient’s social support system including loss of employment (Mental Health Commission, n. d.). Psychosocial issues, on the other hand, contribute to the occurrence of acute episodes of mental illnesses (Purdy, 2010). In this regard, it is essential for the patient to be discharged in a timely manner. The unit manager should also ensure that the patient’s underlying social issues have been addressed prior to discharge.
Medication management fosters smooth effective transition of patients from inpatient to outpatient settings (Stokes, 2012). The patient’s discharge treatments need to be reconciled by the multi-disciplinary team. The patient’s husband and the patient should also be educated about the types, dosing, and frequencies of administration of patient discharge medications. In addition, they should be advised on where they can access these medications in outpatient settings. The patient once discharged is to be followed up in community settings by a case manager. To facilitate continued care, accurate documentation should be maintained and the same sent to the case manager on discharge. Effective communication will enable the case manager to provide care of appropriate intensity as per the patient needs.
The provision of mental health services has been based on the perspective that health practitioners/ services effect changes within mentally ill patients via a range of therapeutic methods and programs (Warne & McAndrew, 2007). The traditional clinician-nurse relationship in this setting has, in effect, been marked by a power imbalance whereby clinicians are seen as experts on account of their knowledge and training. Recipients of the services, on the other hand, have been deemed to have little awareness and as a result, given minimal opportunity to articulate their views with respect to treatments and what really supports their recovery process. Indeed there is little available literature on the role consumers/carers play in the management of mental health problems. A study conducted in the UK by Bee et al. (2008) that sought to examine amongst other objectives the degree of involvement of consumers of mental health services in the provision of these services concluded reported that service users felt that they were denied opportunities for collaborative care. The same scenario is replicated in Australian settings. Goodwin and Heppell (2007) cite evidence that suggests that carers and consumers of mental health services have been given little opportunity for genuine participation. Warne & McAndrew (2007) whilst acknowledging the importance of nurse education and training emphasize on the importance of harnessing patient experiential knowledge. Nurses utilize theoretical knowledge derived from their education and practice in the provision of mental health services. They, however, fail to use patient lived experiences as an educational resource and these are often lost in the milieu of ‘practicing’ nursing.
Since consumers of mental health services play a significant role in the smooth delivery of treatments and care, Warne & Andrew (2007) contend that mental health nurses need to adopt a more reflexive approach to care provision that appreciates the importance of patient lived experiences in their patient encounters. Goodwin & Happell (2007) denote the importance of respect and communication to this process. In the case of Margaret, the patient’s verbalized concern that she felt that she did not feel ready for discharge as she was inadequately prepared to face her home and other commitments. Establishment of a collaborative relationship in this case would entail treating the patient as a normal human being with insight and expertise. As a nurse, I would reflect carefully on the patient’s verbalized concerns and seek to find out what the patient perceives as helpful in her situation and the management options she thinks will promote her recovery. In so doing, I would be providing opportunities for the patient to participate in her own care. I would strongly desist from creating the impression that the patient is suffering from a chronic illness that merits her been taken care of. The response by the nurse in the case scenario that the patient would be supported during the transition period by a case manager creates this unfavorable impression as it depicts the patient as helpless and dependent. In contrast, I would aim to create hope and optimism about the patient’s condition. I would help the client arrive at realistic expectations of her acute and ongoing care by for instance helping her appreciate the goals of acute care and incorporate her personal views into her long-term care. I would also emphasize to the patient that she will always have access to the unit.
With regards to the information required to foster successful transition of the patient into the community, it is recognized that carers provide a significant proportion of mental health services in community settings such as administration of medications (Clealry, Freeman, Walter, 2006). The available literature is also equivocal on the importance of appreciating the unique needs and circumstances of individuals drawn from diverse backgrounds including those of persons from culturally and linguistically diverse backgrounds (Mental Health Commission, n. d.). Also essential in the recovery of individuals with mental health problems is having access to good housing and employment, meaningful social and personal relationships, access to high quality mental health services, and opportunities to engage and contribute to community activities (Mental Health Commission, n. d.). In this regard, the information required to foster successful transition of Margaret into the community would include details of where she lives, whom she lives with, family responsibilities, occupation, social support system, where she works, shops, hobbies, community activities she participates in, general practitioner, health insurance, and the mode of transport she uses when commuting between places. These details are important in the planning of discharge care responsive to the patient’s needs.
Medication nonadherence is an important clinical issue amongst patients with mental health problems (Jonsdottir et al., 2010) as it leads to frequent rehospitalizations and poorer outcomes (Australian Psychological Society, 2013). Complexity of drug regimens and family instability are some of the reasons that contribute to medication nonadherence. Research evidence also suggests that poor communication between clinicians and patients particularly lack of consensus at the onset of treatment contribute to poor concordance with prescribed medications (Mitchell & Selmes, 2007). Information about carers is thus important as it will help their incorporation in discharge planning and delivery of an individualized care pathway that maximizes their independence. The patient and her carers would be educated on how to administer her home medications. Strategies to enhance adherence through simplification of the drug regimen such as use of pill boxes or behavioral prompts would also be explored with the patient and her carers (Tammy & Gail, 2010). Their perspective would be sought as to the appropriate timing of medication administration. The appropriate time for administration of home medications should be a time when both the patient and carer are available. The patients home and work related responsibilities should also be considered in the determination of the appropriate medication times. This is because some of medications prescribed for mental conditions have side effects such as sedation that may impair the patient’s cognition and ability to concentrate. Information on the health insurance status of the patient will also help in ensuring that the patient can afford the medications prescribed as cost is often cited as a reason for medication nonadherence (Mitchell & Selmes, 2007). Information about the patient’s carers, occupation, and other responsibilities is essential as it will help the patient and her carers to be assisted in the making of informed choices and decisions on home care.
It has been established that mental health patients are at an increased risk for suicide post-discharge. There is no single known cause of suicide. It is thought to result from interaction between numerous factors in various life domains and life stressors like family conflicts and financial issues (Mental Health Division 2009). Margaret has expressed concern that she is not ready to face her family and work obligations. This has implications on her care as it indicates that she will require ongoing support once she leaves the hospital. Knowledge of her demographic information will thus facilitate the planning of high-level clinical and intermediate care in the community. This will be achieved through ensuring that the health and social care systems are ready to receive and proactively support the patient and her family once she returns to the community. Information on the residence of the patient is useful in assisting clients identify the hospitals where they can obtain future prescriptions. The latter aspect is particularly important in promoting drug adherence (Department of Health, 2010). Details of the patient’s general practitioner are necessary as they would enable the health care team to send the patient’s physician discharge information upon the patient’s discharge. If necessary, they would also enable the health care team to make telephone calls to ensure important information about the patient’s management is relied as appropriate.
In summary, this paper has established that discharge planning is an important dynamic, collaborative, and comprehensive process. It should be commenced at the time of admission with the goal of identifying the client’s care plans and the support he or she would require after exiting from the psychiatric unit. In relation to Margaret, the central issues of concern are patient preparation for discharge, effective communication between the various stakeholders, social support, and medication management. Establishment of a collaborative relationship with the patient would require consideration of the patient’s perspective on her management and the factors that will contribute to her recovery. Her demographic information as it will facilitate the planning of care that will facilitate her successful transition to the community.
Australian Psychological Society (2013). A consumer-centered intervention to enhance antipsychotic medication adherence. Retrieved from https://www.psychology.org.au/Content.aspx?ID=5100
Bee, P., Playle, J., Lovell, K., Barnes, P., Gray, R., & Keeley, P. (2008). Service user views and expectations of UK-registered mental health nurses: a systematic review of empirical research. International Journal of Nursing Studies, 45(3), 442-47.
Cleary, M., Freeman, A., & Walter, G. (2006). Carer participation in mental health service delivery. International Journal of Mental Health Nursing, 15(3), 189-194.
Goodwin, V. & Happell, B. (2006). Conflicting agendas between consumers and carers: the perspectives of carers and nurses. International Journal of Mental Health Nursing, 15(2), 135-143.
Goodwin, V. & Happell, B. (2007). Consumer and carer participation in mental health care: the carer's perspective: part 1 - the importance of respect and collaboration. Issues in Mental Health Nursing, 28(6), 607-623.
Goodwin, V. & Happell, B. (2007). Consumer and carer participation in mental health care: the carer's perspective: part 2 - barriers to effective and genuine participation. Issues in Mental Health Nursing, 28(6), 625-638.
Jónsdóttir, H., Opjordsmoen, S., Birkenaes, A. B., Engh, J. A., Ringen, P. A., Vaskinn, A., Aamo, T. O., Friis, S., Andreassen, O. A. (2010). Medication adherence in outpatients with severe mental disorders: relation between self-reports and serum level. Journal of Clinical Psychopharmacology, 30(2), 169-175.
Mental Health Commission (n. d.). Mental Health 2020: Making it personal and everybody’s business. Perth: Government of Western Australia.
Mental Health Division (2009). Suicide. Retrieved from https://www.health.wa.gov.au/publications/review/chapters/mental_health_3.2.pdf
Mitchell, A. J. & Selmes, T. (2007). Why don’t patients take their medicine? Reasons and solutions in psychiatry. Advances in Psychiatric Treatment, 13, 336-346.
Nurjannah, I., Mills, J., Usher, K., & Park, T. (2014). Discharge planning in mental health care: an integrative review of the literature. Journal of Clinical Nursing, 23(9-10), 1175-1185.
Purdy, S. (2010). Avoiding hospital admissions: What does the research evidence say? Retrieved from http://www.kingsfund.org.uk/sites/files/kf/Avoiding-Hospital-Admissions-Sarah- Purdy-December2010.pdf.
Stokes, B. (2012). Review of the admission or referral to and the discharge and transfer practices of public mental health facilities/services in Western Australia. Retrieved from https://www.health.wa.gov.au/publications/review/main_documents/mental_health_sum mary_2012.pdf.
Tammy, W. & Gail, P. (2010). Medication adherence: Adherence strategies: We can do better. American Journal of Nursing, 110(4), 4-15.
Warne, T & McAndrew, S. (2007). Passive patient or engaged expert? Using a Ptolemaic approach to enhance mental health education and practice. International Journal of Mental Health Nursing, 16(4), 224-229.