Hello and welcome. I am Jose Villarreal, Clinical Director of Behavioral Health at Erie Family Health Centers and Community Care Expert for SMI Advisor. I am pleased that you are joining us for today's SMI Advisor webinar on Improving Efficacy in Aftercare, Targeted Interventions for People Living with Serious Mental Illness. SMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is an APA and SAMHSA initiative devoted to helping clinicians implement evidence-based care for those living with serious mental illness. Working with experts from across the SMI community, our efforts have been designated to help you get the answers you need for the care of your patients. Today's webinar has been designated for one AMA PRA Category 1 credit for Physicians, one Continuing Education credit for Psychologists, and one Continuing Education credit for Social Workers. Credits for participating in today's webinar will be available until January 17th of 2023. Slides from today's presentations are available in the handout area, found in the lower portion of your control panel. Click the link to download the PDF. Please feel free to submit your questions throughout the presentation by typing them in the question area, also found in the lower portion of your control panel. I'll reserve 10 to 15 minutes toward the end of the presentation for some Q&A. And now, I have the pleasure of introducing the faculty for today's webinar, Ashley Gonser, Licensed Clinical Social Worker. Ashley Gonser is a mental health clinician who specializes in working with youth and adults, in particular, individuals newly experiencing mental health symptoms who are seeking therapeutic interventions for the first time. She is passionate about decreasing the barriers to mental health access, including the use of psychoeducation for individuals and their supports to decrease stigma around services. As a former team leader of specialty coordinated care for individuals experiencing their first episode of psychosis, or what we like to call clinical high risk of developing psychosis, Ms. Gonser values collaboration with multidisciplinary providers and natural supports. By utilizing preventative strategies and strength-based intervention, she aims to assist youth and young adults and their families with identifying tangible ways to break generational cycles and begin to create sustainable, healthy, and adaptive patterns. Ms. Gonser, thank you so much for today's presentation, and I yield the floor to you. Thank you so much for the introduction, Jose. I'd like to start off by saying I have no disclosures to report for this presentation. As I go over the learning objectives, I want you all to think about what made you sign up for this webinar today. Please think about a specific question you're hoping to have answered from the training or something that came up as to what made you interested in this topic. If at the end of this presentation, your question hasn't been answered, please throw it out in the chat box, and I will do my best to answer it during our Q&A portion. So upon completion of this activity, participants will be able to explore challenges that people living with serious mental illness experience when they discharge from a psychiatric hospitalization. Next is to evaluate approaches utilized to coordinate care when a person living with serious mental illness transitions from the hospital to aftercare. And finally, we're going to talk about ways to integrate strategies to improve engagement with aftercare services and decrease the likelihood of readmission. So we're going to go ahead and start off with what are some challenges to treatment. So people living with a serious mental illness may experience some barriers to treatment. Some of them include non-assurance. So this can be more of a challenge with being like medication-specific. It could also mean frequency of appointments, if it's recommended that they meet once a week or not, or weekly, but they're not. It could also be about different strategies or interventions that have been suggested to them. Next is service disengagement. So again, this could be more specifically about missing appointments, coming in late, canceling last minute, but also to be disengaged could be during appointments if someone is maybe quiet or withdrawn, non-communicative. Maybe they don't want to answer questions. Maybe they're looking away. It could be a multitude of things. And the next one is poor interpersonal communication skills. Inadequate access to information about available mental and healthcare services. I think this one is so critically important. Sometimes we kind of just want to hand off information and anticipate people will take the initiative to run with it. But when we're thinking about all that comes with a psychiatric hospitalization, we want to be sure that we're including information that makes sense, that's up to date and relevant, such as I had someone I'm working with be provided information about intensive outpatient or IOP or HP care, but it was included in the suburbs as opposed to they live within the city of Chicago. So it misses the mark there. So that's another key component, wanting to make sure people are informed and able to actively choose things that could be beneficial to them. Next is difficulties navigating the mental healthcare system. I think we all can agree insurance can be very confusing and also trying to get a clear cut answer sometimes can be so challenging and frustrating that we just want to give up. So just to normalize that as a process with the people we're working with is so critically important because it helps for them to feel like, oh, I'm not the only one. This isn't my own struggle. Some of these systems are very complex and confusing. And with insurance, we want to make sure they're getting services that are covered for them or helping them find a way to get coverage if they qualify. And lastly is the lack of opportunities to engage in shared decision-making. So shared decision-making is crucial for increasing buy-in, level of commitment to a treatment plan, and just being able to be sure that we're on the same page with the people we're providing services to. One example I thought of that kind of helps to paint a picture of what I think of when it's shared decision-making is I was trying to think of what's a really challenging thing that no one really wants to do, but maybe they're at a place where they have to do it. The thing that came to mind was going to buy a car. So it's something that you're like, ooh, my car got totaled or my car completely done. I need to go get a new one. Let me go to the car lot and see what I can come up with. So if you're the person going to the car lot looking for a purchase, a big purchase at that, and there's a car salesperson that they see you and immediately start talking about what you need in a car, they say, okay, you need to make sure you have four-wheel drive. You need to make sure you have the rack on top of the car to carry any accessories and you need the biggest car we have. And they keep going and going and going about all the best features of really fancy, nice cars. But you come in there and you're like, I'm barely going to use a car. I want something that's eco-friendly, fuel efficient, small enough to squeeze into a parking spot that's on a road where there's not a lot of parking. There's going to be that mismatch, right? It's someone who specializes in cars telling you everything you need without taking the moments to step back and ask you what it is that's important to you. What is it that you're willing to invest in or that you want? So that's something that I think of when we think of shared decision-making, that we want to be sure that we're allowing that space for engagement so that we can provide a plan that will be best for the person who's engaging in services. Some additional challenges to treatment can include those that present as barriers within the actual organization or structure of services. These can include a lack of resources, limited availability of inpatient beds, lack of continuity of care, and lack of community care follow-up services. So now that we've begun to discuss potential challenges to treatment, let's transition to factors at play when it comes to engagement in aftercare. So approximately two-thirds, or around 65%, of patients fail to attend scheduled or rescheduled initial outpatient mental health appointments after a hospital discharge. Those who are at risk for unsuccessful linkage to outpatient care may include persons living with a persistent mental health condition, persons or patients with no prior public psychiatric hospitalization. So again, if someone's experiencing a psychiatric hospitalization for the first time and there's so many new things happening at once and it can be incredibly overwhelming, that can be something that can impact their desire to engage in aftercare, especially dependent on what their experience was like while they were psychiatrically hospitalized. The next one is patients with no prior experience of long-term care. So this one I think about if an individual's involved in a community mental health agency or maybe let's say they've been engaged in outpatient therapy, have a good rapport with their therapist, those are things that could help with transitioning back to the aftercare. But without that, it could feel like, okay, I just went to the hospital, I did it, it's done, let me go back to life as normal as it was. The next one, patients admitted involuntarily. So think about that. When there's something you really don't want to do or something that you don't see the need for, but it's pushed upon you anyway, like that pushy car salesperson or someone trying to upsell you for something or think about too maybe as like a kid, if you had a parent or caregiver that's like, nope, we just got to do it. We have to go to this person's house because that's what we do, doesn't feel good. As humans, we naturally want to rebel against things that are pushed on us. And so I think this one's super important when we think about what it means to have our autonomy taken away from us when we're involuntarily hospitalized and what that looks like, especially if there's a longer stay in inpatient care, which is the next one. So if it's a long period of time, if it's a couple of weeks, if it's more than a few days, or let's say if there was like an important date that happened like a birthday or for school and exam and that the individual missed because they were hospitalized. Those are all things to consider when we think about whether or not someone may engage in aftercare services. Sticking with this theme here about engagement and aftercare, we look at, is there co-occurring substance use disorders at play in the actual physical environment? Is it rural or under-resourced communities? Let's say maybe I've worked at a very rural community mental health system back in Michigan. One of the things I could not get over was that it's outpatient community mental health care program was located in what was called like the government complex, which also housed Department of Human Services. And it also housed the county jail where individuals would meet with their probation officer. So being in a space like that, where there's difficult connotations of the other places that exist there and or being within a small community. If you know someone whose cousin, sister or mom works at a place, are you really going to want to go in and receive services when you feel like in a small town things are going to be talked about? So those are super important when we're talking about different environments and how they're structured and also the opportunity for people to run into someone they may know when they're looking to seek services. Additionally, being discharged against medical advice. So if an individual discharges themselves and it's not something supported by the medical providers, there's a high probability that they're also not going to be interested in participating in aftercare services if they're trying to get out of that inpatient care services very quickly and against what providers are suggesting could be helpful. Racial and ethnic disparities in behavioral health care. Prior professional relationship with a mental health provider. This comes into play too when we're talking about an involuntary hospitalization, right? If someone involuntarily hospitalized by a provider who they used to feel like they can trust and had a good rapport with. If the aftercare plan is to return to that provider and this individual has not spoken to this provider since they were hospitalized, they might be really hesitant to go back and meet with this provider given there could be a breach of trust on their end or they could feel like, well, what if I talk to them and they hospitalized me again? So we'll talk a little bit later about why it's important to help bridge this gap between inpatient care and aftercare, but just keep note of that and like how it is within your own personal relationships when someone does something that maybe you don't agree with how you return back to them. And last is type of insurance or uninsured. Again, certain programming is provided based on your insurance, right? And if you're uninsured or underinsured, that could be hard pressed to find something that matches. So we also want to consider too, if like the suggestion is a step down partial hospitalization program or intensive outpatient program, what is the availability for that city and place where the person would receive services? Is it something that's covered and if it's something that is more intensive, what are we looking at when it comes to transportation and coverage as far as getting to and from those appointments? So now we're at the why. So why is it important to have effective aftercare? I'm going to go ahead and read a quote here that is relevant. So the failure of patients to engage in specialty mental health care shortly after hospitalization undermines important clinical gains made during inpatient treatment and affords the intended trajectory towards future stabilization, maintenance, and community adjustment. Evidence that patients are connected to ongoing care shortly after a hospital stay is also indicative of a clinically integrated system of care. With the investment of considerable resources in inpatient care, much effort needs to be directed to preparing patients adequately for discharge and optimizing their linkage to appropriate community services. So we're talking about aftercare while keeping in mind what's been done during that inpatient care. What are the clinical gains made? What are some insights an individual may be leaving with that they could bring into the outpatient care and help with their prognosis long-term? So we want to think about that long-term stabilization and maintenance and recovery and the adjustment within the community because it's such a different experience when you're in an inpatient place, right? Or you can't leave to and from. And then to go back into the community, we have to think about what that can look like for someone both personally, professionally, and within the dynamics of their interpersonal relationships. So we want to connect, meaning avoid gaps in delivery of psychiatric services and improve that routine care. So that weekly, biweekly appointments or meeting with a psychiatrist once a month or being able to follow up with their primary care physician for any medical needs or any prescription refills needed. And we also want to enhance. So we want to enhance the coordination and collaboration between providers. Are we sharing relevant information? Are we engaged in exchange of things that have come up that might better serve the individual when they leave the hospital? And we also want to ensure a quality of life for the service user. So we want to touch on what is it that this person wants once they leave the hospital? And what is it that's going to make their life feel like it's more quality and a reason to live, right? Quality of life means we're less likely to experience that, those thoughts of not wanting to be here anymore, and that severe hopelessness. So all things to keep in mind. All right, so we're going to talk about transition from inpatient to outpatient care. So two reviews on care transition models and interventions involving the transition from inpatient to outpatient care identified components that are relevant to the mental health setting and people with serious mental illness. The components can be divided into three parts, patient, provider, and system levels. So starting off with the patient level, components include perspective modeling to identify individuals at risk of deteriorating health, and patient and family engagement in treatment and transition planning. Barriers to successful intervention that were reported at a service user level included behaviors that are often in opposition to recovery. So for instance, this could be substance misuse, dependency on services, or unstable social relationships. Similarly, facilitators on a service user level included behaviors or affect that are facilitative of recovery, such as a sense of belonging within community or community services, structured daily routine within the community, and being part of stable and structured social networks. So of note, this does not indicate that the success of the intervention is dependent on the behavior of the service users. But instead, this highlights the considerable effects of the complicated personal and social variables that surround mental health care transition interventions. Next, for provider level components, this includes guidelines and instructions for what to do and when the provision of properly tailored information. So the effectiveness of the intervention was often highly dependent on the behaviors, opinions, affect and education of the staff delivering them. The willingness of the staff to adapt and exhibit flexibility was key, as was providing staff with adequate training around intervention. So something I think about in my work with first episode psychosis, if I was going in there with a plan of attack of providing psychoeducation about what is psychosis, what are hallucinations and delusions with an individual who maybe didn't identify as experiencing psychosis. If I went in with handouts and just start rattling off all the information I knew, that could very quickly rupture my therapeutic rapport with that person, or stop engagement completely during the session. Maybe the person would withdraw, maybe they give short answers, maybe they start looking away or ask how long they have to meet. So instead of that approach, we really want to ask the individual what they went to the hospital for, what was their experience like, and what are their priorities for that particular session and within the scope of treatment. So that can help with that collaboration piece much more. Lastly, the systems level components include use of quality metrics and feedback and feedback, and the establishment of accountability mechanisms between providers to ensure shared responsibility for patient care. From a service level perspective, barriers were related to insufficient funding of services or interventions, ineffective information sharing, and the effect of the physical location of services. So particularly for rural community services, effective planning was also a reported facilitator. So in this way, I think about like community outreach and support. This means literally meeting people where they're at, especially if they lack effective transportation, or maybe they don't feel safe going to a place they don't know. Or they might worry if they come into an office, are they at risk of being hospitalized again if they disclose specific symptoms. So the revolving door phenomenon is a pattern in which an individual is admitted to the hospital for inpatient care. Then they go back to the community only to be re-hospitalized for the similar reasons within a short period of time. This reduction of reliance on inpatient care is a key component of the deinstitutionalization movement. So that is the process of replacing long-stay psychiatric hospitals with less isolated community mental health services for those diagnosed with a mental health disorder or developmental disability. So deinstitutionalization works in two ways. First, focuses on reducing the population size of mental institutions by releasing patients, shortening stays, and reducing both admissions and readmission rates. The second focuses on reforming mental hospitals institutional processes. So as to reduce or eliminate reinforcement of dependency, hopelessness, learned helplessness, or other maladaptive behaviors. Frequent psychiatric hospitalizations may be related to poor service quality or lack of coordination between levels of care. So we want to be sure we're paying attention to what we're doing and our actions in order to help keep people the least restrictive level of care. So why is it important to intervene? And why are we talking about aftercare? Well, when we think of moments from leaving a hospital, in general, we typically think, what's next? For example, after a birth, you think about what's next, what does it mean to care for a tiny human, or recovery from a surgery, or leaving the hospital after a major diagnosis with cancer, or even leaving a hospital after losing a loved one. You're leaving and thinking about what are the next important steps. It's natural to plan ahead for the next day, the next week, month, and year. In the same way, we want to prioritize discharge planning and aftercare from a psychiatric hospitalization to ensure that those gains made during that time aren't in vain, but rather they're able to be continued into outpatient care. So here's some of the why's, why in why it's important. So we're starting off with a high risk of suicide. In addition, some adverse complications may include family conflict, social segregation, work conflict, academic problems, financial troubles, legal problems, substance misuse and self harm. For a lot of these, I see them as key opportunities to intervene. Are we talking with someone about how to navigate a conversation with a friend or family member about where they were for the last week? Are we helping them to develop a letter that allows them to be excused from work while able to return to their job, or even write a letter to their teacher or professor in order to give them more time to complete the work that they may have missed when they were gone? Up to 80% of individuals do not receive outpatient treatment following their initial assessment to the emergency department. So think about going to the ER to try to get help and really feeling like I am in crisis, I need help. And then up to 80% don't receive follow up from them. So a huge step forward, but nothing that comes after that. So of the patients who attempted suicide and received follow up care up to 38% of them terminated care within the first three months following their suicide attempt. So we're doing this essentially in order to help people live better quality of life, so that this suicide attempt can be reduced, right, especially after a hospitalization, which could be the reason why the individual went to the hospital for the first place. So here's when to intervene during transitions across settings within care teams, among care participants, and between encounters or care episodes. Let's talk about what coordination is. Coordination includes the organizing processes, measures, and networks at the interfaces of the mental health hospital, primary care delivery, and community health systems. Coordination commonly occurs during and in response to care transitions, as an individual's care needs change. It involves bridging activities among healthcare professionals, establishing shared accountability for patient care, communicating with stakeholders, exchanging information and transferring care responsibly, facilitating care transitions, performing clinical assessments of care, needs and goals, monitoring care and responding to change, and supporting self management and providing links to relevant community resources. I think of coordination as being able to merge the inpatient and outpatient care where maybe we're talking to the assigned caseworker during the hospital stay and getting updates. And even if we're at the place where we can go and visit a client when they're in the hospital, like I was able to do, especially with the emerging adult population, and the first episode psychosis program I was part of, we get some longer term hospitalizations. And I remember the caseworkers being more likely to communicate any updates, changes, or if they had believed the individual might be preparing to discharge, they would alert me and let me know, because I had more of a physical presence going on the unit, being able to meet with the person and engage with them so that we could begin the conversation of what things might look like when they discharge from the hospital. Let's talk about some of the gold stars for aftercare. So controlling for risk factors, three clinical interventions used during the hospital stay more than tripled the odds of successful linkage to outpatient care. These included communication about patients discharge plans between inpatient staff and outpatient clinicians. I think we can all say everyone's day to day is probably looking pretty busy when it comes to both inpatient and outpatient providers. But when we think about wanting to be effective and efficient, that communication is so important, because both hold valuable information that could really help create a different trajectory for this individual we're collaborating about. Next is patients starting outpatient programs before discharge. So we all know insurance can be a little tricky. And that might not always be a reality. But could this mean going to visit the individual or participating in some of their meetings or discharge planning appointments? Could this mean contacting them via phone to check in with them, ask how they are and also start to develop the plan of what outpatient care will look like once they are discharged. Lastly, is family involvement during the hospital stay. So family involvement, it's important to note this caveat, family is whoever the individual chooses or identifies as family. It could be biological family members, could be caregivers, could be friends, could be partners, whoever they want to be part of their process. It's important to try to include, obviously, with releases of information, but also when we think about discharge planning, if an individual is staying at someone's place, maybe they need help to come up with the language to communicate to that person or those people about what's been going on, what their needs are, and how they can best collaborate to create like long standing progress and change. So those are things we're very capable of doing. It's just with being able to be intentional about integrating that. Lastly, it's also like brief low intensity case management intervention. So we're going to get into that on the next slide. So this is called brief critical time intervention, or BCTI. So this study assess the effectiveness of a brief critical time intervention model for veterans with serious mental illness who are being discharged from inpatient psychiatric treatment facilities. So CTI was originally a nine month model designed to prevent reoccurring homelessness among men with mental illness who are being discharged from homeless shelters. The original CTI model was effective at reducing extended homelessness and negative symptoms, and it was cost effective in comparison to usual care. CTI has subsequently been adapted for other populations, such as homeless persons with mental illness who are being discharged from psychiatric hospitalizations, homeless families, homeless veterans, and men with mental illness who are being discharged from prison. So this model that I'm going to talk about is shortened and adapted from that original CTI model, creating a brief, meaning three month long intervention that seeks to enhance continuity of psychiatric outpatient care. It was hypothesized that veterans randomly assigned to receive BCTI would have significantly better continuity of care. Some of the eligibility criteria included being between 18 to 70 years old, living within 50 miles of the inpatient facility, being diagnosed with schizophrenia spectrum disorder, major depression, bipolar disorder, or psychotic disorder, not otherwise specified. Participants were determined to be at risk of dropping out of treatment post discharge if they were diagnosed as having a co-occurring substance use disorder, history of medication non-adherence, inpatient admission, followed by a readmission, emergency room visit, or no outpatient visits within 30 days post discharge. Patients who were homeless or currently receiving or eligible for services from mental health intensive case management team by virtue of four or more psychiatric inpatient hospitalizations within the past year were excluded. So this study's adapted BCTI model routes patients within existing systems of community based services and social supports, thereby facilitating the transition from inpatient hospitalization to outpatient services and community living. The three month intervention begins before hospital discharge. The BCTI clinician who has training either in nursing or social work would receive a referral and immediately meets with the patient to assess individual needs and barriers to outpatient care. The clinician would work on building rapport, develop individualized treatment goals, identify barriers to treatment, and establish a case management plan. Next, we're going to discuss nine of the possible target areas for clinical focus. So you'll see that there are nine here on the screen. So these are aimed at improving the continuity of psychiatric care for persons living with serious mental illness. The focus areas are determined by the initial assessment and ongoing reappraisal of the patient's needs. Clinicians are trained to emphasize systems coordination and psychiatric stabilization and to identify an additional two to three target areas. So for systems coordination, the description and goal is described as coordinate referrals and work with patient to identify long term treatment goals. Possible activities would include accompanying patient to appointments and develop a system for tracking for keeping track of appointments. For psychiatric stabilization, the description and goal was described as assist the patient with managing symptoms and feeling more empowered in making active use of psychiatric services. So this might look like helping the patient optimize relationships with treatment providers, talking with providers regarding the in vivo observed strength and vulnerabilities of the patient. The three phases of the original CTI model were reduced into two for the B-CTI model. The phases are labeled bridging the transition to outpatient care and facilitating engagement in community based services. So some of these could include home visits, again, accompany patients to initial appointments and providing both emotional and practical support for the patient and the family. Now let's go to the results of B-CTI. So in reviewing the results for the study, both the continuity and intensity of care are considered. So compared with the control group, the B-CTI group had significantly fewer days between hospital discharge and the first outpatient visit. A greater portion of participants in the B-CTI group had a mental health or substance use visit within 30 days and 180 days of discharge. Participants in the B-CTI group had more total mental health and substance use visits within that time frame as well, the 30 days to 180 days. Those in the B-CTI group also had greater continuity of outpatient care, as evidenced by a greater number of two month blocks with two or more outpatient visits over the course of 180 days. From the participants perspective, overall satisfaction with mental health services did not differ between the groups. Participants in the B-CTI group reported receiving significantly more help in scheduling mental health and medical outpatient appointments and in tracking and getting to those appointments. So that's why it's really important in the beginning when they do the assessment process to identify potential barriers to follow through so that we can do these things with the individual, whether it's making a call or coming up with a script of what to say when you call and figuring out, are they someone who could use a planner or with technology these days? Is there a way to be able to track these appointments with reminders to increase the likelihood of attending? Those in the BCTI group reported receiving more information on the name dose and type of medication prescribed for them and receiving more aid in contacting family members and social supports Making community connections and helping family members to better understand mental illness and other related issues The two groups did not differ in receiving general information on substance abuse understanding why problems are made worse by substance abuse attending substance abuse treatment receiving information on how medication controls symptoms and side effects and receiving help with practical housing and budget needs Compared with participants in the control group Those in the BCTI group described significantly greater levels of satisfaction with legal and safety issues and greater frequency of social contacts No difference was found in the satisfaction with living situation daily activities and functioning family relations finances work school and health Psychiatric symptoms did not differ between the groups Conclusion the study contributes to an emergency an emerging body of evidence Supporting the effectiveness of brief critical time intervention to improve continuity of care for individuals with psychiatric conditions So this transition of care so we're We're focusing on Bridging this gap between a very intensive inpatient care into outpatient care settings So what we want to do is support safety ensure that it's good quality of care You can decrease costs, right? If we're able to get someone actively involved in a more intensive outpatient programming that could reduce the amount of readmissions that they have in the hospital and Help them to feel more empowered of how to navigate certain things within the context of staying within the community We want to provide a positive experience for the patient and a positive experience for the family so one thing I do know from my own experience is how important especially when an individual lives with or has a close relationship with their family how important it is for us to Include the family again that could be a caregiver a family member like a cousin sibling Could also be chosen family a partner. It could be a friend a person that they're living with if we just focus on serving the individual but don't pay enough attention to Their environment or the other players within their environment We're doing a disservice to them and to the work that we are doing as well We want to make sure that the individuals within this person's environment also feel empowered To know what are some warning signs if things aren't going well What are the important reasons to be consistent with attending therapy appointments or psychiatry appointments? we want to offer options for Potential meeting with the family members or finding a local group where they can talk with other family members And have their own experiences heard and normalized. It's so important that we think about this as a comprehensive approach to providing services for this individual Because not only is a psychiatric hospitalization incredibly Challenging for the individual because of how it may Impact their their life, but also for the people that they identify as their supports and care people So additionally Individuals living with serious mental illness who discharged from Inpatient settings without being connected to outpatient treatment services are at a higher risk of recidivism So to be clear this means like a tendency to relapse into a previous condition or a mode of behavior So not just in regards to how it's typically referenced for crimes after discharge Individuals living with a serious mental illness are at high risk of adverse outcomes including first episode of reoccurring homelessness psychiatric hospitalization suicide incarceration and financial cost So delayed or non-existent outpatient follow-up treatment can contribute to poor outcomes And is estimated that about half of all discharged psychiatric patients transition successfully to outpatient care Four key components of pre-discharge and treatment of in transition of care are Medication reconciliation and education structured needs assessment scheduling follow-up appointment prior to discharge and psychoeducation For bridging the key components are timely communication by inpatient staff with an outpatient care or community service provider after discharge Meeting with the outpatient mental health provider prior to discharge and Use of a transition manager the transition manager serves the patient best Through the transition of care on the foundation of a therapeutic alliance begun either prior to hospital discharge or soon after discharge to optimize the transition out of the hospital At post-discharge there are eight key components Such as telephone follow-up efforts to ensure psychiatric follow-up psychoeducation home visits family education and intervention structured needs assessment post-discharge hotline and peer support Some Top causes of ineffective transition of care include accountability breakdown So this occurs in systems where there is no psychiatrist or a clinician to take responsibility for coordinating the patient's health care Failure at the accountability level can be magnified for patients with complex psychiatric Medical and social needs so we could assume Oh This other person will take care of that because they have this specialty or this background or we assume that they're just going to jump in Whereas collaboration and integration are the structural underpinnings for solution So we want to make sure that we're not contributing to ineffective transition of care Next is patient education breakdowns. So this could be failures in patient education Which can occur with poor medication reconciliation conflicting information being provided to patients and family members or even a lack of provision of patient education So maybe assuming right if someone's been on medications before or has been hospitalized before we may have certain assumptions So it's really important to key in and ask an individual before just assuming they may know certain details or information And then lastly this communication breakdowns So communication breakdowns are one of the top causes of clinicians not effectively Communicating with each other the patient the family and other caregivers underlying factors can be inadequate time organizational culture lack of standardized procedures and even differing expectations between persons on both sides of the transition of care bridge And then this is where we're talking about the service user perspective so super important Many participants found coping in the community after an inpatient stay to be challenging Several participants highlighted the importance of planning and preparing for hospital discharge during the hospital stay Participants mentioned that this was rarely done adding that this lack of adequate planning increased the risk of crises and rehospitalizations some participants emphasized the importance of going through what services were available in the community and what to expect in terms of follow-up appointments Some participants described beneficial discussions during their inpatient stay with health care professionals Who outlined treatment options and provided advice on how to develop a supportive social network? So we want to provide options not just tell people what to do actively identify potential barriers and help them to find solutions for that but also to Developing a supportive social network so that we're thinking about when this person leaves here. Who are they gonna lean on? when they come across a challenge or difficulty Several participants mentioned the need for meaningfulness in day-to-day life as well So the importance of preventing loneliness and lack of structure, right? Some hospitalizations are highly structured So then leaving the hospital we think about how am I gonna spend my day or my time? Even if I have an appointment scheduled during a week, that's like one hour, maybe two, right? So we want to consider that as well Participants also mentioned the importance of individual planning such as developing Emergency or crisis plans prior to discharge. So if certain Warning signs happen. What are we gonna do? Who are we gonna talk to? maybe they would be open to having different information about crisis centers that are peer-run such as the living room and being able to come up with a list of ones in their area and That the times that those are available So some strategies to implement Definitely shared decision-making again think about doing something like going to a car lot and like a Salesperson approaching you or even when you're doing holiday shopping like having someone approaching you and telling you what you need That doesn't really feel so good. So making sure we're collaborating together with shared decision-making We're supporting Providing support for caregivers or whoever the individual identifies as their core support people We're addressing barriers related to accessing medication We're addressing barriers related to complicated medication So we want to make sure that an individual feels empowered to follow the recommendations So whether it's writing things out or talking them through it Ensuring that people feel empowered to take the next steps to take a hold of what their life looks like post Hospitalization So lastly I'll leave you with this quote the state of well-being in which Every individual realizes his or her own potential can cope with the normal stresses of life can work productively and fruitfully and is able to make a Contribution to his or her community. That is what mental health is defined as At this time if you want to take a moment to reflect on what's the most important thing you learned today or what's one thing you plan to implement or if you have any questions for me, feel free to put it in the chat and we will transition to our Q&A session Thank you so much Ashley for such an interesting presentation Before I shift over to Q&A I want to take a quick moment and let everyone know that SMI advisor is accessible from your mobile device Use the SMI advisor app to access resources education Upcoming events complete mental upgrading skills and even submit your questions directly to our team of SMI experts It's as simple as downloading the app at smiadvisor.org or slash app So actually I don't have a lot of time. So I'm going to just feel two questions. The first one Has to do with the with the intensity of this type of system of care We have the individual experiencing a crisis or a difficult difficult situation Accessing care into an inpatient setting while inpatient setting like you mentioned there's this sense of like Engagement that takes place that leads to good aftercare So the question for you When it comes to this how important is shared decision-making how important is person-centered approach In regards to gaining that person's interest pertaining to aftercare goals or Also involving folks who they actually feel like they can help them in the process once they leave the inpatient setting Yeah, that's a great question and I think it's important to you know ask permission from the individual about Discussing these goals if we're able to connect with them prior to discharge, right? So then we can come up with a way of communicating that to the inpatient providers But also think of it as what does this individual want to happen in this moment when they discharge and from there? so you really want to tend to What it is that is important to them and their values And so I always ask about who they may want included in those scenarios and especially when it comes to discharge planning so it's really about just trying to connect with where that person's at and even if you go into like a Conversation with them at that time trying to inquire about that and they're not at that place. It's like using that flexibility like I talked about earlier to shift and adjust and really try to like build a rapport with them right because Sometimes when we're in the midst of something Kind of digging in deeper to what someone wants out of it or future planning might feel like too much and so we have to really be willing to Adapt and make these adjustments based on what the individual is telling us I always come with creative options of things to do games to play while talking about these things And also I recognize that even if I come in with an intention of what to discuss or talk about It's that person's not ready or willing or wanting to I have to be okay with that and look for a different Opportunity to connect with them because the rapport is also very critically important Yeah Really good response is almost as if we're we're gaining that person who wants to walk with The individual experiencing the situation but going a step further and even involving them in treatment I had the experience when I used to work an inpatient back Not only did I identify the individual who was going to be part of the treatment once they left But I involved them in the process while inpatient because we all know that this system of aftercare is really complex There's a long wait list shortage of psychiatry shortage in in therapy so forth and so on so that individual can be like Walking with them be part of the process So as I got time for one more question, so how important is to include parents Potentially that are overbearing or disengaged in the treatment course of the youth and young adult That's really really a great question too, and I think that that question Should certainly be explored with the individual I mean there's differences when we're talking about a minor or a young adult who's 18 and over right because We want to make sure that we're respecting their right for confidentiality but also if this is a main caregiver and support person potentially someone who could be Accompanying them to appointments That's something we really want to key in on and also even if the individual maybe doesn't want them to join in certain Appointments that doesn't mean we can't provide psychoeducation to the parents or caregiver at that time so I think it's important to also as like the provider to be mindful of if a parent or caregiver is overbearing over involved or Disconnected that means something and that could really create an opportunity to intervene To have better like long-term trajectory for this individual so while it may feel like More work initially to engage the person or to manage all the questions and concerns that they may have Long-term it's gonna better be better for the individual and it'll help make your work easier because then you have other people who can also be observers of Different warning signs things that are going well or challenges that you can incorporate into treatment But also I just to reinforce you definitely want the individual in on those conversations about what that may look like Yes, thank you. Thank you. So I'm going to move forward if anyone Has any questions about this topic or anything pertaining the discussion held today? You can access the roundtable topic discussion board just to connect with colleagues in this presentation Or in the field in general This is just a basic easy way to share ideas with other clinicians who participated in the webinar If you have questions about this webinar or any topic related to evidence-based care for SMI You can get an answer within one business day from one of our SMI advisor experts This service is available to all mental clinicians peer support specialists Administrators or anyone in the field of mental health who work with individuals with SMI it is completely free and confidential Also SMI advisor is just one of many SAMHSA initiatives that are designated to help clinicians implement evidence-based care We encourage you to explore the resources available on the mental health addictions and prevention TTCs as well as the National Center of Excellence for eating disorders and Suicide prevention resource centers These initiatives cover a broad range of topics from school-based mental health throughout the open epidemic And last but not least the claim credit for participating in today's webinar You need to have met the required attendance thresholds for your profession Verification of attending may take up to five minutes You'll then be able to select next to advance and complete the program evaluation before claiming your credit And please join us on December 1st as Dr. Michael Birnbaum presents the role of social media and the internet in early psychosis intervention Again, this free webinar will be Thursday, December 1st from 3 to 4 p.m. Easter Standard Time Thank you so much for joining us and until next time. Take care You

aftercare

serious mental illness

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evidence-based care

continuity of care

person-centered care

family involvement

Brief Critical Time Intervention

medication reconciliation

home visits