Sesión 4: TheRainbow Fish 60

Psychiatry inpatients are discharged in precarious states. With brief hospitalizations the norm and minimal evidence of effective inpatient anti-suicide treatments, the risk of suicide around the time of discharge is significant. It is possible that these risks can be somewhat attenuated, but they in no way can be eliminated. 273, 321 _{It is not at all surprising then that the highest number of post-discharge} suicides occurs within the first one to two weeks of discharge. 12, 27, 42, 59, 280 _{Immediate follow-up after} discharge and adherence to the discharge plan are opportunities for suicide prevention.

Every inpatient receives a discharge plan. The difference between a loose plan and tight plan are the elements that permit rather than discourage suicide. For this reason, considerable attention has been given to discharge interventions prior to patients’ transitioning to the community. These interventions provide information about the importance of aftercare, give realistic expectations for outpatient treatment, motivate the patient’s alliance with the aftercare plan, and suggest means to overcome impediments to getting outpatient services. Such interventions may take hours and may be distributed across the course of hospitalization; some forms of pre-discharge “compliance therapy” run several sessions. 322-324 _{A referral coordinator or discharge planner may take many} hours making the necessary phone calls, securing the necessary appointments, finding transporta- tion, and sending reminders and, thereby, improving compliance for the most difficult, chronically disturbed older patient. 325

Dealing with patients that have been non-adherent with prior discharge plans requires creative thinking and an alternative plan so as to avoid repeating the past failures. Patients with a pre- existing relationship with an outpatient mental health professional are most likely to follow-up.326 Homelessness, substance use, and serious general medical problems make the process of dis- charge planning challenging. 49, 255 _{Predictably, adolescents from the most dysfunctional, least} involved families are most unlikely to follow-up. 327 _{Patient-perceived absence of symptom im-} provement and a dismissive staff attitude naturally predict dissatisfaction with inpatient treatment and non-adherence with the recommended discharge plan. 328 _{Overcoming these impediments is} difficult. The application of specific and creative discharge procedures to these circumstances has

had mixed results. Methods and procedures that improve adherence to the recommended treatment plan will be reviewed on later pages. Suffice it to say that new initiatives for getting patients to the first appointment have an average success rate of about 43 percent over baseline rates. Discharge planning procedures have limited effects on retention after the first appointment. 322, 323

As suggested by these findings, there is wide variation in what constitutes best practices for dis- charge planning. Best practices tend to be established by guidelines susceptible to varied interpre- tation and application. Since firearms and other means restriction prevent suicide, making means restriction a standard of care across settings is an improvement that will save lives. 214 _Family involvement may be and often is critical to the success of discharge planning. Perhaps the most complete set of family-centered discharge planning recommendations have been issued by the American Association of Suicidology. 329 _{Among these are a family session and family education} about suicide, warning signs, adherence to the recommended treatment plan, removal of means, and various outpatient observation, monitoring, and emergency procedures. For youth, such fam- ily sessions are critical to the success of discharge planning in general. 181, 236

The most comprehensive discharge planning guidance for high-risk inpatients comes from the United States Department of Veterans Affairs (VA). Examples include weekly evaluations dur- ing the first 30 days after discharge and specific follow-up for missed appointments. 330 _Barbara Stanley and Gregory Brown have developed a “Safety Plan Treatment Manual to Reduce Suicide Risk;” there is a version of this made specifically for the VA. 160 _{More information about the VA’s} overall efforts is presented in Parts Seven and Eight.

Due to the absence of nationally recognized, explicit and directive standards and requirements for high-quality discharge planning, minimally acceptable practices may become the default standard of care. 266, 267, 331, 332 _{In the absence of directive expectations for high quality work, more easily and} quickly accomplished practices may seduce hospital staff into making minimally acceptable but largely ineffective discharge plans. Indeed, more should be expected from psychiatry inpatient units. New initiatives are needed to improve the process and outcomes of discharge planning. Part Seven of this report (see page 91) examines guidelines and standards in much more detail.

Section-at-a-Glance:

The difference between a just adequate discharge plan and tight plan are the elements that permit rather than discourage suicide. Immediate follow-up after discharge and adher- ence to the recommended discharge plan are opportunities for suicide prevention. Without explicit and directive best practices and standards, more easily and quickly accomplished practices may seduce hospital staff into making minimally acceptable but ineffective dis- charge plans.

Section-related Recommendation:

• Define expected best practices for discharge planning and eliminate unacceptable practices.In the absence of such information what is easy to do may be mistaken for what is best to do. (Please see Part Seven of this report, page 91, for more information.)

Continuity of Care for Suicide Prevention and Research Continuity of Care for Suicide Prevention and Research

Part Five

Survival on the Way to Follow-Up