The International Journal of Psychosocial Rehabilitation
a New Culture
Establishing a Transitional Living Community at a
The Recovery and Empowerment model has been successful in many types of programs. Attempting to establish such a change of culture in a traditional medical model hospital has been well worth the efforts. This model, adopted in the Transitional Living Community (TLC) at
Keywords:Recovery and Empowerment,
Psychosocial Rehabilitation, Culture Chang
In evaluating the program’s efforts, it was determined that there was a segment of the ESH patient population who might no longer be benefiting from the traditional inpatient model. It was determined that quality care could be improved by taking a closer look at how resources were being utilized with respect to individual patient needs.
Within the hospital there are individuals who are psychiatrically stable and ready for discharge, but who are unable to leave due to non-behavioral reasons. Problems with funding and placement issues in the communities are encountered and, although community efforts toward outpatient placement are strong, a large number of clients remain awaiting discharge. At any given time, there are approximately 50 clients on the Discharge Ready List.
Forensic clients with unescorted community
privileges are another segment of
Additionally, the national nursing shortage crisis has impacted health care everywhere. ESH has experienced an increase in mandatory overtime with subsequent staff burnout, recruitment and retention difficulties, and a large increase in spending for overtime pay. The average monthly expenditure for overtime was contributing to budgetary constraints.
Movement toward an empowerment and recovery model to develop independent community living skills for the patients who have maximally benefited from inpatient programming but are unable to be discharged was therefore considered. This model, adopted in the Transitional Living Community (TLC) at ESH, narrows the gap that is intrinsic when moving from hospitalization to living in the community. This provides a more appropriate level of care, is a much less restrictive environment and alleviates some staffing and budgetary difficulties.
“Our vision is of a community-based system of services that promotes self-determination, empowerment, recovery, and the highest possible level of consumer participation in work, relationships, and all aspects of community life” (Governor’s Conference: Self-Determination, Empowerment and Recovery, December, 2004).
The basic principles of psychiatric rehabilitation remain consistent with all programming efforts:
a) equipping clients with skills;
b) emphasizing client self-determination;
c) using the resources of the environment;
d) emphasizing social change;
e) providing different assessment and care;
f) emphasizing employment;
g) emphasizing the here and now; and
h) providing early intervention. (Cnaan, Blankhertz, Messeger & Gardner, 1990).
The establishment of a Recovery/Empowerment Model in
the TLC at
ESH created an environment that encourages and supports the development of autonomy and skills necessary for successful community tenure. Self-management skills are emphasized, to include self-medication, scheduling and performing home management and self-care tasks (meal planning and preparation, laundry, cleaning, money management, budgeting, shopping, making and keeping appointments, etc.). Individuals pursue their goals for employment or volunteer experience within the hospital or in the community. They explore community resources and support services, participate in off-campus AA/NA meetings and consumer groups, and practice resource acquisition skills. Opportunities for role development, peer counseling, self-advocacy and the development and practice of personal and social boundaries exist. It creates a smoother transition from being an inpatient to an outpatient and moving from forensic status to civil status. It increases the clients’ self-confidence and decreases public safety concerns as they gain successes in the community. Community Services Boards are able to assess clients’ progress in a less restrictive setting and are able to provide more suitable housing as available. This program also enables direct admission to a step-down level of care after being stabilized in the community. Finally, with the increased autonomy of the clients, nursing staff and other resources are able to redeploy to other areas of the hospital, thereby decreasing overtime.
The individuals referred to this program by their treatment teams are encouraged to function as independently as possible in this more normalized setting while working through their barriers to discharge. Individual goal setting and opportunity for achievement are an integral focus of the Transitional Living Community. The consultative model proposed that the program be staffed with one psychologist, one consulting psychiatrist, one social worker, one rehabilitation services staff member and, per shift, one direct services associate. One LPN comes to the unit twice daily for medication management issues. There is no full time nursing staff assigned to this unit.
What did it take to make such a large change in the treatment modality?
1. Readiness for Change
2. Culture Change toward Recovery and Empowerment
3. Commitment from the top of the organizational structure (DMHMRSAS, Hospital Director, and Medical Director)
4. Committed staff
5. Innovative thinking
6. Belief in the clients
7. Clients’ belief in themselves
8. Appropriate staff support
9. The ability to adapt to change
ESH was ready for a change and the aforementioned budget crisis and nursing shortage was pronounced. The Virginia Department of Mental Health, Mental Retardation and Substance Abuse Services (DMHMRSAS) began implementation of a Recovery, Empowerment, and Self-Determination model of care and based on this philosophy, ESH Hospital Director, John Favret, redeveloped the idea of creating a TLC that was originally proposed in 1997.
The first step was to create a place for this community. One of the wards housed patients whose medical needs outweighed their psychiatric needs. These patients were not benefiting from the centralized programming available in PSR. It was decided that they would maximally benefit from the proximity and services available in our Medical Services Unit (MSU) and they were therefore relocated. The MSU contains medical equipment, medical and physical rehabilitation clinics, x-ray, lab, and pharmacy resources, and is staffed by several internists. ESH received several notices from the families of these medically fragile patients who were pleased with this move.
This relocation of patients left one 19-bed ward open for the use of the TLC candidates and allowed 11 members of the nursing staff to be redeployed to assist other wards experiencing staffing shortages.
A Recovery Council comprised of consumers and individuals who possessed an enthusiasm for the project was formed. The goals were established with the following premise in mind: “…recovery is a deeply personal, unique process of changing one’s attitudes, values, feelings, goals, skills, and/or roles” (Anthony, 2000).
Recovery Objectives to Support Individuals:
1. Making increasingly independent decisions by identifying risks and benefits of daily living choices.
2. Moving toward self-management of medication and healthcare.
3. Learning to co-exist with peers in supportive environment.
4. Learning to problem-solve with decreasing staff involvement.
5. Developing a personal recovery plan.
a. Setting daily, short and long-term goals
b. Identifying and seeking resources, assistance and support
c. Accepting consequences of personal choices
d. Re-evaluating/self-evaluating individual plan
e. Other independent choices
Admission criteria were created for the unit.
1. Interested, willing and capable of living in a co-ed setting with appropriate staff assistance, according to the TLC guidelines.
2. Able to safely manage unescorted grounds privileges during free time. If NGRI status, must have unescorted community privileges and be adequately managing their risk factors.
3. Is an active participant in programming that may include but is not limited to: Vocational/Clubhouse/Living Skills Groups.
4. Is knowledgeable about prescribed medications (i.e., can name medications and state the reasons for taking them). Is able to identify the risks/benefits of taking the prescribed medications and can state the risks associated with discontinuation.
5. Can assist in the management of their physical illness, if applicable.
6. Is capable of maintaining personal hygiene and room management.
7. Any history of assaultive or self-harm behaviors is carefully evaluated and does not contraindicate TLC placement.
8. Any history of sexually aggressive behaviors or sexual trauma is carefully evaluated and does not contraindicate TLC placement.
9. Actively participates in the discharge planning process.
Due to a large number of forensic patients referred for the TLC, the Internal Forensic Review Panel approved candidates to the unit and revised Risk Management Plans.
The three rules the individuals suggested were: “1) Be honest, 2) Respect others and their stuff; and 3) Keep the peace.” They have more choices, more personal freedom and subsequently more sense of self-worth. The positive change in the affect of some of these individuals is so pronounced, it begets the question, ”Why didn’t we do this sooner?” One of the individuals on the unit eloquently expressed himself in a progress note. With his permission, I have included it here:
“My name is ___ and these are the
reflections relating to my stay,
and thoughts thereof, in the TLC unit at