The International Journal of Psychosocial Rehabilitation

Building a Bridge from Hospital to Community: One Patient’s Experience


Peter J. O’Brien, MSW, RSW,

Clinical Consultant

Shared Mental Health Care, Alberta Health Services,


Christine Hewitt, BScOT,

Occupational Therapist

Community Mental Health Rehabilitation Team, Alberta Health Services


Shahid I. Hosain, MD, FRCPC

Consulting Child and Adolescent Psychiatrist

Foothills Medical Centre, Calgary, Alberta


Mary Elizabeth Lauzon, RN

Staff Nurse, Department of Psychiatry,

Foothills Medical Centre, Calgary, Alberta



O'Brien PJ, Hewitt C, Hosain SI, & Lauzon M. (2010).  Building a Bridge from Hospital to Community:
One Patient’s Experience. 
 International Journal of Psychosocial Rehabilitation. Vol 15(1) 101-112

Correspondence should be sent to: Peter J. O’Brien, Shared Mental Health Care,
 Sheldon M. Chumir Health Centre, 1213 – 4th Street S.W., Calgary, AB, T2R 0X7
or sent to:
Note: The four authors worked together as part of the staff complement of the
Young Adult Program, Foothills Medical Centre, when this “patient experience” occurred.

This article describes a unique and comprehensive rehabilitation plan that was created between staff of a hospital psychiatric unit, personnel from two community agencies, high school staff and the family of a patient admitted to hospital with a complex illness, in order to integrate a treatment plan that would lead to successful discharge home. The steps taken to augment the care on an acute psychiatric unit, as well as to create a collaborative rehabilitation plan that involved the integration of hospital, community and school staff to develop an effective continuum of care for the patient and family will be described. Tensions and challenges addressed throughout the process, as well as the success in achieving genuine community collaboration will be highlighted. The spontaneous and informal creation of a collaborative enterprise with the patient, family and community of care will hopefully prompt others to share similar stories.

Terms: rehabilitation, collaboration, community, hospital.

The admission of a seventeen year old student to an acute adolescent psychiatric program offered a unique opportunity to develop a comprehensive rehabilitation program to support this severely ill patient in transitioning home. This involved addressing administrative and acute care staff concerns about the capability of a psychiatric unit to provide an extended rehabilitation plan in the care of the patient and family.

While providing medical and psychiatric care to this adolescent it was necessary to negotiate a comprehensive rehabilitation plan and to recruit the involvement, during the young man’s admission to hospital, of community agency personnel already contracted to offer services to the patient and his family.

The steps toward realizing the goal of transition back to home and school will be chronicled and discussed herein.

Admission Crisis
Upon attendance at the Emergency Department, the young man was reported to have experienced two days of sudden decline in functioning with the onset of severe anxiety, delusions, hallucinations and catatonic symptoms. According to his parents this was a profound vegetative shift. On admission, the patient did not respond either verbally or physically and required one-to-one assistance with all activities of daily living (ADL’s). The symptomatic presentation impressed as organic in nature, and therefore, full medical investigations were completed. The results of virtually all of the investigations were normal, apart from a positive parvo virus serology, which is usually self-limiting, as is the case with most viruses.

Early on in the admission, the patient was started on anti-psychotic medication, Olanzapine, and after approximately one month started to respond quite well to the medication. After about one month of complete silence he gradually became verbal and it became evident that he was suffering from a number of obsessive thoughts. For example, these included the worry that some fictional character would come to the hospital unit to do harm to him. Accordingly, the patient was started on the SSRI, Sertraline, in order to treat these obsessive thoughts. (Sertraline had been prescribed when the patient was at a much younger age, with reported efficacy).

Cognitive testing by the unit psychologist and a full functional assessment with the occupational therapist (O.T.) suggested that the patient was significantly compromised in terms of cognitive and functional capacity. This adolescent already had several diagnoses over the course of a few years, including Pervasive Developmental Disorder with secondary psychotic symptoms, speculation of Asperger’s Disorder based on previous symptomatic presentations and Obsessive-Compulsive Disorder. A further diagnosis of a primary psychotic process was also being considered as a result of the admitting symptoms.

Over the course of the three month, three week admission there was a slow, steady improvement in the patient’s functioning and in his ability to interact with family and staff. However, one-to-one care and constant supervision in the hospital environment was required through almost the entire admission, and as transition to community was contemplated.

The patient was assessed in the Emergency Department of a major teaching hospital, affiliated with the university and serving a city population of almost one million. The acute deterioration of physical condition, functioning and communication prompted admission to an inpatient adolescent psychiatric unit. The admission was for three months and nineteen days in total.

The eleven bed adolescent inpatient unit serves teens ages thirteen to eighteen years with mental health concerns. The adolescent unit is staffed by psychiatrists, nurses, a psychologist, recreational and occupational therapists, family therapists, a pastoral services representative and a Board of Education teacher and behavioural specialist in the on-site classroom. The patient and family had access to the full complement of these services throughout the admission.

Initial Steps in Hospital
 As noted, this young man was seriously compromised in literally all facets of daily functioning at admission to hospital. Within a few days concerns were articulated across the staff complement as to how this patient could possibly be cared for long-term on this unit. The adolescent psychiatric unit was simply not staffed to provide such acute, twenty-four hour nursing care for an unforeseen period. A debate arose over organic vs. psychiatric causes of his illness. The puzzling nature of the illness, its sudden, inexplicable onset and inability of all professional staff to predict its course or duration, alarmed staff of the adolescent unit and the family. In addition to requiring constant nursing care and being immobilized in bed, he was initially unable to benefit from any of the multi-disciplinary assessments or treatment, or the milieu therapies that were intended for residents of the adolescent unit program.

The initial nursing care plan addressed both physical and psychological deficits manifested on admission. Nursing staff dealt with the patient’s self-care deficits including feeding, hygiene, dressing grooming and toileting. The patient was suffering total incontinence, hyperthermia, risk of fluid volume deficit, altered nutrition, risk for self injury, sleep disturbance as well as altered thought content, sleep disturbance, decreased insight, reality impairment, anxiety, fear and impaired verbal communication. For example, the patient’s father related to staff that the patient appeared to be terrified of both contamination and of disinfectants. Nurses began planning and implementing specific techniques dealing with all aspects of this patient’s care.

The parents were perplexed and alarmed by the rapid and severe onset of the symptoms. Their concern included wondering if the staff of a psychiatric unit could or would meet the complex medical needs of their son. Unit treatment staff met with the parents and began to ‘map out’ a course of action that would provide basic nursing care and also incorporate the parent’s ability to supplement the daily care alongside intense psychiatric observation.

It was clear to all concerned that this situation could not be sustained with the current unit resources. A critical turning point arose early in the admission when a small subgroup from the staff of the adolescent inpatient unit, comprised of the admitting psychiatrist, a few of the nursing staff, the occupational therapist, psychologist and social worker formed an informal and impromptu treatment team committed to fashioning a rehabilitation treatment plan in support of this young man and his family.

This subgroup took a special interest in the evolving rehabilitation plan, above and beyond the demanding daily schedule of a psychiatric unit.
A commitment to working collaboratively with one another, the family and community partners to successfully facilitate the eventual discharge home and return to school were realized as a result of this plan.

Community Partner Recruitment
From the initial family meeting on the adolescent unit, staff was aware that this patient had an open file with a provincial agency mandated to offer funding support to children qualifying for handicapped children’s services. Over a series of preliminary discussions with the assigned caseworker from Children’s Services it was learned that the case worker had considerable leeway to augment the care being provided in hospital. However, affecting the kind of program created required front-line staff and supervisors within the respective community agencies to respond with a reciprocal intention of being truly collaborative.

An initial Case Conference was held on the adolescent unit to explore with Children’s Services their willingness to support a hospital rehabilitation program on an acute unit. Members of the hospital unit, the case worker from Children’s Services and the parents of the patient participated in this meeting. The teen was not yet well enough to attend the Case Conference. Assessment findings, treatment recommendations and an outline of a treatment protocol with time lines were discussed at this meeting.

The major thrust of the Case Conference was to consolidate resources between hospital staff, the family and a funded community agency, to share the care plan while the patient remained on the adolescent unit. The parents had been augmenting the daily care plan from admission, particularly at the supper hour, in the early evening and on weekends. The more innovative idea was to enlist the support of a community agency that offered daily living support in the community to further augment the care being provided on the unit. In particular, the request from hospital staff was that caregivers/aides be available to support the patient and hospital staff in the morning, when breakfast and basic hygiene care was required, thereby exacting a heavy toll, as this was not normally required of staff on a psychiatric unit.

The next significant step was for the case worker to return to Children’s Services to review the proposal for collaboration between hospital, family and community with their supervisor and secure authorization and funding support for the unfolding innovative plan. Following agreement to the proposal with the Children’s Services supervisor, the case worker was in contact with a community resource agency that was mandated to provide activities of daily living support to clients of Children’s Services. The request was that two staff of the community resource agency would be contracted to attend at the adolescent psychiatric unit to initially provide daily living assistance to the patient, and subsequently to be involved in the more comprehensive rehabilitation program that was evolving.

The case worker from Children’s Services was instrumental in recruiting aides to attend at hospital to augment nursing care for up to five hours per day in the morning, seven days per week. Implementation of the daily schedule involved a further meeting with the members of the community of care team. Once this program was established it remained in place through the entire course of the hospitalization, through the transition phase to community and beyond discharge into the teen’s return home and resumption of school studies.
Hereafter, all people involved in the rehabilitation plan, including the subgroup from the hospital unit, the family members and community agency personnel will be referred to as the community of care team.  

The Rehabilitation Program
The first involvement of the occupational therapist (O.T.) was to complete an assessment of the patient’s ADL functioning. The purpose of the assessment was to create a structured daily routine that all staff involved could follow to ensure the same routine and the same cueing was used to assist the patient. This patient functioned better with a structured routine and appeared to decompensate when his routines were altered so this was an important principle in his recovery plan. The team also believed that a visual aide that encompassed the ADL routine may help cue both staff and eventually the patient to the routine. The O.T. created a wall poster for the patient’s room of the daily ADL routine with feedback from unit staff.

The most important and critical component of this ADL routine was the cooperation and use by all staff involved in this patient’s care. The wall poster, structured routine, and cueing strategies were discussed in detail at a meeting of the community of care team. These team members had knowledge of what already worked for this patient and what the issues were. With this feedback and brainstorming session the team was able to create a viable structured daily routine. Added to this plan was a checklist of ADL’s that staff would use to track the patient’s activities and increasing level of independence.
 A recommendation was to maintain consistent staffing with this patient instead of continuously introducing new staff to the treatment plan. The result was that the patient was assigned three primary nurses who would work with him on different shifts to provide continuity of care.

As the patient began his slow recovery and started ambulating it was important to use other means of cueing to assist patient to engage in these self-care activities and create opportunity for the patient to relearn skills, a routine and gain independence. These cueing strategies included: hand-on-hand with verbal, partial hand-on-hand with verbal, demonstrative, just verbal and eventually cueing to wall poster for next step.  

A second purpose of the O.T. assessment was to look for adaptations that could be made to equipment and environment to assist this patient in gaining independence in his ADL’s. Suggestions included having his parents bring in easy-to-don clothing such as elasticized waist pants and t-shirts and slip on shoes.  Other examples of equipment recommended were: pump top shampoo bottles, large grip brush instead of small handled comb, bathroom bars for safety in transfers, larger grip cutlery, grips for writing utensils, and beginner level reading books.  

The patient had reduced function in both gross motor and fine motor abilities due to the slow recovery from his initial catatonic state. It was important to use the patient’s leisure interests in combination with participation in gross and fine motor activities to improve function.  The patient was interviewed regarding his leisure interests and staff and family also brainstormed ideas on activities the patient showed interest in.  Activities were made readily available on the unit for the patient. A list of recommended activities for patient was charted and discussed with all staff at one of the regular rehabilitation meetings regarding the patient. Some activities included were: playing catch with a ball, kicking a ball, coloring, reading, puzzles, tic tac toe wall game, crafts, board games, and regular walks outside. This was time consuming for staff but by sharing this task between multiple staff it created a variety of interactions and activities that created intense rehab program for the patient to enable him to improve his skills.

Keys to success of this patient’s recovery included:

1.)    Small graduated steps towards increasing independence
2.)    Structured daily routine
3.)    Slow integration back to community and home with lots of support

But the most important component that enabled these first three points to be possible was:
Team work and regular, clear communication and cooperation between all involved as part of the community of care team.
The tasks for the aides during the five hour morning shift were determined in consultation with the community of care team to incorporate the patient’s ‘high demand’ early morning care requirements. The parents’ schedule allowed them to be most available at the supper hour and during early evening visiting hours.

The original daily schedule was basic and included much verbal direction and cuing for the client in terms of relearning to wash appropriately in the shower and after toileting, dressing, using utensils for meals, brushing his teeth and combing his hair. Over the course of several weeks and the repetition of daily routine the care staff shifted their focus to cuing the patient as he became more independent and capable with his ADL’s.
In the early rehabilitative phase the patient was only able to tolerate brief walking excursions on the unit. He expressed considerable fear about using the elevators in order to connect to any other area of the hospital. He also continued to express paranoid ideas about evil apparitions that might attend at the hospital to harm him.

The process of basic rehabilitation was exceedingly slow in the first few weeks, but with the daily chart of successfully achieved self-care activities being tracked by the aides, nursing staff and parents each day, it was possible to confirm incremental gains from week to week. At approximately the mid-way point in his hospitalization the patient began to verbalize much more freely, finally indicating his comprehension of his situation. His improvement in overall functioning and weekly gains also began to accelerate at this point.

The role of the classroom teacher, classroom behavioural specialist and the psychologist became more significant as the patient increased his basic skills, began to communicate more directly verbally and showed an inclination to return to the structure and familiarity of the classroom. On a number of occasions the treatment team introduced more elaborate rehabilitative steps, based on the progress being noted, often in the service of monitoring the length of stay issue. Invariably, there would be a significant regression in the patient’s overall functioning when changes to the daily rehabilitation regimen were introduced. The rehabilitation team learned to introduce alterations to the program in the most modest fashion, resulting in progress becoming more uniform over time.

The introduction of the classroom component was a significant feature of the rehabilitation program and served as an effective barometer of the patient’s readiness to embark on more ambitious steps, including forays out of hospital with family initially, and eventually consideration of a return to school as a key goal of the discharge plan. The ability to tolerate participation in the classroom, initially for only brief periods in the morning in the company of the aide who would assist with reading, led to a gradual increase in time spent in the classroom milieu, and the introduction of independent academic activities.

The fact that the patient had advanced through the school system prior to illness, made the classroom setting a place of familiarity and success. He was motivated to be in the classroom and this served as an effective way to interrupt his isolation from other residents of the hospital unit. Social interactions that were gradually introduced in the classroom led to interactions with peers in the common area of the adolescent unit and at the meal table. Observation and information gathered from these interactions was documented by the rehabilitation team and served as additional evaluative data to confirm that an effective course of treatment was unfolding. During this phase of participation in the classroom, it was noted that the psychotic symptoms gradually resolved.  

Transition to Community School
The next phase of the rehabilitation plan, initiated after a couple of months in hospital, involved consulting with education staff from the community school. A similar process to the one entered into with Children’s Services, of open communication, accenting collaboration and a sharing of resources unfolded. A Case Conference now involved the patient and his community of care team, which now expanded to include the school guidance counsellor and the patient’s classroom teacher.

Similarly to the initial Case Conference discussion in hospital, considerable trepidation and doubt was articulated about the capacity of the school to contend with such a compromised and disabled student. An added dilemma was that the school administration would have difficulty obtaining approval for aides who were not employees of the school system to attend in the classroom to assist the student, as had been happening so effectively in hospital with the aides from the community resource agency. This dilemma was resolved by the school reallocating their internal resources to provide a classroom aide for the student during school hours, which initially involved only one or two classes, then increased to the entire morning at school and ultimately to the full school day.

The ability of these major institutions to be flexible and innovative in fashioning the treatment plan, rather than being wedded to policy and protocol that inhibits creative problem solving was critical to the successful outcome of the process.

The aides from the community resource agency took responsibility for assisting the patient to get ready for school, accompanied him to the school, and then met him for the return to hospital at the end of his morning. The resource agency and aides continued to adapt to the increased school hours and adjusted their support to still be available to accompany the student to and from school each day. As the rehabilitation program expanded to introduce home visits and eventual discharge from hospital, the aides adjusted their schedules further, to accommodate time at home as well as hospital. The commitment of the aides was tied to the patient and family, regardless of setting.

When home visits were added to the rehabilitation plan, they initially involved day passes home on the weekends, when the parents could be most readily available, and incorporated the participation of the aides from the resource agency. Gradually, overnight passes home on the weekends were added, and as these were successfully incorporated a full weekend pass was introduced. Finally, dinner passes through the week, and evening passes during the week were added to increase the time that the patient spent at home and in the community, thereby decreasing the reliance on hospital.

All parties involved in the rehabilitation plan were aware that the prolonged hospitalization had left the patient secure with the routines and relative comfort of the institution, even while protesting about the desire to be back at home. Lessons learned in the early phase of treatment, related to increasing autonomy in a carefully graduated manner, as opposed to abrupt changes in the expectations for enhanced independence, supported the slow but steady progress through the transition period.

The introduction of the school community component occurred while the patient was in hospital. This step supported the rehabilitation team on the adolescent unit in continuing to monitor progress toward readiness for independence and discharge. Consultation with the community of care team was frequent during this phase.

Discharge Plan
The circumstances surrounding discharge involved a continuing dialogue among the community of care team. In the last few weeks of his admission to hospital, the patient was increasingly impatient with remaining in hospital, though there was a shared apprehension among all concerned about his readiness to be at home full-time. The parents alternately expressed exasperation with the prolonged transition out of hospital and anxiety about being able to cope completely without the support of the hospital unit.

The school staff remained ambivalent about their capacity to continue increasing their care and instruction to allow the student’s return to a full academic program, especially as the one-to-one aide being allocated in the classroom was proving to be onerous in a system already taxed by several years of cutbacks and resource reductions.

The ambivalence of school personnel was juxtaposed by increasing concern and pressure from the administration of the adolescent unit about the patient’s extended length of stay in hospital. In spite of the creative and effective approach of all involved in addressing this complex admission, the institutional pressures continued to build.

This confluence of pressures led to a decision to discharge the patient after three months and three weeks in hospital, though there remained several unresolved matters. For example, how to structure the remainder of the patient’s day after his partial academic program was completed at noon hour and he left the school for home was unresolved. An additional concern arose as to the community resource agency’s ability to indefinitely maintain their high level of involvement, at five hours of direct one-to-one aide time per day, seven days a week.

Subsequent to his discharge from hospital and in the couple of months that followed, the patient was described as increasingly responsive in returning to his former level of functioning. In fact, before the end of the school year this young man had resumed his former level of full-time school attendance. Just seven months after being discharged from hospital with a tentative prognosis, he successfully completed his final requirements to graduate from high school. Such an outcome attests to the resiliency of the patient, the faith and dedication of his parents, and the quality of the rehabilitation plan, which included the collaboration of hospital, school and community staff with the young man and his family.

No re-admissions to hospital were required.

A main interest for the authors in reviewing this course of illness and rehabilitation is to highlight the ability of mainstream systems to adapt and offer high quality care, bringing to life ideas of meaningful collaboration between traditional institutions of the community and the patient/family. The inexplicable and dire circumstances of the admission, and the successful outcome arising from the determination of all concerned parties to create a collaborative rehabilitation program, deserve elaboration.
These efforts were maintained from the outset of the admission and through the lengthy rehabilitation course, even while contending with a high degree of emotional turmoil and even some resentment generated in the health care and educational systems, in particular, about the propriety of being responsible for the comprehensive treatment plan that evolved. In addition, myths about the inability of an acute care hospital unit to offer effective long-term rehabilitation, and about the inviolability of financial and logistical barriers between the main hospital institution, Children’s Services and the contracted community resource agency in creating a comprehensive and collaborative rehabilitation program, were successfully addressed.

Length of Stay
Concerns about the length of stay in hospital and the capability of the school to support an incrementally increasing school program over a number of months arose and persisted despite considerable and consistent success in the overall treatment plan. This young man was successfully rehabilitated from an acute, inpatient adolescent psychiatric unit and then graduated from high school barely 10 months after becoming incapacitated and catatonic in the Emergency Department of the hospital.

Several important issues are raised in situations such as this one. In a health care climate of fiscal restraint and cutbacks (McGrath & Tempier, 2003) length of stay may become a principal measure of the efficacy of a treatment approach or program (Parsons, 2006; Murphy & Noetscher, 1999). It is possible that individuals with more complicated circumstances are screened-out, as there is an understanding that they will tax limited resources and do not allow for a speedy resolution. However, decisions related to treating the mentally unwell individual in hospital or not will also be influenced by the social climate of the community and the availability of alternatives (Gordon, 1997)

Although not necessarily articulated directly, when an acute unit of a hospital is faced with such a complex circumstance as evidenced with the admission of this young man, pressure can build quickly to transfer elsewhere. The combination of uncertainty about diagnosis and prognosis, as well as acute care staff not being proficient in organizing a modified rehabilitation plan, and pressure to demonstrate efficiency via meeting administrative targets related to length of stay, can conspire to shift a focus from client/family needs to those of the hospital unit.

Ability to Provide Care
From the outset, there was apprehension among the staff of the unit as to their capability in providing care for this. The demands placed on the nursing staff, in particular, in the first several weeks of the admission, prompted much questioning of the merits of having such an ill teen on the unit. As well, many staff of the hospital program were unfamiliar with a long-term rehabilitation orientation. “While programs may refer to themselves as rehabilitation programs, and systems may consider themselves rehabilitation oriented, if the personnel are not trained and experienced in rehabilitation, then rehabilitation will not be practiced.” (Anthony, 1992, p.167). However, there is a growing awareness that the quality of care can be improved as rehabilitation-oriented services are introduced onto hospital units (Birkman, et al, 2005), and this was certainly the experience on the unit in this situation.
Perceived Hardship for Staff
Even the introduction of the community resource agency aides on a daily basis, providing the bulk of the direct and labour-intensive care of getting the patient up and ready for his daily routines did not divert some staff and administration from the lament that the patient needed to be placed elsewhere than a psychiatric unit with limited resources. With the family being in attendance on the adolescent unit over most supper hours and each evening, thereby providing further care for the high-demand bed-time routines, there was actually considerable relief being provided for the acute care staff.

 In fact, it was the community of care team who were addressing the most significant care demands, and these tended to be in the domain of fine-tuning the rehabilitation plan. The family bore the principal emotional burden and the Children’s Services agency accepted the financial burden of supplying aides via the community resource agency. Once the patient was able to transition back to school, the Board of Education and the host school found the funding support to provide the additional classroom aide.

In this context the concerns being expressed by many staff were striking. Anecdotal feedback suggests that the concerns reflect the stress/distress being experienced by many staff in ‘doing more with less’ and facing ever-increasing acuity overall. It suggests that an opportunity to think and practice innovatively remains a challenge. The immediate response to the suggestion of an impromptu and informal long-term rehabilitation team within the acute care psychiatric setting can be sharp and pessimistic. And, even with each successful step forward in securing additional support to relieve the demands on the unit staff, it can be difficult to alter an entrenched and pessimistic mind-set.

Competing Goals at Admission
Decisions about resource allocation often occur via administrative processes in which the complex needs of the patient with a challenging mental illness are not adequately represented (Rosenheck, et al, 1998). Impatience with acute and chronic illnesses, coupled with the extraordinary pressure on current health systems, risks that poor decisions will be made. The quality of care cannot always be measured in dramatic results (McGrath & Tempier, 2003). An unclear focus on specific goals, or unresolved concern about the goals of the admission, also risks disregarding the excellent work being done in the management and rehabilitation of the most severely mentally ill.

Such a situation calls for an examination of the mission of the program or unit, as well as familiarity with current and relevant concepts such as recovery (Anthony, 1991; Anthony, 1993; Mental Health Commission Canada, 2009). It is not enough for health care staff to know about the existence of standards of good practice. It is essential that staff are prepared to participate in discussions about their role, construction, adequacy and acceptability of these standards (Cribb & Duncan, 2002).

The tenets of the Canadian health care system, including universality and equal access (Canada Health Act, 1985) can provide an alternate focus at admission which will not necessarily be in sync with an administrative focus on admission goals. One could also argue that there is an obligation to treat the least well off (Rosenheck et al, 1998), not to arbitrarily discharge them to units in other cities with no discussion with family about the implications.

At the very least, a discussion among the treatment staff and with the patient and family is imperative, if appropriate goals of the admission and a complex rehabilitation plan are to be undertaken. Constructive discussion involving all of the concerned parties will hopefully allow for realistic and clear treatment goals to be set (Rudnick, 2002). Such an approach would also allow all parties to move forward with a clear understanding of roles. In keeping with these ideas, the host of supportive relationships that developed among members of the community of care team were key factors in the recovery process (Mancini, Hardiman & Lawson, 2005).

Implications for Family
There was administrative concern expressed throughout the admission, and on occasion a resolve to relocate the teen to a long-term care institution some 200 miles away, as a way to address the acute unit’s lack of long-term rehabilitation capability and the ongoing length of stay worry. Although this idea of transfer was raised internally to the adolescent unit on a few occasions, it was not raised with the family.

The discussion about length of stay pressures being resolved by transfer to a long-term care setting were muted in the context of the implications of such a transfer for the family. Budget constraints and pressure to provide care for high-needs patients with reduced staffing in recent years are legitimate concerns to address. However, the disadvantage and hardship of hospitalization, or transfer to a chronic-care setting in another city, thereby separating the child from the family and their community also merits consideration (Steinhauer, 1996, p.16).

Steps Contributing to a Successful Plan

A key feature of moving forward ideally includes administrative support for the unfolding plan. In addition, the support and involvement of the admitting physician is critical in a hospital environment. The formation of an impromptu rehabilitation team on the acute care unit was also essential to create the unfolding treatment plan. Especially where there is not whole-hearted support for creating a long-term rehabilitation plan for an acute-care patient, the cohesion of the smaller staff group involved in the rehabilitation plan is essential. The quality of hope shared among the members of this smaller staff group can extend to the client and family to create an essential climate of hope (Spaniol, 2008) that will sustain all involved through the long process of rehabilitation.
Clear communication via periodic formal Case Conferences, and frequent informal communication was essential. Role delineation was important, with at least one member of the rehabilitation group being responsible for the overall coordination and management of the treatment plan on the unit, and facilitating meetings with the patient, family and community agencies.

Importantly, an ethos of optimism and collaboration, informed by actions that underlined these words, was evidenced and encouraged on a daily basis. Starting with the small rehabilitation team formed within the adolescent unit, this attitude extended to the family and to the few community agencies and numerous individuals who became part of the community of care team. Rather than a focus on territory or who might delegate to whom, there was an evolving spirit of camaraderie in sharing a common goal.

Much is written about the value of “team” and collaboration between institutions and agencies, and including a community of caregivers, and most importantly with a client and family. In this instance, these ideas became a lived experience on a daily basis and thereby contributed significantly to the outcome.

Collaboration with Community
As well, the approach delineated in this situation follows protocols of collaboration and collegiality among the three major social systems that are charged with responsibility for the care of children and families in need in this society – health care, children’s services and education. The Steinhauer report (Steinhauer, 1996, p.31) speaks to the need for true collaboration among those very major social systems in order to provide effective care. In seemingly spontaneous fashion, the various individuals engaged in fashioning this community of care demonstrated what is referred to as deliberate and purposeful ways of relating that are simultaneously flexible and responsive to others (London, et al., 2009). The importance of well-planned transition from hospital to community (Watt & el-Guebaly, 1981) and the goal of interactions to support greater continuity of care, a central feature in the provision of mental health servcies (Joyce et al, 2004) were also demonstrated in the team effort.

The individuals that made up the community of care team were all in uncharted territory in terms of creating this collaborative plan. Each of the main community agencies contributed to the effort to maintain a regular dialogue with one another and with the family. Especially in the early stages of this evolving rehabilitation plan, this practice was critical.

While each of the respective agencies was familiar with planning and negotiating with clients and family members, none had experience with such a comprehensive plan for inter-agency/family collaboration. Given that at the outset this patient was uncommunicative and in an adolescent psychiatric unit bed, with an uncertain prognosis, the circumstances were even more troubling. Despite these uncertainties, or perhaps as a result of a collective willingness to tolerate them, the staff that made up the community of care team sat together to create a plan that addressed the patient’s acute needs. This involved hospital staff, non-hospital staff and family members working closely together on the hospital unit, major budgeting requirements and the development of a rehabilitation plan that would unfold gradually over about fifteen weeks.

Each time a new concern or a new opportunity arose in the treatment course, the community of care team gathered, and with input eventually from the patient as well, the concerns and opportunities were addressed, an appropriate adjustment in the treatment plan was made, and the entire community of care moved forward with the patient and his family. An ethos of believing in possibilities and maintaining a focus on the resourcefulness of all involved contributed to this approach and has elsewhere been described as an organizing framework for collaborative practice and family-centered services (Madsen, 2009).

In retrospect, a number of salient traits adopted by the entire community of care team also reflected key narrative principles and practices in community work (Freedman & Combs, 2009). These included the determination to proceed at a pace that worked for the patient more so than for the hospital, remaining cognizant that we were all part of a team that was making significant contributions to the eventual outcome and that it was important to honour each of the “little steps” that were being taken from week to week.

It is our hope that in telling the story of this unique approach to a genuinely puzzling and unusual admission conundrum, others will be inspired to share similar stories of their success in fashioning authentic community collaboration. The whole process was fraught with challenges and occasional tensions, including those caused by the pressures on the hospital and school systems to produce efficient and cost-effective measures.

The comprehensive planning and the determination of all involved, to commitments in the service of a shared goal, over the course of a more than three month admission to hospital, was innovative and effective. The community of care team developed a meaningful and ultimately successful treatment plan.
What goes without saying, is that no one individual, not one discipline, could have forged the result for this patient and family that was collectively reached. The power inherent in the team, evolving as a collaborative and coordinated entity, offered the energy that was shared by each member, and accounted for the salutary outcome that was achieved.

This spirit of collaboration, which arose spontaneously and informally in the adolescent unit, was extended first to the patient and family, and then to the community. This attitude was met with a matching spirit from the key partners that were forged in the community. A simple equation, to be sure, but one easily missed in the relentless and competing demands and pressures that inform health care in the current climate.


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