The International Journal of Psychosocial Rehabilitation
Adult Step-up Step-down:
A sub-acute short-term residential mental health service


Kerry A. Thomas
BSc(Hons); BSocSc.

Debra J. Rickwood, PhD
Professor of Psychology
University of Canberra

Gavin Bussenschutt

BSocWk
Regional Manager ACT

Mental Illness Fellowship Victoria



Citation:
Thomas K, Rickwood DJ & Bussenschutt G (2015)  Adult Step-up Step-down: A sub-acute short-term
residential mental health service.
 International Journal of Psychosocial Rehabilitation. Vol 19(1) 13- 21


Corresponding author:   
Kerry Thomas
University of Canberra
Centre for Applied Psychology
Faculty of Health
Canberra ACT 2601

Abstract
Aim: This article describes the Adult Step-up Step-down mental health service that operates in Canberra, Australia, as a short-term sub-acute residential rehabilitation service. Description: The service accepts mental health clients who are preparing for discharge from an inpatient unit, as a transitional service to support them as they prepare to return to living in the community (step down). The service also accepts mental health clients living in the community who are experiencing an escalation in symptoms and a short stay in a residential rehabilitation program may avoid hospitalization (step up). The service provides 5 beds in an open, home-like environment, with 24 hour staffing, including clinical support. Conclusion: Step-up step-down services are increasingly being implemented in Australia to address the service gap between inpatient and community care, providing a personal and tailored support base for clients prior to returning to independent living.
Keywords:    Mental health, Residential service, Community-based, Transitional service, Mental illness.


Introduction:
Residential mental health services show promise in assisting people suffering from a mental illness to receive treatment in a less restrictive setting than psychiatric inpatient units. The Step-up Step-down program is a sub-acute, short-term, residential mental health service that provides support and access to treatment in a 24 hour staffed, open home-like environment. This article describes the program in detail, as an example of how a step-up, step-down program can be integrated into the mental health system continuum of care.

Continuum of Care
The continuum of care of mental health services ranges from community-based care to psychiatric inpatient units, with jurisdictions differing in their delivery of mental health services across the service continuum. At the less restrictive end of mental health services, many mental health clients live in their own home, with community-based care provided under the care of a case manager and other mental health professionals, such as Assertive Community Treatment (Phillips et al., 2001), which offers a multi-skilled team approach. Community-based care is often the preferred service option for many clients (Rose, 2001). For people requiring more direct support during a time of crisis, there are a range of acute/crisis residential units, some community based (e.g. Crisis Stabilization Units; Adams & Mallakh, 2009) and others attached to inpatient units (Slade et al., 2010), that offer short-term residential support until symptoms have stabilized. Sub-acute residential services offer longer-term accommodation and support options and can provide care in a non-hospital environment for people recovering from an acute episode (Johnson et al., 2009; Sledge et al., 1996) or transitioning from hospital to the community (Sledge et al., 1996; Weisman, 1985). At the more restrictive end of the service continuum are inpatient Mental Health Units, which offer psychiatric services for mental health clients who have acute symptoms, have limited support, or are at risk of causing harm to themselves or others (Horsfall, Cleary & Hunt, 2010).

There is a growing interest in developing mental health services that are effective in promoting both recovery and positive psychology approaches, aimed at not only treating illness but also increasing well-being, within the individual experience of recovery (Slade, 2010). One key component of mental health recovery is hope, and research has identified several hope-fostering strategies that show promise when built into a recovery-focused program, including: collaborative strategies for management of the mental illness; developing relationships; peer support; support for the development and pursuing of realistic goals; and interventions to increase and support positive factors such as self-esteem, self-efficacy and well-being (Schrank et al., 2012). Empowerment, relationships and social inclusion are also important factors in facilitating recovery outcomes, which require recovery-oriented services to work within the community and social systems of the individual (Tew et al., 2012).

Sub-acute Short-term Residential Mental Health Services
Sub-acute, short-term residential mental health services have been developed to provide support and accommodation for people with mental illness in a less restrictive environment than inpatient units, often with a focus on development of skills necessary for successful community living, such as budgeting, domestic and interpersonal skills. These services are designed to provide an alternative to hospital treatment, taking some of the pressure off inpatient units, and comprising a more cost-effective delivery of services in a least restrictive environment (Lloyd-Evans et al., 2009). These services can also offer a transitional service for patients preparing to return to the community. Step-up step-down units are increasingly being implemented in the Australian mental health system as part of system reforms to better meet the needs of mental health clients. Although the research evidence is limited, several studies have found sub-acute residential units to be effective in providing positive clinical outcomes and they appear to comprise a cost-effective alternative to hospitalization (Thomas & Rickwood, 2013).

Adult Step-up Step-down Program
The Adult Step-up Step-down program commenced operating in Canberra in the Australian Capital Territory (ACT) in January 2009. The program is a partnership between a non-government organisation (Mental Illness Fellowship Victoria) and ACT public mental health services (ACT Mental Health, Justice Health and Alcohol and Drug Services (MHJHAD)). The program operates as a five-bed residential unit for adults, taking referrals from the inpatient units at two major hospitals for patients preparing to leave the hospital who would benefit from additional support before returning to the community (step-down). It also takes referrals from clinical mental health workers, on behalf of clients living in the community who are experiencing an escalation in symptoms (step-up), with the aim of providing support to assist the client to return to the community, thereby avoiding hospitalization. The service maintains full occupancy at all times, with clients in the community or in the inpatient unit selected for admission to the residential service, ready to enter the program when a vacancy arises.

The Step-up Step-down service operates under a model of care founded on principles of recovery and psychosocial rehabilitation. In line with research into key aspects of recovery, the model promotes hopefulness, personal empowerment, social connectedness and self-determination in the recovery process, and global well-being for clients experiencing major mental illness. The program provides a safe environment where these elements of recovery can be explored and developed, combined with evidence-based biological, psychological and social interventions. Key features of the recovery orientation of the program are a collaborative decision making approach in the setting of recovery goals, emphasis on development of social connections, and personal strategies to manage symptoms and foster positive mental health.

Clients
People who are considered eligible for the program are generally aged between 18 and 64 years, however older clients may be admitted on a case-by-case basis, if they are identified as potentially benefitting from the program. (Although there is a need for older people with a mental illness to be able to access suitable mental health services, in the Australian health system, mental health clients over the age of 65 are provided with services through the Aged Care system; Dept of Health and Ageing, 2008). Intake and discharge are administered by MHJHAD in collaboration with Mental Illness Fellowship staff, after discussion with the potential client and their case manager. Step-down clients are currently an inpatient, with symptoms that have been stabilized, and are preparing to return to living in the community. Step-up clients are current clients of MHJHAD and generally experiencing early signs of relapse but do not, or do not yet, meet the criteria for hospital admission. Pre-entry screening, by the clinical nurse and case manager with potential clients, is used to determine whether clients have an attitude of collaboration and participation that will enable them to achieve recovery goals. The demographic profile of clients in the program, since the program began, is presented in Table 1.

In order to provide a safe environment for clients and staff, a risk assessment is performed as part of the pre-screening eligibility of clients, with consideration given to risk of self-harm, risk to others, and risk associated with living in a congregate setting. Risk, in a shared facility, is multi-facetted and client and staff safety is an important focus of the service. If there are changes in a client’s ability to maintain their safety, or risk issues for other clients or staff develop, then clients may be admitted to the inpatient unit, or discharged from the residential unit and placed under the direction of their clinical manager.


Table 1
Demographic profile of step-up and step-down clients: January, 2009-April, 2014

 

Step-up

Step-down

Number of Participants

83

117

Female

37

54

Male

46

63

Female Age (mean, SD)

34.77 (12.38)

35.73 (11.13)

Female Age (range)

18-60

19-63

Male Age (mean, SD)

32.35 (10.34)

36.31 (13.23)

Male Age (range)

18-63

19-66

Female Length of Stay (mean, SD)

42.15 (28.01)

38.08 (23.75)

Female Length of Stay (range)

8-133

0-94

Male Length of Stay (mean, SD)

45.49 (25.38)

44.11 (26.53)

Male Length of Stay (range)

1-136

1-129

Exit to Community

96.49%

92.31%

Exit to inpatient psychiatric unit

3.51%

7.69%




Staffing

The program is staffed 24 hours onsite, with day staff including a full-time manager, a mental health specialist nurse who is either onsite or on-call, and two social workers; the night is staffed with one staff member with the manager on-call if needed. The mental health nurse provides clinical support and is responsible for bed management, medication management, clinical risk and mental state assessments, secondary consultation, and ongoing liaison with psychiatrists and case managers. The program employs two social workers (called key workers), who provide support and training to clients on an individual basis, including developing a recovery plan and self-management skills, assisting in developing daily routines, accompanying clients to appointments and actively helping clients establish meaningful community connections.

All staff have training in mental health or social/community work and have an understanding of mental illness and recovery-oriented care. Staff also attend in-house training on relevant topics, and conferences and other training events to continue to improve their knowledge of new developments in mental health recovery. To maximize recovery outcomes, clinical and program staff collaborate frequently concerning individual clients, including updates on recovery plans, client needs, and mental state changes and risks.
Facilities

The residential unit has two wings, one with three bedrooms and a shared bathroom and the other with two bedrooms and a shared bathroom. There is a mix of three male and two female, or two female and three male clients at any time, allowing for gender separation. A large communal kitchen, dining room and lounge room are in the centre of the house, opening up onto enclosed front and rear gardens. A separate sunroom is available, away from the communal living areas. Bedrooms are equipped with bed, storage facilities, phone and a TV/DVD. Clients are responsible for maintaining their room and for cleaning the kitchen and keeping a tidy environment.
Program interventions

Clients enter the program with a range of clinical symptoms and from a variety of social backgrounds. To best meet the varied needs of clients, broad-based and flexible interventions are provided, tailored to the individual’s own needs, with the aim of assisting clients towards recovery, stabilization of symptoms, and development of skills in relapse prevention. Program interventions are listed in Table 2.

Table 2
Components of Step-up Step down program

Community meeting

Clients and staff meet weekday mornings for approximately 20 minutes, to plan the day’s activities, discuss topics of concern and organise community events.

Psychosocial group

A staff-facilitated peer support/educational one-hour session conducted once a week with topics for discussion chosen by clients, such as sleep patterns, depression, medication, anxiety, and health and well being. Clients are given an opportunity to share their experiences and problem solve together.

Optimal Health

The Optimal Health program is a structured evidence based program (Gilbert et al., 2012) facilitated by a trained staff member, which provides clients with knowledge about their illness and supports them to develop personal self-management strategies. The program is run over four weeks, with the group meeting for one-hour sessions, two mornings each week.

Art/music group

A weekly class facilitated by an art teacher, on various styles of art and music. This program is individually tailored, with the teacher encouraging clients to explore their interests and giving support to individual project.

Personal Engagement

Staff provide one-on-one engagement and individual support for clients, with a focus on recovery goals, personal illness management and relapse prevention.

Social

outing

A weekly outing to a local venue chosen by clients. Popular outings include tourist attractions, museums and the lake, designed to give clients experience and growing confidence in being able to access parts of their local community.

Physical therapies

Clients are encouraged to participate in exercise programs at a level at which they feel comfortable, with options including daily walks with a key worker, using the available push bikes, or joining a local sport or exercise group.

Focused rehabilitation

Key workers provide support to facilitate rehabilitation and preparation to return to the community, including assistance with budgeting, learning to use public transport, shopping, developing a relationship with a local pharmacist, job and housing applications, and assistance with government departments.

Daily living activities

Clients are offered support and guidance in the development of basic life skills, such as meal planning, shopping, cooking, cleaning, and personal hygiene.

Communal meal

Clients and staff share an evening communal meal twice a week. Clients are supported to develop skills in meal planning, shopping, food preparation and cleaning up after the meal. The shared meal operates as a social experience for clients and assists in the development of a community atmosphere.

Community linkage

Clients are encouraged to form connections with community groups with whom they share common interests, and other community services that will provide resources and support; staff are available to help establish these connections.

Family support

Family members and carers are welcome in the program and clients are encouraged to maintain family and friendship connections. Family members are offered support, psychoeducation resources, and referrals to community support.

Alcohol or other drug (AOD) counseling

Staff are trained in AOD interventions and provide support to clients in this area. Clients with substance use problems are referred to suitable residential or community support services both during and as they transition from the program.

Transition plan
Transition planning is incorporated into each client’s support plan during the first week of entry, with clients and staff setting goals that clients hope to achieve during their time in the program. The locus of responsibility for treatment moves from the treating team to the client as the client progresses in the program towards exit. In addition to management of clinical symptoms, aspects of the client’s daily functioning are also considered as the transition date approaches, so that clients are able to self-manage their medications, domestic skills, daily routine and appointments. It is the goal of the service that at the time of exit clients will show clinical improvements, be well-engaged with appropriate ongoing clinical and psychosocial supports, and progressing the goals in their recovery plan.

However, at times a client may experience an escalation in symptoms while in the program and this is managed by all clients remaining clients of MHJHAD, which ensures immediate access to the public mental health community treatment team or readmission to an inpatient unit in the event of a crisis.

Pathways of care
Step-up and step-down clients participate in the same daily activities, however, there are differences in the nature and goals of the service for these two client groups. The goal of treatment for step-up clients is to stabilize their symptoms and reduce the length of untreated psychosis in, what is seen by some clients, a less stigmatizing environment than hospital. A recovery plan is developed with clients, with clear recovery goals and transitional steps to return to their usual place of living, and appropriate connections made to provide ongoing support in the community.

For example, a female client in her early 30’s had previously been admitted to the Step-up Step-down program after leaving the inpatient unit. Several months later she began to experience an escalation in psychotic symptoms, which on previous occasions had resulted in her being hospitalized, causing her considerable stress and disruption to the stable life she was trying to build for herself. Admission into the Step-up Step-down program allowed her to have 24 hour support while her symptoms were stabilized. Staff had previously assisted the client in obtaining supported employment, and she was able to maintain connections with her place of employment and continued to work occasional shifts. After a five week stay in the program, her clinical symptoms had improved and she felt ready to return home, receiving four weeks of outreach support to assist her to continue with her recovery goals while back at her home.

The goals for step-down participants tend to be more practical and functional, with a focus on preparing clients to return to the community after an extended stay in the inpatient unit. Although these clients’ symptoms are settling, they may not have achieved a level of functional recovery adequate for return to their usual living arrangements. For some clients, such as those with first episode psychosis, their stay in the inpatient unit may be shortened because of the opportunity to transfer to the residential unit for ongoing clinical observation and support. Key workers ensure that step-down clients are given support in taking on daily living tasks, such as personal hygiene, cooking and cleaning, and that connections with community support systems are established. Where possible, clients are encouraged as their exit date approaches, to sleep overnight at their own home and return to Step-up Step-down during the day, allowing clients to experience gradual gains in their confidence and their ability to cope with living in the community again.
For example, a client suffering from major depressive disorder had been an inpatient for several months, and as part of his continuation of care was offered the opportunity to stay at Step-up Step-down. The client’s symptoms were stable, however, he and his treating psychiatrist had concerns about him returning home as he had lived in a socially isolated area and there were concerns that his symptoms may worsen if he returned to a lifestyle with social isolation. The client stayed at Step-up Step-down for six weeks and was encouraged to develop daily routines of getting up at the same time, taking medications, attending morning meetings and activities, and participating in combined cooking events. Staff assisted the client to find new accommodation and supported his transition into his new home with outreach support and assistance developing community connections.

Cost effectiveness
In terms of cost effectiveness, the cost per day per client in the Step-up Step-down program is $517, compared to the average cost per client per day of $758 in public psychiatric hospitals in Australia (Australian Institute of Health and Welfare, 2011). Although there are daily cost savings delivered through the residential unit, there are community health costs that are not included in this, such as the continued clinical management and specialist support through the community mental health system. The treatment environments are also different, with inpatients provided with on-site medical and psychiatric care and therapy, services that are not provided on-site at the residential unit. The Step-up Step-down program operates at a cost higher than the residential service national average of $324 per day (Australian Institute of Health and Welfare, 2011) primarily because it provides 24 hour staffing, including two full-time social workers, a level of staff support higher than some other types of residential services. Although the cost savings are minimal, when the community health support costs and differences in treatment are considered, the sub-acute residential service does free up beds in the inpatient unit for patients with more serious mental health needs, offering a cost-effective alternative to the inpatient unit for some mental health clients. The Step-up Step-down program currently has five beds, and in addition to this a youth Step-up Step-down service opened in 2013, which provides an additional six beds for young adults aged between 18 and 25 years with mental health problems, to help meet demand for beds in alternative residential services.

What can be learned from the Step-up Step-down model?

Within the mental health continuum of care there is a range of services meeting different needs for safety, treatment, support, and advocacy across the many different types of individuals requiring mental health treatment. In Australia, there is an emerging trend to provide clients with residential treatment alternatives that can meet clients where they are at, either preparing to return home after a stay in hospital, or becoming unwell and wanting to avoid hospitalization. The residential unit is well suited to offering both the functional skills, capabilities and personal support systems tailored to the needs of inpatients leaving hospital in their transition back home, and also assisting clients who are becoming unwell to manage their symptoms, with the aim of avoiding hospitalization and returning to independent living. The Step-up Step-down model promotes both recovery and positive psychology approaches and offers an alternative to hospital, allowing some mental health clients a choice of services on the service continuum.

Strengths and limitations of this model
The Step-up Step-down model provides an individually tailored support service to clients, with peer support and the opportunity for clients to make social connections and to connect with relevant community services. Length of stay is fairly flexible, and a client’s stay can be extended if this will assist the client in making further gains in their recovery goals (although generally not beyond three months). However, there are limitations to the service. It is a small residential unit and if a client finds they are not fitting in to the environment, due to problems with a staff member or another client, then their stay in the program and the likely benefits they could receive are disrupted, perhaps by an early exit from the service. At times, the maximum length of stay is a limitation, as it can be difficult for people with a mental illness to find appropriate long-term accommodation, particularly in a supported setting if this is needed, and they may have benefitted from a longer stay at Step-up Step-down prior to re-settling in the community.

Conclusion
The Adult Step-up Step-down program provides both a transition service for inpatients preparing to return to the community and early intervention for people with mental illness living in the community. The service provides staff support, psychosocial, art and physical activity programs, and enables clients to establish links with external community programs. Further research is required to determine the effectiveness and value of such a service approach for clients, their families and the community, as community-based residential step-up step-down services potentially fill an important gap in a comprehensive mental health service continuum.
 

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