Academic-State Hospital Collaboration for a Rehabilitative Model of Care

This report describes a component of a program that has assisted a traditional state hospital in shifting its focus from symptom control and custodial care to rehabilitation, wellness, and recovery. In 1998 the state of New Jersey and the University of Medicine and Dentistry of New Jersey (UMDNJ) entered into an affiliation agreement to improve the quality of care at a 550-bed state hospital. This unique multidisciplinary model has emphasized education and training to enhance patient care, including staff competencies, the therapeutic milieu and therapeutic communication, and effective discharge planning. Goals include improved functioning in unit and treatment teams, the fostering of individualized "active treatment," and a discharge-oriented recovery orientation. Active and sustained collaboration of hospital leadership has been essential.

One project has been a new 20-bed unit for extended-stay patients considered discharge resistant. The hospital medical director undertook transformation of an existing unit with a traditional, largely custodial orientation. The target group included patients who appeared unwilling to leave the hospital and some patients whose transfers had been rejected by outside agencies. This unit opened in July 2003, under newly recruited medical leadership. The affiliation's strategies included mentoring, training, and modeling recovery-oriented skills and attitudes; identifying individual discharge barriers; developing directed staff interventions; and assessing patient and staff attitudes and behaviors over time. The methodology incorporated established protocols such as Eli Lilly and Company's Team Solutions, the social and independent living skills modules developed by Robert Liberman, M.D., and illness management-and-recovery (IMR) groups, as well as novel strategies adapted for the perceived needs of the setting. Facilitation of successful discharge addressed the unique barriers for each patient. Skills for development encompassed identification and pursuit of individual life goals, improving frustration tolerance, interviewing skills, social and independent living skills, awareness of hopes and desires, personal responsibility, problem solving and independence, and reduction of cognitive symptoms.

Especially during the program's first year, university affiliation staff was a continual and active presence on the unit. Despite initial frustrations, including questioning of the feasibility of change for persons with serious mental illness, staff morale and cohesiveness developed over that year. The affiliation's supportive interactions with hospital and unit leadership, including development of academically oriented collaborations such as presentations and publications, further enhanced morale.

Development of the treatment team emphasized the need for cohesive treatment plans focused on patient-specific barriers to discharge and on identifying explicit roles for each type of professional on the team. Emphasis was placed on the therapeutic relationship and true staff-patient collaboration, on expanding the role of paraprofessional staff as fully contributing members of the treatment team, and on seeking to enhance programming previously filled with group activities that adhered to regulatory standards but often lacked a focus on the individual patient. Staff members were provided therapeutic communication seminars, weekly meetings with university faculty that focused on patient skills and deficits, and more intensive weekly individual supervision of key personnel to address discharge barriers. In addition to the informal interactions with staff around themes of individualized treatment, wellness, and recovery, structured efforts included supportive groups for patients who appeared resistant to discharge efforts, weekly discharge rounds, and the standardized methodologies noted above. Some of these (IMR and Team Solutions) were primarily community-based interventions that were adapted for the inpatient setting. Follow-up showed improved staff attitudes as measured by the UMDNJ Psychiatric Rehabilitation survey and MOOS Ward Atmosphere Scale and decreased patient intrusiveness as indicated by a novel Greystone Intrusiveness Measure (the "GIM"). The unit achieved some success in discharging the seemingly discharge-resistant patients, with discharge rates comparable to those of patients elsewhere in the hospital.

Successful discharge has resulted in placements of 57% of our specialized unit's patients into fully supervised group homes and 34% in minimally supervised or independent settings. Barriers to discharge have, in the interval, garnered increasing attention throughout the hospital. The principles underlying the unit are being applied in extending wellness and recovery strategies (such as widespread use of IMR groups and weekly discharge rounds).

Our work on the unit has led us to believe that rehabilitation- and recovery-focused treatment is possible in state hospital settings. The necessary shift is only partly procedural. It requires a cultural evolution involving beliefs, mores, and attitudes. Implementation of recovery concepts has involved a gradual, often subtle shift to providing services that assist each individual to experience hope, enhanced self-identity, and responsibility. The presence of a care-oriented multidisciplinary university team may have helped to model the transition as well as provide educational and consultative assistance.