Individuals receiving inpatient psychiatric services are often challenged by the transition from hospital to community. Preparing individuals for discharge is a primary aim of inpatient psychiatric services; however, there are often competing priorities and lack of programming to address the skills needed to succeed in the community. This transition between inpatient and outpatient care is a critical time, where individuals with mental illness must adjust to less structured living environments and more independent living opportunities.
The rate of rehospitalization of individuals discharged from hospitals with-in 30 days is high. Approximately 13% to 20% of individuals return to hospitals upon discharge due to poor access to community-based aftercare, poor environment, challenges in self-care, and psychiatric medication nonadherence (Heslin & Weiss, 2015; Kalseth, Lassemo, Wahlbeck, Haaramo, & Magnussen, 2016; Kinter, 2018). In addition, barriers such as housing, health, and employment issues are present in approximately one half of readmissions (Mark et al., 2013). These factors suggest an urgency to better prepare individuals receiving care in psychiatric hospitals for discharge.
Current trends in psychiatric hospital care suggest a shorter average length of stay than in previous times, which can lead to individuals being discharged with higher levels of symptom acuity (Babalola, Gormez, Alwan, Johnstone, & Sampson, 2014). In addition, there has been an overall reduction of beds in state psychiatric hospital systems with greater emphasis on community supports, community integration, recovery philosophy, self-management of illness, and independent living (Anthony, 1993; Davis, Fulginiti, Kriegel, & Brekke, 2012). Although the mental health system is adjusting to fewer hospital-based resources, community mental health services are challenged by a population that may be experiencing greater psychiatric symptoms than in past years (Lamb & Bachrach, 2001). Community support service providers have raised concerns about the independent living skill deficits that many individuals recently discharged from state psychiatric hospitals exhibit (Birkmann, 2014). Furthermore, there has been a call for psychiatric hospitals to provide interventions designed to improve readiness for community housing opportunities (Bhuiya & Wilson, 2016).
Existing programming in state psychiatric hospitals is often focused on psychoeducation or therapy groups with symptom reduction as the desired outcome. In addition, these hospitals may adopt a “private practice” model, where each facilitator independently defines curriculum and group structure, resulting in inconsistencies in skills teaching and outcomes (Snyder, Clark, & Jones, 2012).
Nurses and direct nursing staff are critical to therapeutic programming, as they provide significant care to individuals in state psychiatric hospitals and have a primary role in developing therapeutic relationships with service recipients. Nurses in acute psychiatric hospitals typically spend significant time teaching medication and symptom management, developing therapeutic relationships, performing assessments, and making discharge preparations (Myers, 2016; Seed, Torkelson, & Alnatour, 2010). Although little information is available regarding nurses in state psychiatric hospitals, it is likely that they share similar roles as nurses in acute settings with the added challenges of increased symptomology and longer lengths of stay. Positive relationships between nursing staff and service recipients are well documented to improve transitions to community care and adherence to follow-up care (Price, 2007).
Standardized community preparedness curricula are needed to ensure that individuals receiving services in the hospital learn the skills and knowledge necessary for continued community tenure in more independent housing. Despite this urgency, there are few evidence-based practices (EBPs) available designed for use in hospital settings to specifically address skills teaching for community living. Two widely available programs have been used. The Social and Independent Living Skills model demonstrated improvement in social skills through behavioral management techniques, and Illness Management and Recovery has demonstrated efficacy in reducing rehospitalization following discharge (Bartholomew & Zechner, 2014; Liberman, Glynn, Blair, Ross, & Marder, 2002). Although these programs address social skills, goal setting, and illness self-management, they are not specifically designed for knowledge and skills needed to transition into community housing. There have also been nursing projects to improve this transition, such as a pilot study examining the impact of follow-up telephone calls from a hospital-based advanced practice nurse to encourage medication and appointment attendance (Price, 2007). However, the current authors were unable to locate nursing programs in the research that focused on the knowledge and skills needed for transition between state hospital and community. Therefore, inpatient-specific teaching curricula are needed to address these deficits and prepare individuals for discharge into the community.
Previous work in this area has targeted individuals with mental illness living in the community as well as individuals at risk for homelessness. The Substance Abuse and Mental Health Services Administration (SAMHSA; 2010) developed a toolkit, Permanent Supportive Housing: Tools for Tenants, which was designed to help communities develop permanent independent housing for individuals with mental illness. This toolkit is in the public domain, offers an evidence-based approach with a systematic implementation plan, and includes brief handouts for individuals served (SAMHSA, 2010).
The toolkit provides a helpful overview aimed at assisting individuals in choosing, finding, and keeping housing options, and it includes eight general tools needed to achieve permanent community housing (Table 1). These tools contain some relevant information for individuals receiving services in psychiatric hospitals; however, the original material was developed mainly for individuals already living in the community, whose needs and challenges are different than those in an inpatient setting working toward discharge. The toolkit offers information about supportive housing, yet individuals receiving services in psychiatric hospitals are often discharged into a range of housing placements. Therefore, information regarding housing choices and levels of support must reflect the diverse range of housing options available to an inpatient population. In addition, the Tools for Tenants toolkit was not designed to be a stand-alone program or presented in a group format (e.g., no curriculum, lesson plans), thereby making it difficult for group facilitators and group participants to use in a hospital setting.
Description of Original SAMSHA Tools for Tenants Curriculum
Although the gold standard in the treatment of mental health conditions is to use EBPs, there are often unique challenges in implementation of EBPs and specific populations. Adaptations are at times required to better serve target populations (Chen, Reid, Parker, & Pillemer, 2013). It is common practice to adapt EBPs. In fact, there are many examples of effective adaptations of EBP materials within the mental health system (Blank Wilson & Farkas, 2014; Foshee et al., 2015; Mullen et al., 2017; Osher & Steadman, 2007). Osher and Steadman (2007) reported reductions in rehospitalization and recidivism in the criminal justice system with an Assertive Community Treatment team adapted for the forensic population. Another example in the forensic system explored an adaptation of Integrated Dual Diagnosis Treatment targeted to young adults with substance use and mental health diagnoses, which combined multiple types of services into one holistic program (Blank Wilson & Farkas, 2014).
One state report documented community mental health service providers' perceptions about skill deficits of individuals being discharged from state psychiatric hospitals and provided several recommendations to improve the transition between hospital and the community. These recommendations include: (a) increased focus on community living skills, (b) more rehabilitation-oriented skills, and (c) empowering individuals to make more person-driven choices that reflect the responsibilities of living in a community residence (Birkmann, 2014). Individuals receiving services from state hospitals experience significant skill deficits related to illness and the iatrogenic effects of long-term treatment, which impact community functioning, such as social skills, communication, household chores, transportation, and managing finances (Bellack, 2004; Patterson, Goldman, McKibbin, Hughs, & Jeste, 2001; Spaulding, Montague, Avila, & Sullivan, 2016).
To facilitate discharge and improve community housing skills, university consultants developed a community skills training and discharge readiness program adapted from the Tools for Tenants toolkit. The current article describes the development of a new curriculum, Tools for Moving On (TFMO), targeted to individuals receiving services in psychiatric hospitals to increase knowledge and readiness for discharge to community settings.
The TFMO curriculum was adapted from the SAMHSA (2010) evidence-based Tools for Tenants toolkit. The objectives for the project included expanding the skills needed for community living and improving awareness of local housing options while maintaining the core recovery-oriented philosophy of the original materials. The modified curriculum included a participant manual, self-assessment, and facilitator guide with structured, topic-specific lesson plans, location-specific resources, and strategies for collaboration between staff and participants. Best practice strategies for implementation of new programs often include standardization of participant and facilitator guides as well as a standardized procedure and protocol (Powell et al., 2012).
The process of adapting the materials into a new manualized curriculum included several steps: (a) informal discussions with hospital staff responsible for discharge preparedness groups; (b) review of existing scheduled groups within a U.S. northeastern state psychiatric hospital; and (c) adapting existing materials and expansion based on the critical skills and tools from staff suggestions and literature review.
Two coauthors (J.S.S., M.R.Z.), who are university consultants at the hospital, met informally with social service providers in a U.S. northeastern state psychiatric hospital as part of ongoing discussions regarding programming to discuss TFMO and identify their perspectives on skills and knowledge areas most needed for discharge preparation. In addition, the knowledge gaps that impact discharge most were explored. Existing group names and protocols were collected from social service providers and online group programming catalogues and reviewed by the primary author (J.S.S.).
Although the SAMHSA toolkit is considered an EBP, as stated earlier, it was designed for the development of permanent supportive housing for individuals already living in the community, not those in inpatient settings. It was difficult to use the original toolkit in the hospital without modification because of the unique resources and environment. The curriculum needed to be expanded to include topics relevant to individuals receiving services in a psychiatric hospital and to address the challenges identified by staff and community stakeholders. Language also needed to be simplified and lesson plans and activities developed to offer the curriculum in a group format. The authors reviewed the existing toolkit to identify the most relevant tools for individuals receiving services in a psychiatric inpatient setting.
A comprehensive review of the SAMHSA toolkit led to the identification of topics to be included and expanded in the TFMO curriculum. From the eight original tools (Table 1), four topic areas were identified for expansion: housing choices available, housing preferences, tenancy skills, and support needs (Table 2).
Description of Modified Curriculum for Tools for Moving on
Previously collected feedback offered by community housing providers (Birkmann, 2014) and from literature review (Bellack, 2004; Patterson et al., 2001; Spaulding et al., 2016) highlighted skill deficits in housing and community living domains among those discharged. Examples of the skills needed for community tenure included: successfully living with roommates, budgeting, understanding tenant/landlord responsibilities, and accessing supports and resources in the community. Informal discussions with hospital staff responsible for providing discharge preparedness programming identified recommendations for improved discharge readiness materials. In particular, lack of discharge-specific group materials and the frequent repetition of existing groups offered were noted. Concerns regarding practical usability of materials and appropriateness for a range of cognitive abilities were also raised.
The review of existing programming identified significant variability in the curriculum and materials used for the groups based on individual facilitator preference and acuity of individuals attending the group. Further, much of the existing group-based interventions used primarily psychoeducation groups and a didactic approach. Few of the existing discharge readiness or preparation groups used EBPs or a standardized curriculum at the time of review.
Using the review of the SAMHSA toolkit and information from hospital staff and community providers, two coauthors (J.S.S., M.R.Z.) adapted the original materials to develop an engaging and standardized manual to address the unique needs of individuals served in an inpatient psychiatric hospital to prepare for community living. Each topic area was examined to create level-of-care specific language and modifications to content to increase relevance to discharge readiness while incorporating the philosophy and spirit of the original materials, namely strengths and recovery orientation. In addition, the authors considered theories of adult learning and Universal Design for Learning principles and provided multiple means of representation to increase comprehension, options for action and expression to allow for varying skill levels and functioning, and several means for engagement to sustain the motivation for learning (CAST, 2018; Rose, Gravel, & Gordon, 2014). Specific group strategies for engagement included interactive questions, discussions, experiential activities, role play scenarios, skills teaching, and practice opportunities for each topic. Information was chunked into easy to follow sections and the manual was designed in a visually appealing way—ensuring adequate white space on each page; intentional use of color, font styles, and sizes; images and icon-like symbols to designate page sections; page layout; and readability of materials (Rotundi et al., 2007).
Adapting an evidence-based curriculum for hospitalized individuals is a promising strategy to address gaps in programming and improve skills for community living. SAMHSA's (2010) Tools for Tenants describes a model for developing permanent supportive housing, which is not currently in place in all U.S. states. The program was designed for individuals already living in the community, as an individual interaction, and as a guideline for state-level housing administrators to expand housing options for individuals with mental illness. Participant handouts in the original toolkit were only a small portion of the program.
The curriculum, however, offered excellent community living skills assessments and strategies that are beneficial to individuals with mental illness. This focus on community living skills is particularly useful for individuals transitioning back to the community from a long-term inpatient psychiatric setting. However, the existing format was not conducive to group facilitation and lacked practical implementation strategies, such as session goals, lesson plans, group protocol, and a facilitator guide. In addition, the original content did not address the specific needs of individuals in a hospital setting, including an understanding of the continuum of housing choices available or the hospital discharge process.
The authors adapted the curriculum to address the unique needs of individuals preparing for discharge from a state psychiatric hospital. The content and presentation were novel for group participants as well as staff facilitators using the materials. Adapting an evidence-based curriculum to meet the needs of a target population is common practice. Evidence-based curricula are often developed for a specific population and can be modified to fit other settings and environments. Nurses working in mental health settings have begun to address the challenges of individuals being discharged from state psychiatric hospitals. In addition, a call has been made to expand evidence-based nursing interventions to improve outcomes for individuals with serious mental illness (Alzayyat, 2014), suggesting this area is ready for additional nurse-led interventions for discharge preparedness.
Certain adaptations may dilute or reduce effectiveness of an EBP. To maintain the fidelity of a program, the core components of an EBP (i.e., content, pedagogy, and implementation) must not be altered in ways that would produce different outcomes than the original program. In addition, when adapting an EBP, it is imperative to identify adaptation challenges, address fidelity concerns, and ensure that all adaptations are meant to make the EBP more relevant to the target population. Lastly, any adaptations to an EBP should be piloted and monitored on a subgroup of participants before full implementation (Administration for Children and Families, 2018). Discharge readiness programming is traditionally offered by social services or rehabilitation and is not inclusive of other disciplines, particularly nursing. Nursing staff are best positioned to address the significant health concerns that can impede successful community living.
The adapted TFMO curriculum will be piloted across all state psychiatric hospitals in one northeastern state and will be offered in place of existing pre-discharge or goal setting groups currently offered by social service staff. A pre/post knowledge assessment will be conducted in each group to measure knowledge acquisition of group participants before and after the intervention and 1 month later to assess knowledge retention. Upon completion of the pilot groups, focus groups will be held with facilitators and group participants to obtain a more qualitative description of their experience with the new materials and adapt them as needed based on that information. Future research on TFMO will focus on measuring housing placement data post-discharge, including housing retention, satisfaction with housing, and rehospitalization rates. Additional modules related to community living, including health, safety, and wellness materials, will also be developed to support successful community discharge. Finally, strategies to include nursing staff will be explored to ensure all areas of independent living are addressed.
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Description of Original SAMSHA Tools for Tenants Curriculum
|Original Curriculum||Description/Goal of Tool|
|Tool 1: What is Permanent Supportive Housing?||Provide an overview of permanent supportive housing and describe ways in which housing staff can assist in finding, applying for, and keeping housing in the community.|
|Tool 2: How Can You Afford a Place of Your Own?||Provide an overview of different financial supports available to help individuals with psychiatric disabilities retain housing.|
|Tool 3: Your Housing Preferences||Assist individuals in identifying what is most important to them in their housing choice.|
|Tool 4: What is a Lease?||Describe what a lease is and explain tenant rights and responsibilities.|
|Tool 5: Your Support Needs||Explore what supports are needed to keep housing in the community.|
|Tool 6: Being a Good Tenant||Provide an overview of what it means to be a good tenant and the responsibilities of maintaining a home in the community.|
|Tool 7: Time to Move On?||Describe the steps involved in leaving a house (i.e., notify landlord with plenty of notice, repair any damages, and clean).|
|Tool 8: Fair Housing is Your Right!||Describe the federal laws in place for housing for individuals with disabilities and reasonable accommodations for individuals with special needs.|
Description of Modified Curriculum for Tools for Moving on
|Modified Curriculum||Description/Goal of Tool|
|Tool 1: Housing Choices in this Northeastern State||Provide a broad overview of the levels of housing in the state and what services are offered, describe the key components for applying for housing while in the hospital, identify an individual's rights and responsibilities during the process, and introduce several population-specific housing providers to individuals.|
|Tool 2: Housing Preferences||Assist individuals in exploring likes, dislikes, and interests to discover and identify their personal housing preferences and prioritize personal choices to develop a personal housing goal.|
|Tool 3: Tenancy Skills||Provide an overview of what it means to be a good tenant and/or roommate, explore tenant/roommate and landlord responsibilities, discuss personal safety in community living, and learn skills for communicating needs to others.|
|Tool 4: Support Needs||Assist individuals in identifying skills needed for living in the community, identify existing supports, and develop a plan for getting support and accessing resources while in the community.|