Discharge Planning Report

A Survey to Determine the Adequacy of Discharge Planning Process in Provincial Psychiatric Hospitals May 1999

Contents:
Introduction
Method
Results
Staff Responses
Community Agency Responses
Analysis
Conclusion

The quality of discharge planning is an important systemic issue for persons receiving inpatient psychiatric treatment. Patient advocates located on-site in 10 locations were asked to conduct a survey with patients who were being prepared for an imminent discharge. One-half of the patients interviewed were not satisfied with thedischarge planning process. Some of these patients stated they had no input in finalizing their service arrangements while others indicated they felt intimidated into accepting housing arrangements they did not want. The PPAO recommends that discharge planners work closely with patients to ensure a client-centred and patient-first process which addresses the individual's needs to the extent possible utilizing all available regional and community resources.

Introduction
In Ontario, psychiatric services are delivered through a variety of mechanisms including provincial psychiatric hospitals, specialty psychiatric hospitals, general hospital psychiatric units, community mental health programs, homes for special care, consumer/survivor initiatives, psychiatrists and family physicians. Individuals who are experiencing mental health problems may require access to any or many of these services throughout the course of an illness. There are times when inpatient care is needed, at other times, community-based care or a non-traditional approach may be what the person requires. The ability to access services when they are needed is an important factor in maintaining and enhancing an individual's mental health. Providing options and choices to the person in need of service and supporting them to achieve their goals is the foundation of a client-centred and patient-first system of care.

Provincial psychiatric hospitals (PPH) provide specialized care, rehabilitation and reintegration to individuals identified as seriously mentally ill. Most patients receiving services in a PPH are likely to be hospitalized for a significant period of time. For example, in the 1997/1998 fiscal year, patients averaged a length of stay of approximately 175 days. Further, patients are likely to have been diagnosed with either schizophrenia or an affective disorder (46% of admissions). The process for planning a discharge from hospital is a critical issue for patients receiving services from a provincial psychiatric hospital due to the importance of this process in determining the patients' quality of life when returning to their home community following a hospital admission. As well, effective discharge planning is vital to the patients' ability to remain well and out of hospital.

The Psychiatric Patient Advocate Office (PPAO) proposed to find out from patients their experience of the discharge planning process. This paper reports the results and tentative conclusions of the PPAO's patient survey. Included are recommendations intended to enhance discharge planning from a patients' rights perspective. We are aware that processes are evolving to improve hospital discharge planning processes. Our survey will assist planners to fully incorporate the patient's perspective in planning improvements.

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Method
Patient advocates located on site in 10 locations were asked to conduct a survey with patients facing an imminent discharge. Advocates used a series of questions based on factors identified by researchers as likely to lead to successful patient discharges if incorporated into planning. In anticipation that proactively speaking to patients about the discharge process would provide the patient an opportunity to raise advocacy issues, patient advocates were also asked to complete a short questionnaire with the hospital staff person to whom they were addressing the patient's issue. The staff's familiarity with the hospital discharge policies and procedures was felt to be an important first step in working with patients requiring discharge. Hospital staff were also asked to share their perspective as to whether patients were willing participants in the discharge planning process. In addition we asked whether staff members felt there were problems affecting the discharge process which were related to resource issues at either the institutional or community level.

Advocates also contacted several of their local community agencies likely to provide services to discharged PPH patients in order that the community provider perspective could add to our understanding of the issue. Agencies have a unique point-of-view of the patient's transition from hospital to community in that, traditionally, they have become involved in providing patient services at the moment the patient leaves the institution. We wanted to identify whether agencies felt adequately prepared to respond to the special needs of discharged PPH patients and whether agencies were knowledgeable about available follow-up services from the facilities. In light of hospital restructuring and the planned expansion of community-based mental health service delivery we wished to identify a tentative baseline of community agency participation.

The survey was conducted over a period of six months in 1998. In total, 180 patient surveys were completed, 35 agency responses were received and 10 staff interviews arising from instructed advocacy contacts were submitted for review.

Interview questions are listed in Appendix 1; Appendix 2 charts patient responses.

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Results

Patient Responses:

• 62% of patients interviewed indicated they had been involved in planning their discharge;
• 50% said they were dissatisfied with the preparations;
• 61% stated they wanted staff assistance in planning their discharge;
• 62% of patients stated that they were involved in choosing their housing;
• 42% reported they had visited their new home prior to their discharge;
• 67% of patients said they knew who would be providing follow-up services to them; and,
• 53-55% reported that treatment, financial and transportation arrangements were complete.

Some patients reported dissatisfaction with the discharge process because they were going to be discharged to a specific housing type, like a boarding home, that they did not wish to reside in because of the lack of privacy. We also heard from many patients who felt ready to leave the hospital long before their discharge actually happened; these patients complained of boredom and a lack of activities on the ward. Some of these patients also reported that their actual discharge took place suddenly and that they were made to prepare to leave hospital on very short notice. In addition to this, some patients reported feeling intimidated by staff to accept housing arrangements that they did not want. For example, one patient reported that the staff refused to assist with financial and therapeutic arrangements unless the patient agreed to a placement in a co-op living situation. Other patients said they wanted more choices when considering their housing options and more information about what other communities had to offer. We also found that some patients interviewed over the course of this project were discharged and re-admitted to hospital within the brief period in which we focussed on this issue.

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Staff Responses:
Some PPH discharge planners reported experiencing frustration in arranging patient relocations to the community. They found long waiting lists for the few local programs providing suitable services. One staff person pointed out that, in the past, if safe, clean housing was not available for the patient, staff could refuse to discharge. This staff reported feeling pressured to discharge patients to substandard housing. Some staff members felt their hospital's discharge planning policy did not clarify well enough the respective responsibilities of institutional versus community-based care givers. They also pointed out difficulties with respect to continuity of care and staff roles during any rehospitalization of the patient. We were also advised by staff that programs to teach patients, who have been hospitalized for an extended period of time, the skills necessary to live independently are not universally available.

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Community Agency Responses:
Community agencies reported an inconsistent reception to their efforts to link with PPH staff and patients prior to patient discharges. Only 13 agencies out of 35 indicated an agreement with the question: "from your perspective, were patients discharged to your program from the local provincial psychiatric hospital adequately prepared for their discharge?" Agency staff noted that they generally felt that discharged PPH clients required more structured housing than was available or better preparation in areas such as money management, medication management and in preparation for basic decision making. Agencies reported that they were not always informed when patients required special foods or specific support for behaviours or addictions. Most agencies reported that, with the permission of the discharged patient, they were provided with the names of contacts or follow-up services. Additionally, one agency reported that, from their perspective, patients were advised and consulted about the discharge process, but not supported in their choices if the choices were not accepted as viable options by hospital staff. One agency which had frequent contact with a specific hospital unit which most often discharged patients to their program reported a good working relationship with the hospital throughout the patient's stay, through the discharge process and beyond.

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Analysis
The Ministry of Health Manual of Operating Guidelines for PPHs states that each PPH shall:

The difficulty in extrapolating on discharge processes across the province is that there is neither a provincially mandated standard for providing a level of service, nor an equitable distribution of resources across all regions. Further, patients receiving PPH services are not a cohesive group with comparable characteristics or needs. They will also have experienced different levels of disjunction with their natural support systems.

We found that patient involvement in the planning process did not necessarily equal meaningful participation on the part of the patient. Patients reported they were involved, but that their input was not valued. We also found a high percentage of patients who reported that having choice in housing did not necessarily reflect satisfaction with the process in general; in some of these cases patients were offered a choice between unsuitable options.

Some of the problems and concerns reported by patients were that the process did not start soon enough, that it did not happen fast enough and that information about the actual discharge date was often kept from them. Alternatively, another group of patients reported that they did not want to be discharged from the facility because they didn't feel ready. A significant percentage of those surveyed stated that they were dissatisfied with the discharge planning process. The relatively low number of patients who visited their housing prior to discharge reflects, in part, that a number of patients returned to their own established homes. In some circumstances, patients were returning to a home community several hundred kilometres away from the hospital.

There are very complex issues facing PPH staff who provide discharge planning. The planner may be constrained by a forensic disposition order requiring a secure community setting for the patient offering 24 hour supervision. In those cases, the ability to offer a patient options or choices becomes secondary to locating housing which satisfies legal obligations. Further, staff, in their assessment of a patient's ability to function, may determine the patient is unable to manage independent living. A patient may be pressured to accept a communal setting regardless of the patient's wishes because such a setting is in the patient's 'best interests' according to the perspective of the care provider or a family member. In addition to this, staff may work as part of a team whose members have different views of the optimal setting to meet the patient's needs leading to conflicts and, perhaps, in poorly constructed discharge plans.

The agency responses provided us a snapshot of a system poised to change but still struggling. Community agencies identified a need for more partnering and consultation between themselves and institutional staff. Many agencies reported having a good relationship with the staff in their local PPH, or at least a relationship which was steadily improving. Agency responses, however, highlighted many areas where further collaboration between the three parties involved in the discharge is required in order to improve the experience for all.

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Conclusion
We initiated this project primarily to capture patients' views about their experience in leaving the hospital. We made two assumptions: 1) that a client-centred and patient-first discharge planning system would be one where patients said they were involved in the process and that they had a say in where they would live; and 2) that involvement in the discharge process and having a choice in housing would lead to patient satisfaction with the process in general. We found, in reviewing the comments of patients, hospital staff and community agency staff, that the basic discharge process does not meet a similar standard for every patient. Patient choice did not appear to guide the discharge process, rather the process is most likely to be framed according to the patient's best interests as determined by professionals or family members, or in turn, by legal obligations, resource limitations and fiscal pressures.

There are several issues on the horizon which will impact on the process and quality of discharge planning in PPHs over the next several years. PPHs will change governance structures prior to their planned closure dates, which will impact upon mental health service delivery in unknown ways. Given that the recommendations of the Health Services Restructuring Commission will result in a net reduction in inpatient beds regionally, hospital discharge planners may experience significant pressures to move patients into the community, whether or not appropriate housing and services are in place. While the government has announced funds for housing and community supports for psychiatric patients, there will be a delay in implementing new community placements and services. Further, new services must be evaluated prior to our reliance upon them.

The Psychiatric Patient Advocate Office (PPAO), a quasi-independent program of the Ministry of Health since 1983, provides advocacy and rights protection services to patients in the provincial psychiatric hospitals and the newly established Centre for Addiction and Mental Health Services in Toronto

The PPAO's reports, including responses to Health Services Restructuring Commission reports are available by calling 1-800-578-2343. General information about the program, our services and submissions in response to task force reports or proposed legislation can be found on the PPAO web site located at www.ppao.gov.on.ca.

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Appendix 1

Patient Questionnaire:

1. Patient involved in discharge planning process?
2. Patient satisfied with preparations for discharge?
3. Patient wants hospital staff assistance for discharge?
4. Patient had a say in where they would live?
5. Patient visited their new home before discharge?
6. Patient knows who will be providing follow up?
7. Therapeutic (treatment) arrangements are complete?
8. Financial arrangements have been made?
9. Transportation arrangements have been made?
10. Patient provided an instruction to the advocate?
11. Any other issues? Expand

Staff Questionnaire: (Instructed Advocacy) Staff Response to Patient Concerns

1. Discharge planning problem related to process issues?
2. Staff unfamiliar with hospital policy?
3. Policy is unclear?
4. Client is unwilling to participate in the process?
5. Discharge planning problem related to resource issues?
   Institutional resource?
   Community resource?
6. Expand

Community Perspective:

1. Does your program regularly provide services to patients being discharged from the local provincial psychiatric hospital?
2. From your perspective, were patients involved in the discharge process?
3. Was there a gradual transition of the patient from hospital to your community based program as required by the patient?
4. From your perspective, were patients discharged to your program from the local provincial psychiatric hospital adequately prepared for their discharge?
   
   If not, in what areas?
5. From your perspective, was your program adequately informed of any special needs or considerations which the discharged patient required?
   
   If not, in what areas?
6. Was your program provided with the name and telephone number (with the patient's permission) of the person providing follow-up services?
7. Expand

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Appendix 2

Patient survey responses All Responses = 180
Question	Yes	%	No	%	N/a	%
1. Patient involved in discharge planning process?	112	62.2	58	32.2	10	5.6
2. Patient satisfied with preparations for discharge?	91	50.6	77	42.7	12	6.7
3. Patient wants hospital staff assistance for discharge?	111	61.7	52	28.8	17	9.5
4. Patient had a say in where they would live?	110	61.6	36	20.0	34	18.4
5. Patient visited their new home before discharge?	76	42.2	37	20.5	67	37.3
6. Patient knows who will be providing follow up?	121	67.2	39	21.6	20	11.2
7. Therapeutic arrangements are complete?	97	53.8	48	26.6	35	19.6
8. Financial arrangements have been made?	100	55.5	37	20.5	43	24.0
9. Transportation arrangements have been made?	97	53.8	44	24.4	39	21.8
10. Patient provided an instruction to the advocate?	39	21.6	141	78.4	0	0.0

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RIGHTS - EMPOWERMENT - RECOVERY