Meet the New Nursing Management Team

         Pomegranate announced an updated nursing management infrastructure recently. Under Pomegranate’s new Director of Nursing, Melveena D. Edwards, PhD, RN, BSN, MA (with significant psychiatric nursing experience),  three nursing supervisors were named: All have demonstrated psychiatric nursing proficiency and supervisory experience.  The new structure includes a supervising nurse manager, Thomas Engram, RN, whose focus is management and support for nursing and care staff in both the acute hospital and residential treatment setting across all five wings. Pomegranate employs over 200.  

          Edwards explained the new nursing model, ‘Nursing C.A.R.E.S’, which stands for: compassion, accountability, respect, excellence and service. The inspiration behind the model is Watson’s ‘Ten Carative Factors’.  “The DON will assume a more educational focus to promote excellence, innovation and change management encompassing evidence-based practice.  There are now rounding nurse huddles, a greater reliance on strategy, data collection and statistics as well as documentation. When a resident/patient is admitted, he/she is assigned a therapist and a CPST (psychiatric case manager) and now, his/her own nurse.  In addition, nursing is assuming a more prominent leadership role as part of the enhanced corporate-wide emphasis on trauma-informed care,” said Angela Nickell, MS, CEO.

           At the October 2015 All Staff meetings, nursing supervisors presented an updated and more thorough trauma-informed care module which will be expanded upon in small group sessions with participation of Pomegranate’s compliance/quality improvement manager, Kia Brown, LPN.  Nurse Engram, the presenter, shared statistics that ‘90% of public mental health clients were exposed to trauma and most to multiple experiences of trauma.’  He explained that the effects of trauma predispose a client to maladaptive coping mechanisms such as the body’s natural alarm system not functioning as it should -which can result in a diminished capacity to trust others and affect an individual’s sense of safety.  A maladaptive response might include the survival mode of fight, flight or freeze with rational thought less possible. A client might experience hyperarousal or shutdown mode.

             According to Nickell, “along with the nursing infrastructure update, an intake social worker is joining the acute admissions team due to Pomegranate’s growth and quality enhancement initiative.  The exam room is being renovated and updated with an enhanced focus on patient and family care upon admission, with a streamlined entry process in the works.  Nurse Tiffany Folmar RN was named residential UR/admissions manager as Valerie Nutter transitions to the business development & marketing team as customer relations manager.  This will continue to contribute to our positive, safe and therapeutic environment in building professionalism, enhanced therapeutic communication, rapport, and patient advocacy as Pomegranate continues to look toward the future.”

Can teens recover? Do Pomegranate teens make it? YES!

Within the past two weeks we’ve rejoiced with three client success stories. It goes without saying that working with behaviorally challenged teens sometimes presents the team with opportunities to exercise patience and use every skill they’ve been taught. And then, there are the success stories, the kind that make faces beam with pride and eyes mist. [The teen and her mother interviewed here completed a media release and wanted to share their experience with others.]

For 16 year old Isabelle and her mother, Samantha, ‘Pomegranate is a little diamond in the rough. We hadn’t heard much- if anything- about it.” Isabelle explained that ‘It’s sometimes about being an example for other people. It’s important to share good things about my healing journey, and to give them hope.’ Both women agree that, “recovery is a lifetime process,” and they could not be more pleased with this outcome. Isabelle was treated in Pomegranate’s acute hospital. In appreciation, she created abstract artwork for Valerie in admissions, Tiffany-CPST, and her therapist, Brandi. The transparent overlays of colorful shapes are reminiscent of stained glass windows. The two returned on a steamy July day to express their thanks.

Client A.R. wrote us on Facebook. [Because of the HIPAA privacy act and under 18 population, we do not feature an open forum.] A.R.’s learning opened a new world to him. He says, “My name is —- and I was one of your recent patients. I want to thank you for your treatment and services. It has changed my life so much (that) words can’t explain how happy (I am) and set on my future. I love life, and your facility is the best thing that has ever happened to me. I am at a positive stage in my life and have goals for the future. I thought to myself when I got out of Pomegranate that I wanted to help people with their life problems such as: stress, anxiety, depression, PTSD, suicidal thoughts, and cutting problems. I am only 17 but I have (begun) my first goal and dream in life. I have written a biography of my life and it includes information of how I have used my coping skills, and how to view the better part of life. I include information about setting goals, finding natural remedies for treating stress, anxiety, depression, and PTSD- the main, most common source of all of those symptoms.”

AR want to share the proceeds from his book “as a way of saying thank you for the wonderful treatment and help that Pomegranate Health Systems provides to the youth who need the help and treatment your company has to offer. I was really impressed with how life-changing your system is. Thank you . . . “

Another resident who came to Pomegranate through the Department of Youth Services celebrated her high school graduation, and plans to go on to college and career. https://twitter.com/OhioDYS/status/617709815171805184

At  Columbus State for the mental health resource fair last  year, a transition age young adult visited our table.  We asked if he’d heard of Pomegranate and he said he’d lived here- it helped change his life significantly for the better.  For many, it comes down to learning new skills and making the right choices. Without that interval of intensive daily therapeutic intervention, outcomes may not have been as positive. We congratulate all our teens and wish them the very best wherever they are in their journey.

Teens take art to new level

Art therapist Darci, ATR works with Pomegranate’s teens in the acute hospital to explore memories, moods and dreams as part of the therapeutic process.  CPST Ruthie brings her art background to encourage teens on Pomegranate’s five residential campuses to express themselves through art-which can include painting, drawing, knitting and assorted arts & crafts.  A guest on tour recently was exceptionally impressed at the emerging art in residential day rooms, corridors and meeting rooms. Afternoon light streamed in and the murals glowed- while teens alternately finished up their day in the classroom, went to the gym, watched a movie for group discussion, or were scheduled for a short quiet period. The entire facility continues to evolve and improve aesthetically with unique and interesting murals and art creations.  In addition to the Madison County 4H contribution to the cafeteria, Pomegranate’s own teens designed their day rooms, mixing their own colors and diligently painting their hearts out across all 5 wings.

“The residential art program gives teens the opportunity to learn to make decisions and control the process, to learn from their mistakes. They can still have a success even with a ‘mistake’-and teens learn to focus on the process, not merely on the outcome.  Art touches all the intelligences; you can teach almost anything through art.  As creators, each child has a different goal; and it is cool for them to discover and share their perspective.  I have them acknowledge what skill they learned, and how to practice it.  It is more than just making art, however. I ask, ‘What do  I need to do to move them along the healing process?’  They’re craving this SO MUCH,” explained Ruthie.  A client said to her, ‘I wouldn’t ever be painting. I wouldn’t ever be knitting if it wasn’t for you.  Its helped me realize  I can create something meaningful. Thank-you! Thank-you!’

Currently, in process:

• The Celso unit mural is an ornate elephant, blowing colorful bubbles through his trunk.
• The Kennedy unit mural has a woman lying in the grass with emerging flowers.
• The Sathappan unit mural features super-heroes.
• The Meena unit mural features random designs.
• The Kaufman unit mural has well-known icons-like Mario or Popeye.

Teens have now painted inspirational sayings in the gym, and plans are in the works for additional corridor enhancement. You can see all the individual paint cups representing the inspiration which contributed to a beautiful outcome. Beauty is more than skin or surface deep! It changes attitudes and inspires hope.

See previous posts:

http://pomegranatecares.com/2011/06/30/unlocking-feelings-through-art-as-a-therapeutic-tool

Pomegranate to offer acute outpatient services

 “We are very excited to announce that we will start scheduling out-patient appointments for our acute hospital the week of January 26^th,” said Angela Nickell, CEO in a memo that went out to staff. “Unit Clerk, Phatima, will be scheduling the appointment while the patient is still in Pomegranate’s acute hospital. Phatima will coordinate the out-patient consent forms with the nurse who discharges the patient from acute.  It’s important for the parent to sign the out-patient consent,” explained Nickell.

“Our acute hospital serves to stabilize adolescents who suffer suicidal or homicidal ideation or psychosis. The purpose of the transitional outpatient treatment space is to provide follow-up psychiatric care and medication management for Pomegranate’s acute hospital patients. With the scarcity of available psychiatrists (who are often booked for months on end) it became necessary to offer pharmacological management to maintain continuity of care for our patients,” explained Nickell.  “Appointments will be welcomed and the Google calendar maintained by Stephanie, in coordination with the nurse practitioners and psychiatric services team, as scheduled.  The NPs will then be scheduling follow-up appointments. The medical software system has been updated to reflect the change,”  she said.

The outpatient office is located off the administrative corridor and will be fully equipped.  Initially, outpatient appointments will serve Medicaid patients until contracts with private insurers are  completed, and in place.  Pomegranate is also adding a bed availability e-mail notification system for area referring sources. ‘We’re asking that referring ED personnel provide an e-mail address to be contacted,’ said Nickell.  This will allow us to provide optimum service for exceptionally busy emergency departments, counselors, and pediatricians.  ‘All our admissions forms –acute and residential- are in the process of being updated and will be uploaded to our new website by February. This is an ongoing continuous quality improvement initiative aimed to streamline our processes and make it easy for all our referring agencies,’ she concluded.  “Recent feedback has been quite positive with 93% rating the admissions process good to excellent.  We track and benchmark patient, parent, and caseworker feedback via survey which is then translated to appropriate change as needed.  Outcome measures matter,” added Kia, LPN, compliance and QI manager. “From actionable data to results: It all makes a difference”.

Identifying, Treating and Preventing Teen Violence

At the recent Cincinnati Children’s Pediatric Mental Health Conference, Drew Barzman, MD presented a workshop on “Violence In Our Schools: What Can We Do”. Barzman offered a definition of school violence, ‘Violence is a person’s or group’s behavior or language that causes another person to become hurt, physically or psychologically. It can include assaults-physical fights or attacks with guns or other objects, bullying, extreme teasing, or physical or emotional intimidation- taunting or name calling, for example. Violence can be directed against students, staff, or teachers and can occur at any time of the day or night.’ And, as we’ve seen violence may extend to cyber-bullying according to some definitions.

Dr. Barzman opened his presentation with some clinical examples. In one example a 12-year old girl is referred to (your) outpatient clinic for threatening to kill the teacher and other students. She’s made drawings and is obsessed with violent video games. She has witnessed extreme violence in the past and her parents are divorced. Is she at risk for school violence? Father does not believe in mental health treatment; does come to appointment; they deny any psychiatric symptoms or concerns. There are no easy answers and responses will vary by school, by district, by region, by provider.

This portion of the workshop was then supported by statistics: “Children and adolescents were involved in 12% of violent crimes in 2007. (Puzzanchera, 2009); and in 2008, there were 2.11 million arrests of children and adolescents in the United States. For many adolescents, exposure to violence or contextual socio-demographic factors- poverty, environment- is a leading cause of violent behavior; not mental illness. Pediatric violence is a common and major public health problem that increases the risks of drug and alcohol abuse, violence in adulthood, abusive parenting, suicide, and incarceration.” (Tremblay et al, 2004).
Barzman continued, ‘School violence is difficult to predict. It’s difficult to predict when and whether an individual will complete and violent act versus empty threats.’ Children and adolescents account for 12% of violent crimes in 2007; 33% of students report being in a physical fight and 6% brought a weapon to school. He then discussed characteristics of school shooters: age 6-18 but most between 14 and 15 years old; male; almost always white; isolated-loner. As we’ve seen in last week’s shooting in Washington, the perpetrator was popular and did not fit the stereotype. The motive of the shooter is ‘to punish those who bullied, taunted, rejected or shamed.’ There is a precursor- ‘threat of violence- all said what they were going to do prior to (the) act.’ Personality traits include anger, hate, depression; a strange sense of humor. There may have been suicidal threats, discipline problems, psychosis and violent writing or drawings according to Verlinden et al, 2000.

Risk factors in the family include ‘authoritarian childrearing attitudes, conflict, violence, harsh, lax or inconsistent disciplinary practices, lack of involvement/supervision in the child’s life, low emotional attachment to parents or caregivers, lower parental education and income, parental substance abuse and criminality, poor family functioning, monitoring and supervision of children.’ Coupled with access to firearms, violent video games, media and/or music, it takes very little to trigger a teen explained Barzman. (Verlinden et al, 2000) Community risk factors include poverty, diminished economic opportunity, transiency, high levels of family disruption, low community participation, and social disorganization. The conclusion is that many students could potentially be violent, but it’s nearly impossible to predict, even with red flags.

The latest mental health information is often not shared (or cannot be shared due to HIPPA or lack of parental consent). Barzman explained that often ER personnel are not trained to do forensic psychiatric assessments, and psychiatric intake response personnel are not comfortable evaluating school violence. There is a duty to warn the guardian of a threatened student, or to hospitalize a child; to admit the teen to the ER to protect both. Cincinnati Children’s is working on a school violence risk assessment tool to assist schools in preventing aggression -as has been done with suicidal ideation. Using computerized interview and school safety system using natural language processing, this tool will help to prevent aggression, hospitalization, arrest and suspension. Identifying and preventing violence is a fluid and changing art- more than a science, with many school authorities banning apps, changing policies, even banning backpacks. There are no easy answers.

See: http://www.nbc4i.com/story/27375507/nbc4-investigates-violence-in-central-ohio-schools

[‘Social-media posts] prompt backpack ban’ The Columbus Dispatch Metro & State, Tuesday, November 11th, 2014

[Photo credit: Alptraum/Dreamstime 4318225 Teen in handcuffs]

Teen Cyber-life, Risky Business and Parent’s Role

At the Cincinnati Pediatric Mental Health Conference held earlier this month, Stephen J. Smith, Director of Educational Leadership with CBTS [Cincinnati Bell] delivered a workshop on social media and responsible technology. He addressed technology and the family, and the cyber-crime economy. Two of his slides really captured the visual impact of what has happened in a life-time. Using overlapping circles representing mom, dad and child, he showed a photo where the family would gather in the living room to hear radio broadcasts after dinner in the 1940’s. The 2014 circles are almost completely separated, representing mom, dad and child with a plethora of social media options and digital devices surrounding them. They are ‘tuned in and tuned out’- tuned in to the media; tuned out with each other, unlike the shared, and bonding experience of prior decades.

Teens have ‘NO idea of online privacy and there is a pervasive FOMO- fear of missing out. If parents are addicted to technology too, that is not communication. Technology is supposed to help us, but it can hurt our ability to communicate with those we love most in a data driven society,’ he said. As a result of the digital revolution, there are some ‘not so good behaviors’: “49% teens have posted something they regret online; 50% of teens posted their email address online; 30% posted their phone # online; 14% posted their home address; 45% would change their online behavior if they knew their parents were watching, but unfortunately only 15% of parents track their teens using location services on their mobile device” (according to McAfee Blog Central). Smith described how sexting, privacy and bullying are inter-connected and sadly, apps never forget and can go viral- as we’ve seen with the recent Snapchat debacle where illegal photos were retrieved and implicated a predator who cultivated an illicit sexual relationship with a teen.

Smith explored categories of apps- for media, texting, dating, or anonymous hook-ups. After lights are out in many households, “teens send an average of 34 texts a night”- after going to bed in a study by JFK Medical Center in Edison, NJ. Children’s cell phones should be gathered and locked up until morning advocated one psychiatric expert. Smith shared an alarming quote from a predator who said, ‘I could go on it (Kik app) now and probably within 20 minutes have videos, pictures, everything else in between off the app (Hit Me Up) because I know they’re both still active. That’s where all the child porn is coming off of.’ Another app to be concerned about is the hook-up app, ‘Tinder’ . . . where 7 percent of users are between 13 and 17. OkCupid, and YikYak chat are other potentially risky apps, and Ask.fm was implicated in the suicide of a 14 year old girl in 2013 because of social bullying. The teen chat site, ‘Tagged’ was implicated in ‘sextortion’ against teens. Another bullying (stabbing) incident in the media recently, centered around a fictional character ‘Slender Man’, connected with the Creepypasta.com and SoulEater.com web series and You Tube.

JAMA Pediatrics released recent statistics which Smith cited: 28% of teens had sent nude photos; 31% asked for them, and 57% were asked to send them. Among college students 46% sent sext messages with pictures; 64% received. This raises legal questions and implications of being charged with child porn. Many teens unwittingly wind up in a web of illicit activity and the most frightening thing is how vulnerable they are, posting birth date, interests, relationship status, real name- and up to 24% post videos according to a PEW Research report. Gone or deleted is NOT- user data escapes all the time, even from discarded old phones and digital devices supposedly wiped clean.

Another harmful social media trend is sub-tweeting, or making implications about an individual in a new form of cyber-bullying. They don’t have to name you, but you’re identified by a characteristic. Smith urged parents to control the password for downloading apps, monitoring online time, using monitoring tools, and securing your child’s accounts. He cited awiredfamily.org as one source for more information. Hamilton County Prosecutor Jennifer Deering closed the workshop by talking about how Ohio has no cyber-bullying law and no sexting law. The problem of the law is that you have to prove intent to annoy, harass or embarrass and sometimes the minor who posted a video merely thought it was funny. By using examples in the court room, a child is re-victimized. Recently parents were held liable for a fictitious account created by their daughter to bully another teen. See Smithsonian link below. Pomegranate teens are not allowed to bring cell phones to the facility during treatment. (See acute and residential patient handbook-on the website, http://www.pomegranatehealthsystems.com).

What to do in a mental health crisis

Parents, peers or guardians need to know what to do when a situation gets out of control and a teen poses a danger to him/herself, or others. To move a child or teen past a crisis to a safer state and safer place you may need to call for outside help. If you need help to calm an adolescent, prevent violence, suicide, destructive behavior, a runaway situation, or criminal behavior, it is advisable to call a crisis line (such as Netcare 614-276-2273), or law enforcement for intervention. Be specific. “Don’t be afraid to make the call and take the situation seriously,’ advises Rosetta Cowan, Director of Nursing at Pomegranate Health Systems. Cowan’s experience includes many years of psychiatric nursing at Netcare Corporation and Ohio Hospital for Psychiatry. “Take threats of suicide or harm against others very seriously and don’t try to ‘cover’ for a suicidal friend or family member.”

You will be asked for some basic and very important information such as the teen’s name, age, and parent or guardian’s name, and contact information- such as street address, and phone number. Cowan advises that it is also helpful for crisis responders to know of any diagnoses. Has a teen been diagnosed as autistic, or schizophrenic? Does he/she have a medical condition, or any allergies? Is the child on any medications and what doses? Did the teen take alcohol, drugs, or other unknown substances? Is there anything special which helps to calm this teen? Does he/she need medical care or to go to a hospital emergency room or crisis facility for evaluation? Is a police station, or detention more appropriate? Is it more of a situation where an outside authority calming and reasoning with the teen will make it possible for him/her to remain at home? If so, who will be providing assistance going forward?

Many law enforcement providers and first responders have been trained in crisis intervention. They are known as the ‘C.I.T. team’. The most important thing first responders do is ‘triage’ or assess the situation. The first responders need to secure the scene; quickly establish control, and make sure the setting and the people are safe- whether it is a medical, fire, psychiatric or criminal emergency. It is important to be calm and provide facts to help those responding. It’s also very useful to provide any helpful information: “Our son may be off his medications”; “Our daughter may have taken some pills someone gave her”; “Our stepson goes ballistic when you get near him”; “We think our niece needs a psychiatric evaluation she is so depressed”; “Our grandson is threatening people, and we’re scared”.

Meet the first responder and tell them you made the call for help. You may wish to have a back-up family member or trusted person who can help you through the situation and/or let them know who the teen’s pediatrician or family doctor or counselor is. You will need to stay with the child or youth until the crisis is resolved whether the teen goes to a hospital, crisis center, or police station. Your child will need an attorney in the case of an arrest. The most important thing is for the teen to receive the treatment he/she needs at the time and going forward. It is important to remain calm and not be sucked into the crisis or drama. This isn’t as easy as it sounds.

When Alberta tried to reach her sister Margaret (who hadn’t felt well the previous day) for 6 ½ hours and couldn’t reach her, she drove to Margaret’s home and found her lying on the floor, disoriented. She called 911. The EMT was very abrupt and ‘not very nice with her’. ‘Who are you!?’ he ordered, and demanded to see ID. He peppered her with terse questions which proved aggravating, as Alberta was a medical professional herself. A crisis is always worse when there is a lot of drama present. First responders must be objective, and encounter some highly unusual circumstances. If a parent or guardian isn’t present to help, the adolescent should give his/her name and explain what is going on. ‘I’m Davey Jones and I took some pills someone gave me that are making me feel really strange. I’m hearing scary voices telling me to do something bad.’ [Its better to catch at an earlier point than bringing an unconscious teen to a hospital with no ID; simply dropping them off and disappearing.] The most important thing is to listen carefully and respond calmly. Help is available, there are solutions, and recovery is possible.

[photo credit: Stockbroker/Superstock 1888R-39172 Depressed teen with pills]

In memory of Kurt

We met Lisa Brattain, Indiana/Ohio Area Director of the American Foundation for Suicide Prevention at the New Albany High School Out of the Darkness Walk. A New Albany high school student addressed the crowd of assembled teens. Then, Lisa spoke from the heart about losing her son, Kurt, age 19, to death by suicide, which has inspired her passionate advocacy to honor his memory and prevent others from dying prematurely to suicide. Kurt was 19, and he was diagnosed with depression as a freshman in high school. Kurt died his first semester of college 4 years later, in 2006.

It was a bitterly cold day, more like northern Minnesota than Central Ohio, the day of the AFSP walk March 16th -with a 13 degree wind chill. High school students bravely turned out to raise attention to the cause with resource tables outside the field house. Pomegranate Health Systems exhibits at/sponsors Ohio Suicide Prevention Foundation conferences, and had only recently become aware of this walk. A university Campus Walk is planned to raise money and awareness at The Ohio State University on Sunday, October the 12th at Fred Beekman Park. [Link to info below] We asked Lisa to share her and her son’s story for other parents and the broader community.

‘P’: Did you have any idea Kurt was suffering to the point of taking his life?

Lisa: “We knew he had depression, we were completely uneducated about his illness and had no idea he was suicidal because the connection between depression and suicide had never been made for us. The conversation of possibilities was never had during his 4 year treatment from diagnosis to death. We/ nor did he understand the depths or difficulties that someone struggling with a depressive illness goes through. We didn’t have the words to say, to have the right discussions to keep him safe or even understand what he might be going through. He didn’t have the background or language to understand or express that he was ill. Instead he struggled in silence, thinking he was weak and flawed – not that he was ill, and it was not anything he could have, or would have chosen. It wasn’t his fault.”

‘P’: Knowing Kurt, did you think he planned this, or was it a spontaneous act?

Lisa: “Knowing Kurt before, not in a million years did I ever think he was even thinking about suicide, but we were living uninformed and un-prepared. Certainly now, I understand the warning signs, risk factors, and so much more. He did outwardly show warning signs, we just didn’t know they were warning signs.

[See signs below] It may have happened spontaneously the day that my son took his life, but it is clear that he had experienced that impulsivity before, and knew what steps he was going to take. He had been speaking about doing future things just 30 minutes prior to an impulsive and aggressive episode that ended with his life being over. So to answer that question – both.”

‘P”: What would you tell parents of teens? What would you say to friends of a teen who may be struggling?

Lisa: “If your teen has been diagnosed with a mental illness, please take the time to understand the illness, just as you would if they were diagnosed with diabetes or cancer or any other illness that we acknowledge can be detrimental to someone’s health. Ask questions, make sure you know how to be the support system they need to overcome the illness. Don’t assume that they would tell you if they need something, or that something awful is stirring inside them… they are likely just as scared of it as they are of what your reaction might be if they tell you. They likely don’t have the words to have the right dialog to get help… they need your help for that. We functioned under the “not my child” blindness. Kurt was a football player and a rugby player, he had lots of friends, girl-friends … with several support structures- family, church/youth group, medical, school/team/social supports, and none of these structures were prepared to help or see warning signs and reach out to him. I don’t say that with fault or blame, I say that with the opportunity to raise up a community that is prepared and caring and ready to help those in need… WITH GREAT HOPE.”

‘P’: What do you think those of us in the mental health community need to do better?

Lisa: “I think we (collectively) need to do a better job of preparing individuals given these types of diagnosis, preparing their families with education of the illness and understanding of how to be a support structure, and doing a consistent persistent job of creating a better informed society/community able to discuss mental illness and suicide with the same intensity and openness that we discuss high blood pressure and heart disease…. and don’t cease the conversation until we can say the words without watching the faces we speak to cringe in fear, shame or judgment. No one would choose to be depressed… no one would ever choose that! They want to feel better, just as someone with chronic pain JUST wants to feel better. We all can do a better job of creating the environment that allows and encourages that to happen.”

‘P’: What would you want the broader community to understand?

Lisa: “I would want the broader community to understand that illness is ILLNESS. No one chooses to be ill! Depression is an illness. There is chemically and physically something happening inside someone who has a mental illness. Your brain can get sick, just like any other organ in your body. We need to a better job of caring for each other, understanding each other, and helping each other.“

Lisa: “We never know what the person passing us on the street is going through – but your smile may be the only one that person might see that day… and your smile or greeting maybe the very thing that changes someone’s mind if they are contemplating suicide. Depression is the leading cause of suicide, and Hope is a hard thing to come by when your brain is ill and you are struggling. We are ALL capable of compassion. Many participating in our lives every day are struggling and we don’t even know it. We don’t know it because we can’t acceptably talk about it. We don’t know it because we are afraid of the answer and not being prepared to respond appropriately. Educating ourselves to help our families/friends and possibly even a stranger doesn’t seem like such a bad idea, right?”

Lisa added that In the US, a person dies by suicide every 13.7 minutes, every 14 minutes someone is left to make sense of it. For all of us in the mental health community and the broader community who suffer the loss of a loved one, it has become an urgent mission to: ‘Silence the Stigma of Depression and Suicide! Join the Movement TODAY!’ http://www.AFSP.org

If you need help:

If you are in crisis, call 1-800-273-TALK (8255)

National Suicide Prevention Lifeline

Locally (Columbus) Call 614-276-CARE (614- 276-2273) or Toll Free at 1-888-276-CARE (1-888- 276-2273)

Netcare provides mental health and substance abuse crisis services at 199 South Central Avenue and 741 East Broad Street 24 hours a day, 365 days a year.

Or visit your nearest hospital Emergency room.

To contact Lisa and/or register your support of the AFSP Walk:

Lisa Brattain

Indiana/Ohio Area Director

American Foundation for Suicide Prevention

14350 Mundy Drive, Suite 800, #199

Noblesville, Indiana 46060

Phone: 317.517.5973

Fax: 317.219.0551

email: Lbrattain@afsp.org

http://www.AFSP.org

Support our Walk:

Here is ‘Cia’s [‘P”] page

http://afsp.donordrive.com/index.cfm?fuseaction=donorDrive.participant&participantID=595412

Here is the Pomegranate Health Systems team page: http://afsp.donordrive.com/index.cfm?fuseaction=donorDrive.team&teamID=68275

Also visit The Jason Foundation. The Jason Foundation, Inc. has opened a community resource center at Ohio Hospital for Psychiatry (Acadia). See: http://www.JasonFoundation.com

Signs of:
Persons who are considering suicide generally display symptoms of depression.
These signs may include but not be limited to the following:
* Sudden radical changes in mood, particularly depression
* Increasingly self deprecating remarks
* Feelings of helplessness and hopelessness
* Increased use of alcohol or drugs
* Giving away of cherished items
* Making goodbyes
* Serious withdrawal from activities and significant persons
* Persistent discussions of death
* Self destructive or high risk behavior
* Previous attempts of suicide
* Identification with someone who has died by suicide
* Statements of a desire to explore or complete suicide
-(from Ohio Suicide Prevention Foundation)
Prevention: http://www.ohiospf.org/content

Psychiatric Care Facilities

In the chapter on Psychiatric Care Units in the Journal of Health Care Interior Design, authors Tama M. Duffy, ASID of Ellerbe Becket and Barbara Huelat ASID made the point that “A growing awareness of the real nature of mental illness helps us realize that not all mental health problems require the same type of treatment, therapy and physical environments.” The authors explore the three basic types of healthcare facilities for treating mental health disorders: state/teaching hospitals, private/community hospitals, and specialty facilities. State/teaching hospitals typically provide ‘comprehensive, multi-disciplinary program of tertiary-level patient care, clinical research, professional education and community outreach programs . . . within major university medical centers’.

Duffy and Huelat explain that private/community hospitals are typically investor-owned or not-for-profit freestanding hospitals that may include both a hospital and residential treatment facility and which often promote increasing levels of patient independence. The design criteria differ from that of a hospital, and the facilities often tend to be devoted exclusively to the treatment of mental illness. Specialty facilities might ‘focus on specific disorders such as eating disorders, substance abuse . . . [and] . . . dual addictive disorders. [These] facilities have the greatest success creating smaller, unique homelike centers to treat mental illness.’ The authors name Hazelden as an example.

Research shows that prevention, community outreach, outpatient, substance-abuse, EAP and self-help programs are growing in importance. Since the advent of The Affordable Care Act, and within the past 3 years, we’ve seen more assertive community treatment, the emergence of the health home concept with wrap-around customer focused care- including mental health. Increasingly, the emerging model of care extends to include in-home visits by caseworkers to keep children with their biological parents, and seniors in their homes rather than being moved to residential care centers.

The authors note, ‘The trend in psychiatric facilities has been to treat acute-care patients as outpatients [or] on a short term basis (under three weeks) at a community hospital.’ Pomegranate’s acute hospital stay is typically a week for crisis stabilization when a teen is a danger to self or others. The authors state that, ‘Long term care patients may be confined from 90 days to a period of years.’ A typical longer term treatment stay at Pomegranate is 3-6 months- more like a semester away at college.

‘One of the primary roles of the physical mental health care setting is to serve as a background for and assist in the recovery process. . . One primary goal of mental health facilities is to provide a setting that helps normalize and stabilize life.’ One specialty hospital Duffy and Huelat interviewed stated its primary objective that: ‘Treatment and rehabilitation are best achieved for most patients in a non-institutional, non-threatening environment where the patient is involved in an intensive treatment program- breakfast through bedtime.” The authors added, “The variety of treatments available makes the entire issue of mental health treatment unique and different from that of a medical/surgical hospital.” To that purpose, the Pomegranate facility includes classrooms on each residential unit, day room, game room, quiet spaces, family visiting areas, therapy team room, cafeteria, courtyard, therapist offices and gym. “Many times the gymnasium can be divided into separate areas to accommodate aerobics, volleyball and basketball,” the authors said. All those activities and more take place in the gym at Pomegranate.

One of the design issues is that, ‘Products must be tamper-proof and indestructible; diffusers and light fixtures must have tamperproof screws that require special tools to remove; products must be recessed and free of sharp edges; light fixture lenses must be fireproof; and no fixtures may be made of glass. Bathroom fixtures must be selected with concern: Toilets must have recessed flush valves; plumbing pipes extending into the room should be covered; shower heads should be recessed . . . outlets must be grounded-fault circuit-interrupted outlets; and fail-safe touch controls should be installed. . . . Mental health facility managers struggle to do everything possible to make environments as safe and durable as possible. However, the safety/security area is the biggest budget item,’ according to design authors Duffy and Huelat.

Facilities director John Hedrick said not only regular maintenance proceeds on daily, weekly and monthly schedules, but that includes life safety, repair and replacement considerations as well. ‘That’s all in a day’s work as there are building codes and standards to meet, and those of all the accrediting agencies as well,’ he adds. Because ‘Clinical evidence suggests that sensory deprivation may be one of the greatest mental disturbances in the built environment,’ Pomegranate has made strides in working to add murals, colorful bedding and upholstery and upgrade and update the flooring and finishes through-out the facility. There are forest, cosmos, dock of the beach and ocean view murals at Pomegranate, with more to come. Sitting in these calming spaces helps to connect with the vast world outside one’s mind and troubles.

As the authors state, the goal is ‘creation of a warm, friendly, non-institutional environment; however, finishes can also be the greatest problem for maintenance staff. Institutional-looking finishes may be preferable to ripped or permanently soiled wall coverings, hole-riddled textured ceilings and raveled and permanently stained floor covering, such as carpeting. . . . ‘This is certainly an ongoing concern for any facility management team who know from personal experience the authors are right that,
‘residential-quality products are inappropriate for a highly abused psychiatric facility. . . . patient behavior varies according to patient conditions, requiring radically different design solutions.’

The designers explain that to create a homey ambiance, ‘Many facility designs incorporate as much wood as possible. . . Designers should create a variety of textures within a facility to provide visual relief as well as recognizable landmarks.’ CEO Angela Nickell and the entire facilities team are working to integrate the newer with the newest, as smoothly as possible, as the latest expansion construction continues.

Links to videos on the current Pomegranate facility:

CEO Angela Nickell talks residential treatment: http://youtu.be/jwFpEXApbW8
Facilities Director John Hedrick talks facilities: http://youtu.be/4xQOTud5QWc

[A new mural has been added to family/therapy meeting room.]

What’s unique about psychiatric nursing?

Philip Wang, CNP

Last week was National Nursing Week and Pomegranate held a reception to honor its nursing team. Nursing as an occupation varies widely in scope, specifics, practice type and requirements. Whether one takes blood pressures, teaches, directs a large staff, performs physicals and writes scripts, there are several levels, differing accreditation requirements, and settings- from the smallest town, to a school, to a suburban community practice to the large med-surgical hospital.

According to the American Psychiatric Nurse Association, “Psychiatric Mental Health Advanced Practice Registered Nurses (PMH-APRNs) offer primary care services to the psychiatric-mental health population. PMH-APRNs assess, diagnose, and treat individuals and families with psychiatric disorders or the potential for such disorders using their full scope of therapeutic skills, including the prescription of medication and administration of psychotherapy.” Further, “the PMH-APRN role is an advanced nursing role requiring extensive education in development, physical and mental health assessment, the diagnosis of mental health conditions, integration and implementation of care, psycho- pharmacology, psychotherapy, practice evaluation, consultation, and liaison.” See:
http://www.apna.org/i4a/pages/index.cfm?pageid=3292

According to Rosetta Cowan, RN, BSN, Director of Nursing, “Psychiatric Nursing is different in that a medical model is combined with trauma-informed care and evidence based practices to promote the well-being and stabilization of both youths and parent/guardian. The goal for the patient is to be discharged to a less-restrictive environment with follow-up care appointments for medication management and counseling. Psychiatric Nursing combines several methods of healing including holistic, spiritual, and scientific interventions to enhance the care, safety, and well-being of each youth Pomegranate serves.” CNP Philip Wang explained what treatment team is like, sort of the ‘grand rounds’ at Pomegranate Health Systems with members of a multi-disciplinary team present.

Pomegranate’s registered nurses are responsible for conducting an initial assessment of the patient, to obtain a complete medical history and documenting identified concerns. This responsibility then extends to completing assessment notes, progress notes and required documentation within hospital and regulatory guidelines. In addition to the clinician’s therapeutic treatment, nurses also monitor and evaluate patients in the context of individual and group treatment for progress or development of additional symptoms of mental/behavioral disorders.

Each ‘at risk’ patient also receives risk/lethality evaluations, medication consents and med administration and monitoring. Lab reports, infection control, safety and physical monitoring are all part of the nursing role. Nurses not only communicate with clinicians and medical doctor/s, but with families, guardians, and case manager/s.

Nurses at Pomegranate Health Systems are also required to have first aid, CPR, Crisis Prevention Intervention training, client rights, abuse and neglect, minor aversive intervention and major aversive intervention training, behavior management plan, identification and assessment of contraindications, non-physical intervention/de-escalation techniques, assistance with self-administration of medication, fire and disaster procedures, obtaining medical and psychiatric assistance and other monthly and annual training. There are nurses on all three shifts, seven days a week, year-round caring for our teens.

The nursing team is supplemented by a wellness nurse who conducts nursing education groups on the residential units, unit clerks and medical records staff, administrative nurse and certified nurse practitioner. There are different needs between the acute hospital (treatment team meets daily) and residential treatment (the treatment team meets weekly). This is a different model than you’ll find at many residential treatment facilities with less acuity in the patient population. “A teen in crisis is in a vulnerable place,’ explained Nursing Director Cowan, ‘we work together to stabilize each adolescent and promote healing and resilience.’

Additional resources:

Videos on psychiatric nursing: http://www.apna.org/i4a/pages/index.cfm?pageid=5495