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.]

Weight loss inspires teens

Pomegranate’s first shift senior youth leader on the boy’s unit, Marvin, has lost over 200 pounds to date. He keeps a pair of size 66 shorts in his locker to keep the inspiration going and to show teens how even insurmountable obstacles can be overcome in not only weight loss, but life. At first they are incredulous. They ask lots of questions. They want to know how he did it, what it was like, how hard it was and how long it’s taken.

Marvin struggled with his weight from childhood on, though he played football in high school. He was bullied (mainly in middle school), and made fun of because of his size. Finally, after trying several diet plans, he sought medical assistance through a gastric bypass operation in June, 2003. At first during pre-op testing, he was told it was likely that he had colon cancer or sickle cell. It turned out to be sickle cell trait, which is abnormal blood cell formation. The CDC reports, ‘People who inherit one sickle cell gene and one normal gene have sickle cell trait (SCT). People with SCT usually do not have any of the symptoms of sickle cell disease (SCD), but they can pass the trait on to their children.’ It’s important to be adequately hydrated/drink enough water with the disorder.

When he finally had the surgery everything went well and the weight loss started immediately. In the first two weeks he lost 38 lbs. At first, the weight loss was slow, and then everything sped up. ‘The hardest thing was not being able to eat solid food for almost three months,’ he admitted. ‘I lived on smoothies and soft food . . . ‘ he said. Now he can do just about everything he attempts with ease. It’s been about seven and a half years . . . and I’m still losing. I hope to stabilize at 225 lbs,’ he said. Marvin exercises by walking . . . which is easier now with the 200 lb weight loss. That’s a whole person!

Marvin set healthier goals, dreaming big, and educating others on the importance of eating right and exercise. ‘I learned from my aftercare nutritionist the importance of counting calories and eating smaller portions. I had several adjustments such as learning to put down the burgers and fries, and replace them with yogurt and salad. I also learned to eliminate the soda and replace it with more water,’ he said with a grin. That doesn’t mean totally giving up on favorites, just controlling what, and how much he eats and making better choices more often.

It doesn’t take long to exceed daily calories in one meal if you are not paying attention! For instance, two slices of a popular pizza exceed 500 calories; half a pizza- exceeds 1000 calories. Coupled with a large high sugar soda, and later, a Blizzard (milkshake) or candy bar, and you’ve taken in the entire days’ worth of calories in one sitting, far exceeding fat, sugar, and sodium intake. That’s standard fare for many teens coupled with a 1000 calorie burger and fries at lunch (and more high sugar soda). Three thousand to six thousand calories, sitting in front of a game console most of the day with chips and a sports drink, and it doesn’t take long to gain weight if you’re not active.

Paying attention to diet is especially important with weight gain or loss a side effect with many medications such as mood stabilizers or anti-depressants. A body-conscious teen might stop taking his or her medications, which is not advisable. Wellness nurse Lori does a lot of education on medication, diet, exercise and healthy decisions. A registered dietician makes sure residents and staff alike find fresh fruit, vegetables, or soup alongside wraps, main meals, and favorites.

‘My friends and family love the new Marvin even more than the old Marvin. Most importantly, I think by having the gastric bypass surgery I added a lot more years on to my life,’ Marvin says. When asked if he has anything to tell teens, families and readers alike, he added, ‘Don’t take your health lightly!’ Posing with his old shorts in front, he is half his former size, but twice his former confidence!

What to do, when . . .

What to do, when . . .

Angry Behavior

->Your teen is experiencing explosive temper outbursts, fits of rage, shouting, shoving and you are afraid for your or his/her safety, and the teen is unresponsive to calm reasoning, or his/her behavior escalates.

A: Call 911. Many Columbus and suburban police departments have been trained in CIT. CIT is crisis intervention training. Often, a young person in crisis is then taken to a hospital emergency room and/or Netcare Access for assessment to determine what is causing the behavior and what is helpful next. They might then be referred to Pomegranate Acute Hospital.

Self Harming Behavior

->A teen- (son, daughter, niece, nephew, student or friend) is threatening suicide either after having been depressed, or impulsively. It may be result of bullying, cyber bullying, a bad break-up, test gone wrong, fight, parental separation, abuse- physical, sexual or emotional- regardless, intervention is a must to this cry for help.

A: Bring them to a hospital emergency room for evaluation and assessment by a trained mental health crisis intervention specialist. Larger hospitals either have specialists on staff or are contracted with psychiatrists or psychologists to perform the assessment and referral. They might then be referred to Pomegranate Acute Hospital for crisis stabilization and further treatment.

Scary or Unusual Behavior

->Your teen has had a noticeable personality change, is behaving oddly, might be hearing voices or seeing things that are not real, seems withdrawn or having mood swings, saying unusual stuff or making threats.

A: Make an appointment with a psychologist, licensed professional counselor, psychiatrist for further evaluation or, if threats are involved or actively psychotic behavior (hallucinating), bring teen to Netcare Access or a hospital emergency room. Nationwide Children’s also has several outpatient behavioral health locations.

Disruptions at School

->Your student or adolescent child has been suspended, gotten detention, been involved in fights, made threats, or had outbursts at school (or bullying is involved either as perpetrator or victim).

A: Make an appointment with the school counselor or psychologist for professional counseling referral. For a diagnostic assessment and more intensive level of therapy that cannot be provided on an outpatient basis, residential treatment might be considered. Pomegranate Health Systems has 50 bed residential treatment. The teen will need a professional referral to come to Pomegranate.

Victim of Rape, Abuse or Trafficking

->An adolescent girl (or boy) has been involved with an older boyfriend met over the internet, or was exploited by older male and/or his friends, or subject to previous abuse.

A: Pomegranate Health Systems does see/treat teens who have suffered abuse, trauma, and/or experience symptoms of PTSD (post traumatic stress disorder). The entire staff has received training in trauma-informed care, and the clinical team has been engaged with NMT training through the Dr. Bruce Perry model.

Physical Health Challenges (Allergies, Diet, Seizures, Diabetes, Pregnancy, Sexually Transmitted Diseases)

->My teen also has special dietetic requirements, is diabetic, allergic to peanuts, has chlamydia . . . in addition to bipolar disorder and ADHD.

A: Pomegranate has a medical doctor in addition to psychiatrists on staff, a certified nurse practitioner, RN/s and LPNs to supervise and assist with medical conditions and medication management. Patients in the acute hospital are seen daily in treatment team, and weekly in residential treatment in addition to the 24-7 nursing care. Special situations are noted on the board, in the chart and special meals can be prepared by our dietician and chef.
Pomegranate is a participant in the PREP program, personal responsibility education which teaches skills for living on one’s own, budgeting, setting life goals, preventing pregnancy, parenting skills needed, managing one’s own health condition and medication, preventing sexually transmitted diseases –including learning to say ‘no’, and valuing oneself.

Developmentally Disabled

->My son/daughter is developmentally disabled and considered to be ‘low functioning’. He/she seems to be experiencing symptoms of behavioral health disorder. Do you accept/treat DD patients?

A: Pomegranate reviews each case on an individual basis. Generally, we accept teens who can perform the activities of daily living and/or at an IQ level of 70 or above. Beyond bed availability, its necessary to make sure a teen will be best served by the current milieu.

Arrest, Delinquency or Court Involvement

->A teen has been arrested for a crime (theft, curfew violation, truancy etc.) and the court psychologist has assessed the child as in need of mental and/or behavioral health treatment.

A: Pomegranate’s secure environment provides a safe place for the teen; protection from peers and removal from the situation which may have contributed to the arrest. A highly structured environment coupled with individual and group therapy can provide remarkably beneficial results. Tutoring from Columbus Public Schools special needs teachers can help a teen with subjects that they may need additional coaching in.
Pomegranate provides a competency attainment program for teens that are adjudicated as incompetent to stand trial. The teen receives training on the court system, courtroom environment, charges pending, and legal terminology, to better be able to understand the charges they are facing.

Shelter care; Removed from Dysfunctional Home Environment

->A teen’s parent has substance abuse issues, is incarcerated, or a parent has abandoned the family, there has been an incident of neglect, illegal activity, or domestic violence necessitates removal of the teen and children from the home at once.

A: In high stress situations where county child protection caseworkers are called to the home, adolescents are placed in a safe, secure environment at Pomegranate Health Systems or other provider to protect them, and provide them with room and board, schooling, health care (including medical exam, vision and dental), clothing vouchers if needed, food and recreation and a stable environment until they can be placed with kin, in foster care, reunited with their biological parent/s, or with a loving, forever family.

Clearly, these are more serious situations where typical outpatient, school, or community mental health counseling might not suffice. View our YouTube videos- listed under ‘news’ on the http://www.PomegranateHealthSystems.com/ website, or in earlier blog posts. There’s also an FAQ section as well as sections for parents, professionals and insurance under the admissions tab.

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

April is Child Abuse Prevention Month

The Public Children’s Service Associations of Ohio (PCSAO) act on behalf of children and families to make sure children are safe, fed, clothed, educated and cared for. In Franklin County, thousands of reports of child abuse come in to Franklin County Children Service, which served over 30,000 children and their families last year.

The primary goal is to solve the issues which contribute to child abuse. Educating the community and providing help and intervention for parents and caregivers under stress is the role of Ohio’s children service organizations. You may see blue pinwheels around town and across the state as a symbol of child abuse prevention. Pomegranate staff will be wearing blue on Wednesday, April 9th in support of raising awareness. Pomegranate Health Systems team has posted colored pinwheels on a giant wall-sized poster in the lobby to raise awareness; residents were involved by coloring the wheels.

Of the 31,798 referrals in 2013, FCCS investigated 7,706 abuse cases with 6,014 physical abuse, 1,465 sexual abuse and 227 emotional abuse. About 14.7% were substantiated and 7.3% indicated; 38.5% unsubstantiated and 39.5% differential. There were 3,883 neglect investigations with 12.2% substantiated, 2.9% indicated, 24% unsubstantiated and 50.9% differential. There are over 700 employees; 400 kinship families, 200 adoptive families and 500 volunteers and mentors as well as 100 agencies and organizations who support the work of Franklin County Children Services.

Caseworkers act on behalf of their clients, to make sure a child’s needs are met, and that may, but not always include treatment for mental and behavioral health issues. Residential treatment is advised when a teen is a danger to him/herself or others, or requires a more intensive level of supervision and care than they would receive in a home environment- whether their own, foster, or kinship care. Research confirms that children who have suffered abuse or neglect are significantly more likely to suffer serious emotional disturbance and/or the effects of mental or behavioral illness.

For young Jason, discipline with a wooden paddle whacked over his backside became nearly unbearable, not for the physical pain, but the psychological tear it caused in his relationship with his mother, who had also been abused growing up. His dad had moved to another state, leaving the family in a rather desperate position. Jason became increasingly combative, truant, and ran away. The family situation improved as his mother was connected with food, transportation, and other community resources to help provide daycare to his younger siblings. The family was connected with a therapist to help move in a stronger direction. Working with both Jason and his mom to journal the anger and pain they felt, and understand how to handle their feelings differently, improved the situation. Not every call results in removal of a child from parents, or parents accused, or stigmatized. Jason, of course is a hypothetical situation to illustrate how a child comes into care. Care involves valuing each child; honoring the family and contributing to compassionate solutions which serve the needs of each situation best.

The mission of FCCS is ‘through collaboration with families and their communities, we advocate for the safety, permanency and well-being of each child we serve in a manner that honors family and culture.’ For more information check out http://www.franklincountyohio.gov/children_services

http://www.youtube.com/watch?v=YRAvUBx0sDc Child Abuse Prevention Breakfast video
http://www.youtube.com/watch?v=0JW4wTsnIDQ Tapestry video
http://www.youtube.com/watch?v=KfB3O6LWqPM overview video

[Photo credit: A few of the 2014 Pomegranate Health Systems care team, wearing blue to support April’s National Child Abuse Prevention Month.]

Why do teens self harm?

Tiffany’s mom tiptoed into her room to check on her daughter who had recently had the flu. The girl was sound asleep. It was then, she noticed the cut marks on her daughter’s arms. Tiffany had seemed withdrawn lately. It had been a difficult time since her dad walked out on them. Her mom was working two jobs and cried a lot lately. Her dad had partial custody of her brother. And money was tight. She couldn’t do things with her friends and was too ashamed to tell anyone why.

In her talk at the recent 2014 Intercourt Conference, Kaye Randall, MSW, LISW-CP of Turning Point Counseling gave a workshop titled, ‘See My Pain! Helping Children and Adolescents Who Self-Injure’. She said there are several reasons teens self-injure. There might be neglect or abandonment by a parent, or loss through death or divorce, or a tense relationship- even abusive relationship between parents. There could be alcoholism or drug abuse by a caregiver; physical, emotional or sexual abuse either long ago, previously or currently. Looking at the issue of self-harm developmentally, a teen may not have learned how to handle strong emotion or express him/herself to others. There is often a self-image issue, self-loathing, perfectionism and/or mood swings.

While some professionals see self-injury on a continuum with suicidality, others see deliberate self-harm through cutting, burning, bruising, scratching or worse, as an attempt to manage painful feelings that cannot be expressed verbally. The pain behind self-harm might be expressing a sense of loss, desertion, isolation, helplessness, rage, rejection, grief, anxiousness, guilt, shame or feelings of failure. Families don’t often connect-and teens feel a sense of isolation. Randall says in her workshop guide that, “American youth today are often considered to be in a state of crisis. Approximately half of all adolescents are at moderate to high risk of engaging in one or more self-destructive behaviors, including eating disorders, self-injury, unsafe sex, drug and alcohol abuse; under-achievement, failure, or dropping out of school; and delinquent or criminal behaviors.”

Pomegranate Certified Nurse Practitioner, Philip Wang, says ‘Frequently self-harm and cutting occurs with other DSM IV diagnoses, such as bi-polar disorder, personality disorder, an eating disorder, or depression.” Why do they self-harm? Randall explained that “Many of these problem behaviors are interrelated. Some of these behaviors are related to the multitude of physical, social, and emotional changes adolescents are experiencing. Some are related to dysfunction in families; violence in the streets and at home; and media which portrays alcohol and drug use, extramarital sex, and violence as often-occurring, normal behaviors.”
Teens who self-harm may be trying to use self-harm to avoid overwhelming emotional pain by releasing it physically/symbolically, attempting to control it, or punishing themselves. For Andrew who lost two family members in an accident, “I let the grief out a little at a time, and then ‘put the cap back on the bottle’, because it would be overwhelming- too much- to pour out all at once,” he explained in a husky voice.

Intervening by having a teen explain (to a professional) what it was that they were trying to express is often helpful: what led up to it; what they were feeling; how they felt afterwards. The emotion behind the self-injury should be validated, not dismissed, disparaged, or ignored. Pain in life cannot be avoided, but children and adolescents DO need to learn healthy coping skills. Individual and group discussion may be helpful, identifying emotional triggers, and learning healthy diversionary practices can help. Art therapy is often very useful in expressing emotions too deep to handle. Pomegranate’s acute hospital employs a registered art therapist to facilitate the discovery and healing process.

[photo credit: sad teen boy at vvvstep@dreamstime.com #1286156]

Read more at:
http://www.mayoclinic.org/diseases-conditions/self-injury/basics/definition/con-20025897
http://www.webmd.com/mental-health/features/cutting-self-harm-signs-treatment
http://www.parenting.org/article/understanding-teen-cutting-and-self-injury

YouTube videos: (Note: there are lots of videos on the topic, many self-produced by teens. Our disclaimer is to see a professional; not to believe everything you see/hear. Not all ‘professional’ videos provide the same caliber of information.)

http://www.youtube.com/watch?v=iclExy_qJ-4 (news story Heartland News)
http://www.youtube.com/watch?v=y5JMoeTGLQQ (Dr. Drew)
http://www.youtube.com/watch?v=zv9KORPxMxg (RN- Powerpoint presentation)