Long Term Care Services: Various Treatments

Various Treatment Needs of Our Customers

The creation of treatment programs to meet the individualized needs of our consumers is ever changing and unique to each branch of Long Term Care Services. Discharge planning begins immediately upon admission to a state hospital. The treatment team observes and evaluates the strengths and needs of the patient and uses this information to develop the individualized treatment plan. The programs identified below are a small sample of the services provided by Long Term Care. Success is measured by the number of graduates from the treatment programs.

The all-male population at Atascadero is received through referral from the Superior Courts, Department of Corrections, and Board of Prison Terms. The greater percentage of patients received for treatment is referred as a condition of parole under the Mentally Disordered Offender or Sexual Offender Commitment Program Statutes. Other categories include Incompetent to Stand Trial, Not Guilty By Reason of Insanity, and Mentally Ill Prisoners.

Common reasons for referral are to accomplish and maintain psychiatric remission, reduce the individual's risk for violence, to accept his mental illness, utilize when appropriate psychotropic medications to stabilize psychiatric symptoms and cope with residual symptoms; and utilize techniques of cognitive-behavioral treatment and relapse prevention.

Program III opened two new units for the PC 1370, Incompetent to Stand Trial (IST), population from Patton State Hospital. The patients were carefully screened to meet hospital security criteria. The length of stay for this population is decreasing as more patients are returning to court as competent to stand trial.

The Child and Adolescent Treatment Center is a therapeutic community which enhances independent living, academic achievement, and community integration. The program is unique in that it is the only DMH state hospital treatment program in California treating children and adolescents.

Because some client’s cannot communicate by speaking English, a 24-hour alternative for communication was needed to assure that the hospital meets immediate needs for ALL clients. The Alternative Communication Team (ACT) was established and staff worked with clients to design "picto-graphic" communication tools. More than 600 staff and client surveys identified the needs for our "ACT" project. The initial mission was completed in July 1997.

The work of the team resulted in Communicators for Activities of Daily Living (ADL) topics were designed (wall-mounted and portable), and installed in all residential units: portable designs were made for Clients’ Rights, Emergency Medical Response, and Restraint and Seclusion events; improved morale with increased ability to communicate with clients who have tracheotomy, Dysarthria, etc., and with clients who are non-English speakers; hearing impaired clients reported increased satisfaction, clients now spontaneously use the graphics when they have difficulty and a decrease in "serious incidents" coincided with installation dates of ACT, according to a Behavior Intervention Monitoring Committee (BIMC) report.

Napa State Hospital lacked a formal process to assess the clients’ perceptions of their treatment during the course of hospitalization. In response to this need, a multidisciplinary team of program representatives developed and piloted a client satisfaction survey to assess clients’ perceptions of treatment and service quality. In July 1995, the pilot survey was completed with input from clients and staff. Subsequent hospital-wide surveys occurred in January 1996 and February 1997. Programs, departments, disciplines, the strategy planning team and the executive policy team review survey results. Results are considered when developing both hospital-wide and specific performance improvement objectives.

Comparative results between 1996 and 1997 demonstrated: client participation has been positive: 63% in 1996 and 65% in 1997; client satisfaction increased in areas of participation in treatment planning, dental services, meals and dining room; more clients perceive themselves as doing better than they expected. Clients’ overall satisfaction with hospital services improved.

The survey has been an effective tool to provide meaningful feedback to hospital staff. The increase in client satisfaction was an outcome of improvements in client services. The survey has been a useful tool, and staff, with client input, have made improvements at program and unit levels.

The Client Advisory Council, a mechanism for clients to voice concerns, raise issues, make recommendations, and participate in the decision-making process, was established in 1994 to serve as an advisory body to the executive director. The Council solicits information and recommendations from the individual unit governments and meets three times per month to discuss ideas, issues, and other matters raised by the hospital client body. The Client Advisory Council has resolved 37 significant client-related issues within the hospital community.

In addition, four Client Advisory Council members presented at the California Association of Social Rehabilitation Agencies Conference on Empowering Positive Change from a Client’s Perspective. Seventeen Advisory Council members attended and successfully completed 20 hours of team-building/problem-solving/negotiation training. The intent for leadership training was so clients could use the same language and process as staff in order to resolve issues or concerns.

Napa State Hospital developed a program to assertively increase functional range of motion (rom) for older clients and stop the progression of immobility in our most debilitated clients.

The program established a Mobility Enhancement Team (MET), comprised of three certified nursing assistants (CNAs) and one licensed vocational nurse (LVN) under the direction of a registered nurse, who are specially trained in basic range of motion, ambulation, assisted walking and use of a gait belt, proper use of body mechanics, falls prevention and management, use of special ambulation equipment, and client privacy and dignity. The MET develops and implements individualized mobility enhancement plans to address the specific needs of each client. The range of motion exercises and bed side mobility training has prevented further contractures and has reduced the risk of related medical problems that may have arisen due to immobility for many clients. The function transfer and ambulation training has increased space orientation and built self-esteem in many clients by creating a sense of mobility independence. Additionally, many of the clients demonstrated improved social behaviors, decreased assaultiveness, increased compliance with overall treatment and attendance at group activities and decreased the use of PRN medications. The development of the team to specifically focus on mobility issues of the clients has encouraged unit nursing staff to increase their focus and attention on providing nursing care which has improved the overall quality of care on the unit.

A Napa State Hospital Objective Team has joined other community agencies to develop an innovative skills training program to address the special needs of clients in prisons and/or forensic mental health facilities. More than half of these clients have language learning disabilities, ADD/ADHD, and/or traumatic brain injury. These disabilities are "invisible." Though often not visible, they do contribute to the numbers of clients who enter mental health and criminal justice institutions. Court documented decreases in the recidivism rate of greater than 40% have been achieved in programs where clients have received skills training to increase their awareness, and develop strategies to "by-pass" or to "cope" with these disabilities.

The team has developed a new intake screening procedure for forensic clients to facilitate early identification of those with these deficits. The team has also initiated a new curriculum option known as "S.T.A.R.T." (Success Through Awareness & Responsibility Training.) During the next fiscal year a second curriculum titled "C.H.O.I.C.E.S." (Connecting Higher Order Independent Community Entry Skills) is being developed. This will link S.T.A.R.T strategies to transition skills, and offer higher level, language-based training (and practice) with specific self-determination skills (i.e., goal setting, information gathering, planning, decision making, problem solving, communication, self-advocacy, and self-coaching). "New S.T.A.R.T." classes provide in-depth discovery/education regarding language/learning disability and mental health issues; understanding personal strengths and weaknesses; exploring personal learning styles; specific "by-pass" strategies; problem solving skills; and related anger management and social skills. Two "New S.T.A.R.T." classes have been completed to date resulting in positive feedback from clients and staff. Three more classes are scheduled to begin in March 1998.

The Psychology Service now maintains one of the most complete libraries and storage of psychological tests for use with our patients in the state. This also includes a scanner and the software for computer scoring of the test reports. A library of this caliber is essential for keeping staff at a state-of-the-art level.

The hospital recently implemented a new program which focuses on patients with special needs due to some kind of physical disability. Three cycles will be held throughout the year with each cycle focusing on either physical disability issues, diabetes issues, or brain trauma issues.

A new program, Veterans in Patton, was developed to meet the needs of those patients who are veterans. The program is implemented with the assistance from the West Los Angeles Veterans Administration.

In January of 1997, Patton State Hospital ventured forward in addressing the issue of Cultural Competence in the provision of mental health services with the initiation of the Multicultural Education and Training Program. The program was designed to address the unique and diverse cultural needs of our patients and staff. Patton is a culturally diverse forensic institution, both in terms of patients and staff. Fifty-two percent of our patient population consists of ethnic/racial minorities.

Given the significantly diverse representation of ethnic and racial minorities at Patton it is imperative that we become better prepared to handle the challenges we face providing culturally sensitive and appropriate services. Even though there is significant ethnic minority representation among the staff we realized that this does not denote cultural competence in the provision of mental health services. It is or legal, ethical, and moral responsibility to provide mental health services equal in quality and availability to racial and ethnic minorities as to those patients representative of the majority culture.

Our goals are to shape hospital policies and procedures that directly impact the provision of culturally competent services (e.g., the hospital’s philosophy and mission statement, strategic plan, and the quality improvement management system, etc.) by changing attitudes, behaviors and practices; provide staff with culturally relevant education and training that will enhance their diagnostic accuracy and treatment programming; improve the effectiveness of interdisciplinary multicultural treatment teams by improving staff relations; and improve the quality and availability of mental health services to racial and ethnic minorities, as well as improve treatment outcomes as a result of systemic and individual adaptation to diversity and the development of cultural competence.

The Malingering Project has reviewed statistics regarding the diagnosis of malingering and the effectiveness of documentation to the courts.

Program I:

The Acute Psychiatric Program (APP) recently implemented a new treatment approach for exceptionally difficult patients. The Individualized Treatment Program for Difficult Patients is loosely based on the cognitive-behavioral treatment approaches found in Dialectic Behavioral Therapy (DBT). In this unique approach, therapists are borrowed from throughout the Program's five units to exercise particular specialties to treat the difficult patient. The team assembles regularly to review the case and its progress. This is equivalent to assembling a team of specialists to treat various behaviors and disorders that challenge even the most accomplished mental health professionals.

Program II:

The Intermediate/Day Treatment Program (IDTP) has developed a Treatment Team Conference Preparation form (TTCP) to provide the patient (with assistance from staff as needed) to review his current treatment course, evaluate his own progress, and suggest modifications to his treatment plan when he consults with his treatment team.

The IDTP developed a new range of groups to address past traumatic experiences suffered by patients that may have profound effects upon their thoughts and emotions that often manifest themselves in a variety of behaviors that may result in the victimization of others or themselves. They often lack capacities to gauge proper boundaries or utilize helpful therapies. These specialized groups help patients resolve their trauma issues and promote healthy adjustments to their environments.

In addition to the objective nature of the Patient Perception of Care survey, the IDTP patients are encouraged to provide narrative feedback to the program regarding their overall care, their providers, and the areas of improvement they feel they have achieved. This exercise is designed to reflect upon and promote insight into the patient's treatment gains and how they will be applied after discharge from the program. The Letter of Conclusion may be written with assistance from staff if requested. The patient at his last treatment team conference reads the Letter of Conclusion to staff and receives positive feedback.

The IDTP continues to adapt and refine its Relapse Prevention program to achieve maximum individualized treatment for patients and their various problem behaviors. Whether the behavior is sexual in nature, substance abuse or chronic violence, the patients learn to identify the antecedents and triggers of these maladaptive behaviors, formulate new patterns of thoughts and feelings about them and develop constructive alternative behaviors that break them of the cycle of behaviors that results in victimizing others and sabotaging their own lives.