Monday, December 12, 2011

The Continuum of Care

The continuum of care - I'd put this topic in the category of Things I Didn't Learn in School, but which is vital to (responsible) practice as a mental health provider. It goes along with the ethical principle of providing treatment in the least restrictive environment where the client's safety can be maintained.

At the one extreme are those clients who have difficulty with some area of functioning, but are able to continue self-care and maintain safety, and experience a restoration of functioning with standard outpatient therapy and/or psychopharmacology. At the other extreme are individuals whose functioning is so impaired that they require long-term institutionalization for 24-hour a day supervised care; these individuals are usually either unable to meet their own basic needs, and/or present a safety threat to themselves or others.

As with most continua, the vast majority of clients fall somewhere between these two extremes: many will at some point require more support than weekly therapy, but most will never require long-term institutionalization. Enter the Continuum of Care - a sequence of progressively less (or more, depending which way you go) restrictive treatment settings that allow a client to avoid unnecessary restrictions on their liberty, while also maintaining safety. Moving from most to least restrictive, the continuum of care goes as follows:

1) Long-term Hospitalization, often a State Hospital
Individuals are only admitted to a long-term hospital after conventional inpatient treatment (see below) has been ineffective. They typically have had multiple acute hospitalizations, and may have been on an acute inpatient unit for several months without showing improvement in functioning (or at least insufficient improvement that they can maintain safety out of the hospital). These individuals are typically moved to a long-term facility after they have been "committed" to the hospital by the courts for a period of several months.

2) Inpatient treatment
"Regular" inpatient units (in contrast to their long-term cousins, described above), are intended to provide "acute" care - in other words, they are designed for the short-term treatment and stabilization of individuals experiencing psychiatric crises. Inpatient treatment provides 24-hour a day supervision, aggressive psychopharmacological intervention (up to and including ECT when warranted), and case management in preparation for speedy discharge (admissions are often shorter than one week in duration).

3) Partial Hospitalization
Given the speed with which people are discharged from inpatient units following a crisis, there is often a need for more support than standard outpatient services. So, once individuals can maintain safety and self-care during the overnight hours (i.e., they no longer need 24-hour a day supervision), they are often transitioned to something called a "partial" hospital program. "Partial" (rather than full) refers to the fact that these programs are day programs (typically only about 6 hours per day, 5 days per week), and allow clients to return to their homes for evenings and weekends. Treatment includes some combination of group therapy, psychopharmacology, brief individual and family interventions, and case management.

4) Intensive Outpatient Programs (IOP)
When individuals are able to maintain safety and self-care without the need for such a structured program, they are often referred to an IOP as a transition between partial hospitalization and standard outpatient treatment. IOPs typically run between 3-5 days per week, for three hours each day. They provide group therapy, brief intervention with individuals and families, and case management. IOP may last from a week to several months, depending on the program, the client, and whether IOP is being used as a step-down from higher levels of care (where much work has already been done), or to prevent the need for higher levels of care (meaning there may be more work that needs to be done for the individual to stabilize). The presenting problem and insurance requirements also play a role.

5) Standard Outpatient
Not to be forgotten, standard outpatient treatment is the backbone of mental health services, in spite of its location at the far end of the continuum of care. After all, we hope that most patients can be maintained in outpatient treatment, and will ultimately no longer need treatment to maintain a satisfactory quality of life. This level of care is quite flexible, with the ability to titrate the frequency of counseling and psychopharmacology appointments to meet the client's needs.

Of course, this continuum can also progress in the other direction - individuals who are struggling in outpatient services can step up to IOP or partial, before needing to be admitted to an inpatient unit, and often patients are transitioned to IOP or partial who ultimately need a higher (inpatient) level of care. The existance of multiple levels, and the flexibility to move  between them are what make the whole system "work."

So, what do you think about the so-called Continuum of Care? Is it effective? The best way to ensure the least restrictive environment for clients? Or could we be doing things differently?

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