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Include peer specialists. Cer tified Peer Specialists offer unique support due to their own personal experience with managing their own mental health challenges and can connect with the patient and provide additional social and emotional support, answer questions about post-discharge life, and offer hope for recovery. Engage school and community support. For children, reach out to the school counselor or school psychologist to discuss support resources and safety needs at school. Work collaboratively. Work with the patient and their family members and supporting community to develop a patient safety plan. Ensure that staff has the training to develop safety plans with the patient. Specific to children, with consent, share the safety plan with the school counselor. Schedule an outpatient appointment. Secure an outpatient appointment ideally within 24-72 hours after discharge, but no later than seven days after discharge. Identify any potential barriers to attending the appointment prior to discharge (e.g., transportation, childcare, housing, insurance, additional time away from work). Offer step-down care. Some patients may benefit from an intermediate level of care in a less restrictive environment but with more frequent services than offered in outpatient care (e.g., IOPs and PHPs). Partner with the outpatient provider. Complete any necessary release documents and speak directly to the outpatient provider. Provide background on the patient’s presenting problem, course of treatment, details of the safety plan. A short conversation with the outpatient team prior to discharge can build a bridge across services. This initial contact can be in-person, over the phone, or via videoconferencing. Connect the patient with the outpatient provider. Arrange an in- person meeting or a video conference to allow a therapeutic alliance to begin prior to discharge.
Recommendations for Outpatient Providers A patient discharged from a psychiatric inpatient unit may be referred to a clinic, mental health center, day treatment program, or private practice. Before discharge from the inpatient setting, the provider should connect with the patient to build a therapeutic alliance. This pre-discharge contact triples the odds of a patient engaging in outpatient services post-hospitalization. The following are steps an outpatient provider should follow prior to their patient being discharged 4 : 1. Develop relationships, protocols, and procedures that allow for safe and rapid referrals. •
After discharge, an outpatient provider may contact the patient by phone if the initial appointment is not within 24 hours. Following up by phone following discharge can be helpful to confirm the intake appointment, re-assess suicide risk, and build rapport. It is also important to involve family members and other supports by providing psychoeducation and community resources. A healthy family support system improves the health and well-being of the patient. 4 Pharmacotherapy Each patient should be individually assessed to evaluate the discharge environment for safety. In these circumstances, psychopharmacologic interventions are often employed. If psychopharmacologic interventions are used for patients discharged home, the patient and family members must understand the possible side effects associated with the drugs being administered, especially the use of antidepressants in patients who are depressed and suicidal. 51 Antidepressants Several studies using randomized controlled trials have shown that the treatment of depression using drug therapy, such as antidepressants, has been associated with decreased suicidal ideation in individuals of ages 25 years and older. 51 Some studies suggest that the use of selective serotonin reuptake inhibitors (SSRIs) (i.e., Lexapro, Prozac) results in a more significant reduction of suicide ideation compared to selective serotonin and norepinephrine reuptake inhibitors (SNRIs) (e.g., Cymbalta, PRISTIQ) or norepinephrine-dopamine reuptake inhibitors (NRDIs) (e.g., Wellbutrin) 51 . Interestingly, in patients younger than 25 years old, antidepressant therapy has not been shown to decrease suicidal ideation and behaviors, although it does reduce signs and symptoms of depression. 51 Black box warning of increased SI on antidepressants. In 1999, concerns were raised about antidepressants causing suicidality (Rush, 2021). There were concerns about patients developing intense suicidal ideation while taking fluoxetine (Prozac) as prescribed. In response to these concerns, the manufacturer conducted a meta- analysis of 3,065 patients and found no significant difference in suicidal behavior in patients taking fluoxetine versus placebo. 52 In 2003, similar concerns re-emerged as the United States Food and Drug Administration (FDA) issued a warning regarding the risk of increased suicidality associated with antidepressant use in young people under 26 years of age seen in clinical trials. In 2005, The FDA issued another warning about suicidality in adults being treated with antidepressants.
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3. Collaboratively develop a safety plan. •
Establish relationships through effective communication. Cultivate a relationship with inpatient facilities to ensure smooth transitions for future patients. Establish policies and procedures. Review policies and procedures for referral acceptance and triage appointments. A patient’s heightened risk for suicide in the first week after discharge prioritizes them for an intake appointment. Accept shared responsibility. Work with the inpatient facility, the patient, and their family to coordinate a safe and effective care transition. Negotiate a memorandum of under- standing (MOU) or memorandum of agreement (MOA). Work with inpatient facilities to ensure timely communication and promote the release of records for care continuity. documents. Obtain releases of information, transition plan, treatment plans, medications, and collaborative crisis/safety plan Obtain copies of essential Arrange a conference call. Schedule a call with the inpatient providers in order to gather as much information as possible prior to your patient intake. Train all staff. Staff members can influence a patient’s impression of the outpatient office. Greeting patients with compassion and warmth will help the patient feel more comfortable and can influence the patient’s willingness to engage in treatment.
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4. Connect with the outpatient provider. •
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2. Reach out to their family members or other supports • Meet the patient and family members
After discharge, inpatient providers should follow up with the patient and outpatient provider. A recently discharged patient should receive a phone call within 24 hours to assess the patient’s recovery, and communication should be maintained until the patient’s first outpatient appointment to ensure bridge support. 4
at the inpatient psychiatric setting. If an in-person meeting with the patient is not feasible, consider connecting through telemedicine. At a minimum, call the patient prior to discharge to begin fostering a therapeutic alliance.
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