Greater than the Sum of its Parts: An Integrated, Patient and Family Centered Approach for Adolescents with Med/Psych Presentations.
INTRODUCTION The importance of comprehensive, inter professional care for adults, adolescents and children has been widely recognized as the ideal way to deliver care. Integrating medical and behavioral health practices leads to lower health care costs, decreased readmission rates and improved outcomes including greater functioning and quality of life. Data support the concept that mental and physical health disorders are risk factors for each other; the presence of one can complicate the treatment and outcomes of the other.1 This connection is supported by emerging data that identifies shared physiologic pathways connecting mind and body.2 In addition, there is strong evidence to support the efficacy of family based treatments for youth with chronic medical illness.3 At the foundation of patient and family centered care is a partnership amongst patient, family and providers across levels of care.4,5 The family and patient are considered the experts regarding their experiences; decisions are made from a perspective that the existing family relationships combined with the family's understanding of the illness constitute powerful forces in treatment. When caring for adolescents, prioritizing family in this partnership may seem counterintuitive given the developmental focus on emerging autonomy. However, a variety of studies have identified the importance of maintaining an intensive level of collaborative family involvement around refractory illness presentations across adolescence and young adulthood. These studies suggest that parents remain important mediators of illness experience and level of impairment, and their involvement fosters self efficacy and better psychological health.6,7,8 For patients with disabling illness and functional impairment refractory to more standard interventions, bringing together these two important approaches into an integrated, patient and family centered model is an important step aimed at maximizing treatment success. Despite clear advantages of this truly integrated paradigm, challenges exist in translating these concepts within the confines of current practice as it can be difficult to bring together the resources, expertise and perspectives needed for effective implementation. The Hasbro Children's Partial Hospital Program (HCPHP) and the Hasbro Inpatient Medical Psychiatric Unit are two unique, nationally recognized programs that have operationalized this integrated, patient and family centered intervention, that transcending traditional practice models. In addition, the model of integrated care extends to several outpatient areas including specialty clinics, primary care, and home based services. These hospital based programs provide an inter professional, patient and family centered, collaborative approach to pediatric and adolescent care in two levels of treatment. HCPHP opened in 1998 as a 5 day/week program serving up to 24 patients, ages 6 18 years old, with an average length of stay of 4 weeks. The Hasbro Inpatient Med Psych Unit opened in 2012 to accommodate patients requiring a higher level of care due to medical and psychiatric safety concerns. The inpatient unit is a secure, locked unit with a length of stay that ranges from days to weeks. This treatment continuum remains the only combined pediatric medical and psychiatric treatment in the region and beyond for patients with a wide range of illness presentations. Patients enter either setting with a broad range of presentations including gastrointestinal illness, eating disorders, diabetes, asthma, seizures, and chronic pain syndromes. Patients are referred from inpatient or outpatient treatment when they require more intensive support due to impaired functioning with limited improvement after traditional outpatient interventions. Many patients and families utilize both levels of care throughout their course of treatment. Both programs provide inter professional, developmentally appropriate treatment in a safe, nurturing environment with the expectation that patients and their families actively engage in treatment. Inter professional care includes nurses, milieu therapy, pediatricians, psychiatrists, psychologists, social work, nutrition, PT/OT, speech, educators, subspecialty consultation and comprehensive diagnostic testing when needed. Across levels of care, a strong partnership is established with patients, families and identified outpatient treatment providers. Individualized treatment plans incorporate a balance of medical and psychological support with the goal of a successful transition to optimal functioning at home and school. From the onset of treatment, there is a strong focus
Rhode Island medical journal