Building collaborative plans

Bari K. Platter, MS, RN, CNS, educator at the University of Colorado Hospital, has worked extensively with behavioral health teams throughout this health system to implement BCPs. The BCP is different from a multidisciplinary treatment plan or plan of care—it is a working component of the treatment plan. The BCP is solution-focused and action-oriented. All disciplines working with the patient must be involved in its development. While the ARN often leads in BCP development because of comfort working in a solution-focused therapy environment managing complex symptoms, patient participation is also critical to success. The patient and the staff member who reviews the plan must sign and date it.

A BCP should be broken down into four sections (see sidebars):

• Warning signs. These should be progressive (mild, moderate, severe). The language used should be neutral and nonjudgmental. These lists should include specific behaviors the patient has demonstrated that are disrespectful, unsafe, and not allowed in the facility.

• Expectations of behavior. These should remain positive and solution-focused, and should correspond to the warning signs. “Do not” lists should be avoided and restructured into positive language.

• Staff interventions. These also must be positive and reflect the expectations for patient behavior. They should be concise and enforceable.

• Positive reinforcers. These should be meaningful to the patient, realistic, and use a recipe format with set time frames.

Anticipating complex withdrawal

Many traditional treatment programs are becoming expert at treating and managing ongoing psychiatric and medical symptoms. Because of advances in pharmacology and treatment, we also are able to manage more complex withdrawal safely. Many cases that would have required hospital intervention a decade ago can be safely treated in high-quality residential treatment centers. Still, this means that our cases are more complex, and protracted withdrawal in these cases is not unusual.

Protracted withdrawal is marked by clearing in acute withdrawal symptoms followed by a reemergence of symptoms generally consistent with the substance from which the patient is withdrawing. This can involve slowed cognitive processes, insomnia, and some experiences of increased cravings. Delirium, while uncommon, is also possible during this period. The ARN, teamed with an addiction psychiatrist or specialist, is crucial for this patient. Too often these patients are seen as being “obstinate” or “psychotic,” and it is said that withdrawal is taking too long.

But with excellent collaborative care, patients experiencing protracted withdrawal can remain in and benefit from traditional 12-Step treatment programs. Too often these patients have been sent to other centers for treatment before a benefit can be realized. While the course for recovery from protracted withdrawal varies according to type of substance, length of dependence, and complexity of acute withdrawal, among other factors, generally these are not untreatable patients.

Counseling staff need supportive education regarding the patient's symptoms and expectations for recovery. Protracted withdrawal may require an adaptive program, with the patient offered more breaks to decrease stimulation and anxiety. Early on, the expectation will likely be 60 to 90 days of treatment, as symptoms subside and the patient can fully engage in the program. This does not mean that early on the patient cannot engage in a modified program with fewer assignments. With support, the entire community can learn from this patient. Rather than react to unusual symptoms, staff can play an important role in normalization with the development of an integrative, collaborative BCP.

Staying afloat

When there is a bump in the road of patient progress, rather than reach for the old labels and punitive programmatic restrictions, one should think about the situation differently. One should ask if an action plan that is solution-focused and integrated with the treatment team's collaborative insights could allow the patient to participate more completely. The same question can be asked if it appears necessary to conduct a therapeutic discharge on a patient.

This does not mean that no patient will ever be therapeutically discharged. All patients who refuse to sign a BCP should be therapeutically discharged, and many a BCP will include interventions leading to therapeutic discharge. But perhaps the field should abandon the adage “Get AA or die!” in favor of “Integrate so you can get AA!” The 12 Steps are the anchor; there is no reason to let them sink the ship.

Warning Signs

• Mild: Focused on somatic symptoms; increased sleep during daytime hours

• Moderate: Speaking quickly in loud voice; difficulty accepting staff redirection

• Severe: Verbal threats; repeatedly “talking over” staff and peers

Expectations of Behavior

• Calm, respectful verbal interactions with staff and peers

• Will accept physician recommendations for pharmacologic symptom management.

• Will identify changes in symptoms with nursing staff, proactively engaging in alternatives to manage symptoms as suggested by staff and as identified by patient.

Staff Interventions

• Assigned nursing staff will meet with patient at start of shift to review care plan, address ongoing symptom management, assist patient to set appropriate goals.

• Nursing staff to assess therapeutic response to medication and alternative coping mechanisms and provide patient with ongoing support and education.

• Encourage normal sleep pattern by helping patient engage during daytime hours, avoid naps during the day and go to sleep at 10 p.m.

• Staff will discontinue interactions when behavior is demanding, loud, threatening, and not redirectable. Patient should be informed in calming manner of why the interaction is being discontinued and the patient redirected to the behavioral care plan.

• Environmental rounds will be at appropriate intervals based on patient symptoms and identified to patient with the review of care plan and goals.

• Continued verbal threats will be grounds for therapeutic discharge; patient will be asked to leave campus immediately.

Positive Reinforcers

• Ability to interact with group and continue program participation

• Opportunity to interact with “therapy dog” on Saturdays

Warning Signs

• Verbal outbursts

• Wandering

• Disorganization

• Decreased sleep at night

Patient Expectations

• Patient will exhibit thoughtful and respectful behavior to patients and staff.

• Patient will stay with buddies and group at all times when out of the assessment unit.

• Patient will check in with staff when feeling unsure and confused.

• Patient expected to attempt to sleep during normal night hours, with no naps after 3 p.m. If patient is having difficulty staying awake during daytime hours, she will check in with the nurse.

Staff Interventions

• Staff will implement buddy system for accompanying patient to groups and activities outside of the assessment unit. At least two buddies/staff will be with patient in all of these instances.

• Staff will observe patient at mealtimes to ensure that she is able to move through meal line and obtain and eat meal.

• Staff will observe patient for an unsteady gait and report this to nursing if observed.

• Staff will reorient patient as needed when patient is confused, disorganized, or exhibiting thought-blocking behaviors.

• Staff will encourage a normal sleep cycle, which includes no napping after 3 p.m. and attempting to fall asleep at 9 p.m. each night.

• Staff will gently communicate being unable to understand patient when her verbalizations are confused or disorganized.

• Nursing staff will monitor for therapeutic response to medication and provide patient with ongoing education, documenting patient responses and concerns.

• Patient will be able to attend group when she can sit quietly or is redirectable, doesn't speak over patients/staff, and uses verbalizations that are congruent with the group topic.

Positive Reinforcers

• Continued group and program participation

• Patient may use meditation room during free time

• Therapeutic pass to apartment