For patients at Resnick Neuropsychiatric Hospital, care doesn’t end when they’re discharged

Personalized aftercare plans address patients’ re-entry needs and help guard against loneliness.

The care that patients with severe mental health issues receive at Stewart and Lynda Resnick Neuropsychiatric Hospital at UCLA can be life-changing. While they’re hospitalized, patients are in a supportive environment with round-the-clock attention from a dedicated team. The goal is to have them attain their highest level of functioning and then to maintain it when they leave. 

That’s where Resnick Neuropsychiatric Hospital’s social work team comes in. From the day they’re admitted, every patient has a social worker assigned to them, noted Anna Kurtz, chief of the hospital’s department of clinical social work. That same social worker continues with the patient for the duration of their stay and creates a personalized aftercare plan based on the patient’s specific situation, including their designated support system and their ongoing needs. 

“The first week after discharge is a high-risk period, where everything that was causing stress before is right back there,” Kurtz said. Meanwhile, she notes, patients have lost the “incredibly high level of support” that the hospital offers.

“We do a lot to mobilize support during that first week to help soften the landing,” Kurtz explained.

Post-acute clinic

About two years ago, Kurtz’s team established a post-acute clinic to serve as a bridge for patients during this crucial timeframe. 

The goal, she noted, is to ensure that “100% of our patients have mental health follow-up within the first seven days after being discharged.” 

In some cases, patients may have follow-up appointments already booked with an ongoing provider, but if that appointment is two or three weeks out, they’ll see a social worker or psychiatrist at the clinic in the interim. In other cases, social workers may meet with patients to help them set up ongoing care in the community, Kurtz noted.

Importance of social connections

Prior to this, the social workers at Resnick Neuropsychiatric Hospital also concentrate on mobilizing the patient’s support system, Kurtz explained.

“We start where their connections already exist,” she said. This may involve educating the patient’s family about what the patient is going through and “how they can be the best support system possible.” 

However, this can be complicated by the realities of mental illness, Kurtz noted.

“We do a lot of re-engaging,” she said. “Sometimes, families haven’t been in touch because the mental illness has put a strain on the relationship. We do a lot of repairing relationships here in the hospital, through family therapy and mental health support.”

For many patients, the support system may not be blood relatives, Kurtz pointed out. “We will reach out to whoever the patient identifies as being important in their life.”

Knowing the warning signs

As part of re-entry planning, the social workers at Resnick Neuropsychiatric Hospital educate patients and the members of their designated support team about signs to look for that may signal worsening mental health.

Warning signs can be “any change from your regular self,” Kurtz explained: “Sleeping less, sleeping more, feeling like you’ve slept all night but are still exhausted and have no energy. Not finding joy in the things that usually bring you joy. Avoiding social situations. Suicidal ideation would obviously be a very big one. We try to catch these warning signs before it even gets there.”

Sometimes patients will notice signs that their families don’t, but there may also be cases where the person who’s affected may not have the ability to recognize the signs. “We try to focus family members on observable behaviors,” Kurtz explained. “You can’t know what someone’s thinking, but you can know how they’re behaving.”

Minimizing loneliness

In addition to serving as an early warning system, the patient’s support network performs another crucial function: helping prevent loneliness, which U.S. Surgeon General Vivek H. Murthy has called an epidemic, one that worsened during the height of the COVID-19 pandemic. 

“We know that people who have social connections have better health and better health outcomes,” Kurtz explained. “Social connection is really fundamental for wellness.”

For patients who are making the transition back to their old lives, this can be even more important, to allow them to maintain the improvements they made while in the hospital rather than “having loneliness take over,” Kurtz said.

Preparing for living environments

Patients come to Resnick Neuropsychiatric Hospital from a variety of different settings and, likewise, return to a variety of living situations, Kurtz noted. 

Some, before being fully discharged, transition to a partial hospitalization program that provides ongoing structure and support. In addition to helping patients continue to develop coping skills and providing regular group therapy, the program is a way for them to make social connections. 

“That’s one of the powers of group therapy,” Kurtz said. “You don’t really feel alone. Depression and loneliness can make you feel like you’re the only person experiencing it. Knowing that’s not true when you’re listening to other people who have gone through it as well is extraordinarily powerful.”

In other cases, patients may enter a residential treatment program that’s a step down from their previous level of care to help them make the transition. These licensed facilities are often private home settings, staffed with mental-health-care professionals, and offer a setting where patients can continue to receive treatment for a few months before returning to their homes.

For patients who go straight home, the team at Resnick Neuropsychiatric Hospital helps them establish daily routines and brainstorms with them about strategies they can use as they resume their previous lives. These plans are highly personalized, Kurtz noted, given that patients may be returning to scenarios that include jobs or raising kids. 

“We look both broadly and minute-to-minute on how we can help them use their coping skills to get through the realities and the stressors of daily life,” she said.

Another subset of patients either returns to an assisted living facility or is making the transition into one if they’re no longer able to live at home. Depending on the situation, which can range from a geriatric patient who requires skilled nursing to a child with autism, Kurtz’s team helps locate a facility that can meet the patient’s needs. 

“Our goal is that they can continue to thrive in the community in the lowest level of care possible to get their needs met,” she said.

Finally, there are some patients who are homeless. If they’re interested, Kurtz’s team helps them find supportive housing, but if they opt out, the team notifies agencies in the community, including the UCLA Homeless Healthcare Collaborative, which offers mobile clinics to provide care to people experiencing homelessness.

Providing peer-to-peer support 

Even before they leave the hospital, patients can find inspiration from those who have already gone through the process. Since 2023, Resnick Neuropsychiatric Hospital has offered weekly peer-to-peer support groups facilitated by the National Alliance on Mental Illness (NAMI). 

“Patients can see someone who’s been through a hospitalization themselves and is now further along on the recovery pathway,” said Kurtz.

The groups have been “an enormous success,” she said: There are now two weekly groups for adults, and a third one geared to child and adolescent patients is in the works.

“Hearing from someone who’s been through it gives a lot of hope,” said Kurtz, “that things can get better.”  

Learn more

Resnick serves patients of all ages with psychiatric and developmental challenges.

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