FRAMEWORK FOR IMPLEMENTING A

PARTIAL HOSPITALIZATION PROGRAM

Erin Bachler, Katelynn Krause, & Stephanie Moon

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PARTIAL HOSPITALIZATION PROGRAMS (PHPs)

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COMMUNITY PARTNER: HOLLAND HOSPITAL

• 30 mins southwest of Grand Rapids, near the lakeshore

• Adding a PHP to their continuum of care
• Executive summary will be given to Holland Hospital based on the results of
this research in order to provide an outline for optimal framework.

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 WHY A PHP?

• PHP enrollment is correlated with a decrease in symptoms, and an increase in

functioning (Waddell & Demi, 1993; Schene et al., 1993; Granello, Granello, & Lee, 1999; Drymalski & Washburn, 2011)

• Preference for day treatment over full inpatient hospitalization (Schene et al., 1993)
• Provides an important “gatekeeper” function (McGonigle, Krouk, Hindmarsh, et al., 1992)
• Therapeutic interplay between the community and treatment that
inpatient/outpatient can’t provide (Rosie, 1987)

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 OT’s ROLE IN MENTAL HEALTH
• In the 1920s, OT was practicing as an integral part of this field, and it had
already developed a rich history in mental health through the use of meaningful
and enjoyable occupations (Meyer, 1922).

• Sensory approaches are a successful intervention for reducing distress in mental

health patients and decreasing the rate of patient restraint and seclusion (Scanlan &
Novak, 2015; Strauss, Van Heerden, & Joubert, 2016).

• OT plays a distinct role in life transitions, helping individuals adjust their roles
and routines to meet the demands of everyday life.

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 PROBLEM STATEMENT

Current research is lacking in regard to proposed

structures for the implementation of a new PHP,
and in order for certain components to be
included in the structure, their outcomes must
also be considered.
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 PURPOSE OF STUDY
• Which disciplines, program structures, and outcome
measures are widely used in current PHPs, and what
is OT’s distinct role within PHPs?
• Survey of a sample of PHPs across the U.S. to define
program components commonly used to aide in the
development of a new program.
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 SIGNIFICANCE
• Fill the gap in the continuum of care by assessing
current PHP trends, and contributing to the
limited literature on PHPs.

• Synthesize a proposed structure for a new PHP,

combining common components and literature
regarding their effectiveness.
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 RESEARCH QUESTION

Which disciplines, program structures, diagnoses,

and outcome measures are components of
current PHPs? What is OT’s distinct role in
facilitating these components? What is a
recommended framework for a new PHP?
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 Driving Theory: PEOP
Main Focus: Individual, Population, and Institutional Needs
● Person Factors (intrinsic): psychological, physiological,
cognitive, motor, sensory, and spiritual
● Environmental Factors (extrinsic): physical, natural, cultural,
societal, social, and economic components.
● Occupations: roles, tasks, activities
● Performance: interaction of person, environmental, and
occupation factors

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 PEOP and PHP Integration
● Identifying Person Factors...
○ Prior knowledge and societal needs of population
○ Investigate therapy models which promote occupational
performance
● Identifying Environmental Factors...
○ Combine prior knowledge of Holland Hospital’s needs with
investigation of disciplines, daily structure, therapy models,
and outcome measures of current PHPs
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 PEOP and PHP Integration
● Identifying Occupations...
○ Past, existing, and future occupations form life roles
○ Coping skills to adapt to changing person/environmental
factors
● Identifying Performance...
○ Performance leads to role involvement
○ Participation in home and community life
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LITERATURE REVIEW

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 STRUCTURE
Three main pieces compose structure:
○ Average patient enrollment period
■ 5.6 days - 1.5 years
(Bateman & Fonagy, 2003; Lieberman, & Guggenheim, 2016)

○ Daily hours that the program operates

● 5 days/week, 6hrs/day
(Drymalski & Washburn, 2011; Granello, Granello, & Lee, 1999; Hoge et al., 1988; Lieberman & Guggenheim, 2016;
Thompson,1985; Yanos et. al., 2009)

○ Activities

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 STRUCTURE: ACTIVITIES
May consist of group or one-on-one formats

○ Educational classes ○ Therapeutic meals

○ Family therapy ○ Sensory activities
○ Psychodrama ○ Prevocational services
○ Art therapy ○ Meditation & mindfulness
○ Music therapy

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 DISCIPLINES
PHPs utilize certain disciplines, and the amount
staffed of each discipline varies when it comes to:

● Nurses ● Social Workers

● Occupational Therapists ● Case Managers
● Certified Occupational Therapy ● Recreation/Activity Therapists
Assistants (COTA) ● Dieticians
● Psychiatrists ● Administration Support Staff
● Psychologists ● Chaplain
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 MEASURING OUTCOMES
● Attention and focus, following of instructions, directedness towards activity,
and willingness to participate (Strauss, Van Heerden, & Joubert, 2016)
● Likert scales (Strauss, Van Heerden, & Joubert, 2016; Bystritsky et al., 1999)
● Patient satisfaction questionnaires (Granello, D., Granello, P., & Lee, 1999)
● Stability and routines, skills and abilities, and peer support (Horghagen, Fostvedt, & Alsaker
2014)

● Rate of patient restraint and seclusion (Scanlan & Novak, 2015)

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METHODOLOGY

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 RESEARCH DESIGN
● Descriptive, Quantitative Study
○ Aim: to collect non-subjective information about currently
operating PHPs

○ Information obtained via survey

■ A survey containing less than 30 questions increases the
likelihood of responders providing accurate information
(Survey Monkey, 2011)

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 POPULATION & SAMPLE
● Population: All PHPs within the U.S.

● Sample: 150 PHPs within the United States

○ Members of the Association for Ambulatory Behavioral
Healthcare (AABH)
○ Distributed by Mickey Wright, Executive Director via email

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 VALIDITY & RELIABILITY
● Content Validity
○ PHP staff from two different adolescent programs reviewed the survey:
■ 1 psychiatrist
■ 2 social workers
■ 1 CTRS

● An interdisciplinary team from Holland Hospital reviewed the survey for clarity
and content

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 PROCEDURE

● Survey was created and administered through Qualtrics, a comprehensive

survey program

● Participants were given four weeks to complete the survey, with a reminder
after two weeks

● Respondents were given a chance to win a 1 of 3 $50 Amazon gift cards

● Respondents will receive a copy of the executive summary

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 DATA ANALYSIS

• Results were calculated through use of:

• Qualtrics
• Excel
• Descriptive statistics
• Mean, Mode, SD, Range

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RESULTS

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 RESPONSE RATE
• 31 respondents, but two respondents removed
• Incomplete survey
• PHP not in existence yet

• 29 individuals were included in final data analysis

• Response rate of 19%

• Survey respondents: 83% administrative staff or manager

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 PHP FACILITY DEMOGRAPHICS
• Average length of operation: 22 years and 8 months
• Average daily census: 22 patients

• Staffing across PHPs:

Disciplines Employed Total Number % of Total
Social Workers 92 20.8
Nurses 67 15.1
Psychiatrists 58 13.1
Occupational Therapists (OTs) 13 2.9
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 PATIENT DEMOGRAPHICS
• Ages served
• Adults (19-55 years old) - 91.3%
• Older Adults (56+ years old) - 79.3%
• Adolescents (13-18 years old) - 10.3%
• Children (1-12 years old) - 6.9%

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 PATIENT DEMOGRAPHICS
• Average patient enrollment period: 23.6 days
• Average distance travelled: 13 miles

• Diagnoses:
Diagnoses Treated Number Percent
Depression 29 100
Anxiety 26 89.7
Bipolar disorder 25 86.2

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 ACTIVITY STRUCTURE
• Patients follow similar daily schedule: 89.7% of PHPs
• Majority of activities group based
Therapy Models Number Percent
Dialectical Behavior Therapy (DBT) 21 72.5
Cognitive Behavioral Therapy (CBT) 17 58.6
Mindfulness 17 58.6
Activities
Educational Group Sessions 27 93.1
Group Talk Therapy 26 89.7
Meditation and Relaxation 24 82.8
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 ACTIVITY STRUCTURE
• Sensory methods: 20.6% of PHPs
• Mostly sensory groups and individual activities

• Most commonly used educational group sessions:

Activities Number Percent
Coping skills 26 89.7
Stress management 26 89.7
Medication management 25 86.2
Identifying problem behaviors/triggers 25 86.2

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 OUTCOME MEASUREMENTS
• Most commonly used symptom reduction measurements:
Outcome Measurements Number Percent
Patient Health Questionnaire 9 (PHQ-9) 13 44.8
Observation 9 31.0
Global Assessment of Functioning (GAF) 7 24.0

Time of Measurement Number Percent

End of Treatment 18 60.2
During Treatment 16 55.2
3-Months Post Discharge 1 3.4
6- Months Post Discharge 1 3.4 31
 CONTINUUM OF CARE
• Steps within the continuum of care provided by each
respondent:
Continuum of Care Number Percent
PHP 28 96.6
Behavioral health inpatient unit 24 82.8
Intensive outpatient program (IOP) - mental health 22 75.9
Outpatient therapy 21 72.4

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DISCUSSION

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 PHP FACILITIES
• Pt. enrollment periods, daily census, and hours per day in PHP consistent with
previous research (Drymalski & Washburn, 2011; Granello, Granello, & Lee, 1999; Hoge et al., 1988; Lieberman & Guggenheim,
2016; Thompson,1985; Yanos et. al., 2009; Thompson, 1985; Gunkel & Priebe, 1993; Rienecke, Richmond, & Lebow, 2016; Konopik &
Cheung, 2012)

• Longer enrollment periods for schizophrenia & bipolar disorder (Priebe & Broker, 1999;
Bateman, & Fonagy, 2003; Gunkel & Priebe, 1993; Thompson, 1985)

• Daily census - no patterns noted

• Lack of research evaluating efficacy

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 PREVALENT DIAGNOSES
Depression, anxiety, and bipolar disorder
• High rates of hospitalization for mood disorders (Agency for Healthcare Research and Quality,
National Alliance on Mental Illness [NAMI], 2016)

• 10-20% of adults visit physician due to depressive or anxiety disorder episode

(Hirschfeld, 2001)
• 50% of these patients have comorbid anxiety/depression

• Which patients benefit most still unclear(Thompson, 1985)

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 USE OF THERAPY MODELS
• Dialectical Behavior Therapy (DBT)
• Derived from CBT, created to treat patients with borderline personality
disorder, used for others (DiGiorgio, Glass, & Arnkoff, 2010; Dixon-Gordon, Chapman, & Turner, 2015)

• Cognitive Behavioral Therapy (CBT)

• Well-established model for treatment (Hauksson et. al., 2017; Olatunji & Hollon, 2010)

• Mindfulness
• Has ties to DBT(Allen, Blashki, & Gullone, 2006; Snippe et. al., 2015)

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 EDUCATIONAL SESSIONS
• Top activities in current PHPs: Educational group sessions, group talk therapy,
and meditation/relaxation

• AAPHSG suggested programming: communication skills, assertiveness training,

stress management, symptom recognition, problem solving, and relaxation
training (Block & Lefkovitz, 1991).

• Psychoeducational groups used within PHPs include: goal-setting, stress

management, coping skills, weekend planning, family support,
symptom/medication management, and occupational therapy workshop
groups (Kent et. al., 2000).
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 SENSORY BASED TREATMENT
• Rarely used within PHPs (Scanlan & Novak, 2015)

• Adults who are over-responsive to environmental stimuli experience life

different from others, and are more likely to describe their daily experiences as
irritating, overwhelming, disorganizing, and distracting (Kinnealey, Oliver, & Walbarger, 1995)

• Individuals with sensory defensiveness have significantly more symptoms of

anxiety, depression, and social-emotional issues (Kinnealey & Fuiek, 1999; Pfieffer et. al., 2005)

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 METHODS OF MEASURING
TREATMENT OUTCOMES
1. Patient Health Questionnaire-9 (PHQ-9)
• Depression screen - reliable and valid (Arroll et al., 2010; Inoue et al., 2012)

2. Observation
• Non-standardized (Bateman & Fonagy, 1999)

• Outcomes measured during treatment and prior to discharge (Bateman & Fonagy, 1999)

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 CONTINUUM OF CARE
• PHPs commonly paired with inpatient and outpatient services
• Consistent with past research (Yanos, et al., 2009; McGonigle et al., 1992; Beard et al., 2016; Taube-Schiff et
al., 2017; Durbin, et al., 2017)

• Limited research addressing PHPs and IOPs (Gratz, Lacroce, & Gunderson, 2006)

• Further research address efficacy of pairings

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 THE ROLE OF OT
• Lack of OTs in PHPs and mental health
• 2.4% of OTs worked in mental health in 2014 (AOTA,
2015)

• 2.9% across all PHPs surveyed

• Lack of literature regarding OTs role in PHPs

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 THE ROLE OF OT
• Social work was the most prevalent discipline working within PHPs.
• NASW Standards for Social Work Practice in Health Care Settings (2016)
social workers:
• Required to abide by a defined scope of practice as required by state law
or regulation (p.20).
• Have knowledge of behavioral health conditions.
• Run assessments including “behavioral and mental health status,
including current level of functioning, coping style, crisis management
skills, substance abuse history, and risk of suicide or homicide” (pg.26)

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 THE ROLE OF OT
• Dialectical Behavior Therapy (DBT)

• OTs can obtain DBT certification and conduct

DBT-based classes (Lee & Harris, 2010)
• OT aligns well with DBT

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 THE ROLE OF OT
OT’s Role in Education

• Educational group sessions have been run as OT workshops (Kent et al., 2000).

• OT educational programs are used as a cost-effective method to improve

medication adherence and to reduce hospital readmission to behavioral health
inpatient programs (Steed, 2014).

• Educational groups on: positive parenting skills, understanding child behavior,

building relationships, and managing behavior (Phelan et al., 2006)

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 THE ROLE OF OT
OT’s Role in Sensory Intervention

• Sensory approaches in inpatient psychiatric facilities as an important

component of person-centered crisis prevention that help patients
self-organize, reduce levels of distress, and reduce episodes of seclusion and
restraint (Champagne, 2005; Champagne & Stromberg, 2004).

• Can provide anything from assisting patients in developing and practicing

sensory diets to making recommendations for environmental modifications
(Champagne, 2005).

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 LIMITATIONS
• Sample was limited to PHPs with AABH membership

• One respondent reported they do not have a PHP

• Disciplines were not linked to the activities they run

• Respondents can only report what they know

• Survey incompletion / auto-submit error

• A number of people closed their browser window before clicking “submit”,
which caused the last question to appear incomplete

• Ceiling effect for questions that only went up to the number “100” 46
 IMPLICATIONS
● Behavioral Health
○ Increased need for mental health services; need continuum of care
○ PHPs bridge the gap in care
○ Lack of literature regarding PHPs
○ Efficacy of interventions offered and who leads them

● Occupational Therapy
○ Underutilized in PHPs
○ Expertise to support transition back to home and community life following a
mental health crisis
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 DISSEMINATION
• Executive summary provided to Holland Hospital and AABH
• American Occupational Therapy Association conference
• Salt Lake City, Utah - April 2018
• Publication in Journal of Behavioral Health Services and Research
• Manuscript to be edited and submitted in coming year(s)

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QUESTIONS OR COMMENTS?

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THANK YOU!

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