Discharge Planning for Adolescent Substance Abusers
Charmaine Whitton, AAS, RN
Nursing Case Management
Professor Kontzamanis, PhD, RN
This paper will discuss the concept of discharge planning for the adolescent substance abuser, as
well as cultural competence and how it is relevant to the identified topic. In addition to how the
culturally competent case manager will improve case management practice. Discharge planning can be
identified as a process that arranges for transition of care. It begins on the day of admission to prepare
the resources the patient may need to be transferred or transitioned safely. According to Powell and Tahan
(2010), “Transitional planning is defined as dynamic, interactive, collaborative, interdisciplinary process
of assessment and evaluation of healthcare needs of patients and their families or caregivers during or
after a phase or episode of illness. It aims to transition patients from one level of care to another. It
also includes assessment of the patient’s condition. In addition, the process ensures appropriate level of
care-at the right time, in the right amount, by the right provider, and in the right setting” (p.161).
In contrast, discharge planning is vital to and is incorporated to transitional planning. Ultimately it
focuses on discharging patients from an impatient hospital setting to another facility or home (Powell &
Tahan, 2010, p.161).
Despite the difference in the use of terms transitional planning and discharge planning,
regulatory and accreditation standards continue to focus mainly on discharge planning. The Joint Commission
requires procedures on discharge planning as well. It also requires procedures on patient flow that
indirectly implies standards around transitional planning despite the lack of use of such term (Powell &
Tahan, 2010, p.161). In the discussion of discharge planning for the adolescent substance abuser, the use of
alcohol and illicit drugs by adolescents continues to be a problem in the United States (Kellenher &
Chislom, 2006). According to the Substance Abusive Treatment Prevention and Policy, there are over nine
thousand admissions for substance abuse-related primary diagnoses in the United States (U.S) acute care
hospitals in the year 2000. Most admissions are related to drug dependency and drug/alcohol use (2006).
With numbers rising in today’s society, the number of admissions can be predicted to have doubled since the
year 2000. The National Institute on Drug Abuse, Monitoring the Future [MTF] survey indicates facts and
statistics about youth substance; stated that, “Illicit drug use among teenagers has continued at high
rates, largely due to the popularity of marijuana. Daily use of marijuana increased to 6.5 percent of
twelfth graders, compared to 5.1 percent in 2007” (2012).
The awareness of increasing rates in addition to the passion I personally have for our youth
made this a topic of interest. As a Registered Nurse, we consume the role of advocacy, education,
coordinating, and empowering, which to me indicates that we are strong enough to make a difference. The five
important functions of case management: assessment, planning, linking, advocacy and support are described
within the framework of each phase of an adolescent’s treatment programming which include assessment,
treatment, and continuation of care.
The Case Manager (CM) concept is definitely relevant to and influenced by cultural competence.
There is a need for case managers to be aware and up to date to new drugs and substances, both legal and
illegal on the market, streets, community and the society. The drugs popularity, and what social or
economical groups are at high consumption of these drugs. The CM must also have knowledge of what causes the
increase of substance use and dependency among the youth. Purnell (2009) states, “girls have considerably
less freedom in dating than their brothers. Suppression of personal freedom by parents is a major risk for
suicidal attempt in Greek adolescent girls. Additional areas identified a high-stress level for Greek
adolescents caused by extreme dependence on the family, intense pressure for school achievement, and a lack
of sexual education in the home (p.156). This example does not only disclose the stressors that adolescents
go through, but relates to the Greek culture; thus making cultural competency crucial in case management and
in the adolescents care. A cross-sectional study among university students in France from 2009 – 2011
reveals that university students face multiple stressors such as academic overload, constant pressure to
succeed, competition with peers as well as concerns about the future. Stress should not only be considered a
condition, but should be associated with potential risk behaviors leading to onset of substance use and
related problems (Tavolacci, et al., 2013). Adolescents spend a great deal of time inside and around their
schools where they directly and indirectly affected by school and community norms and culture (Kristjansson,
Sigfusdottir, &Allegrante, 2013). Likewise a population based data from 2009 Youth in Iceland school
survey, with seven thousand eighty four participants, analyzed that school-level peer smoking and
drunkenness were related to adolescent daily smoking and lifetime drunkenness. All respondents, irrespective
of socio-economic status and other background variables, time spent with parents, academic performance,
self-assessed peer respect for smoking and alcohol use, or if they have substance using friends or not,
support the purpose of prevention. They also believe that school communities should be targeted as a whole
in substance prevention programs in addition to reaching out to individuals of particular concern.
As a case manager, he/she must be conscious of the developmental stage of adolescents, young adulthood
carries significant risk for harmful use of alcohol and other drugs (Urbanoki, Kelly, Hoeppner &
Slaymaker, 2012, p.344). Therefore the CM should be unbiased and nonjudgmental. The role of family must also
be taken into consideration. The following should be of concern: What role does the parents and family play
in the adolescents’ life? As examined previously, it differentiates among cultures. What short and long term
effects can occur from the substance that is being abused? How does it affect their daily activities, mood,
or behaviors? What treatment plan is most effective? What will be a safe discharge or transition for this
adolescent or effective discharge plan?
Moreover, when the conversation of cultural competency arises in the relationship between case managers and
adolescents; the “culture” itself of the adolescent is not the only factor that has to be taken into
consideration, but the adolescent as an individual within society. Questions of significance should include:
What are the economical or sociological influences of adolescents in your community or hospital? What are
the contributing factors of the environment? How is culture perceived in a multicultural and behavioral
health setting?
“Substance-related disorders in adolescence are caused by multiple factors, including genetic vulnerability,
environmental stressors, social pressures, individual personality characteristics and psychiatric problems”
(The Center of Drug and Alcohol Program, 2013); all in which the cultural competent CM will need to be open
and receptive to, to collaborate effectively and successfully discharge to appropriate, efficient and safe
care.
Nursing case managers are suitable in assisting in intervention for substance abusers because they
generally have trouble with other aspects of their lives (Rockville, 1998).
Demographic realities in the US dictate that CM will come in contact and work with individuals of different
gender, color, ethnicity, and sexual orientation. Rockville proposes that case managers must respond
proactively and reactively to racism, classism, and sexism. He also discusses the five elements that are
associated with becoming culturally competent: valuing diversity, making cultural self assessment,
understanding the dynamics when cultures interact, incorporating cultural knowledge, and adopting practices
to address adversity (1998). Rockville continues to demonstrate that, “It is crucial for the CM to be aware
of what inhibit minorities participation in the substance abuse treatment continuum” (1998). For example,
the statement made in Alcoholic Anonymous (AA), “accepting ones powerlessness” is a central tenet of 12 Step
self-help programs. Members of oppressed groups may not accept it, given their own societal powerlessness.
“The case manager must always be sensitive to such cultural differences and identify resources that are
relevant to the individuals values. The basic function for the case manager, while being culturally
competent is to improve retention and outcome” (1998).
As anything in life there is always room for growth and improvement. The culturally competent case
manager has the capability to give adolescents hope, motivation, and perseverance with the knowledge that
some adolescents are just at a higher risk of developing substance-related disorders. Some of these
conditions are, but not limited to children of substance abusers, adolescents who are victims of
psychosocial, emotional, physical and sexual abuse. Those diagnosed with depression and suicidal ideations
are also some factors that the CM can be aware of. As well as taking into consideration the tolerance to
certain medications that are prescribed for therapy and expectations that goes along with the patients’
condition.
Prevention of substance dependence is key. There are several approaches that the case manager can
utilize to work with these individuals. This includes school based prevention programs that provide drug and
alcohol education, behavioral skills training along with interpersonal skills. Which is vital to adolescents
because school is a place where children learn to develop relationships, and the opinions of their peers
matter. Most importantly family focused prevention programs that include family therapy, family skills
training, parent training and family-self help groups are essential. I say family focused prevention is of
importance because support from ones family is greater than no other. The American Academy of Family
Physicians confirms that “Family therapy is crucial, and the provision of family support in strength
building” (2005). However, the case manager must also be knowledgeable to the patient’s substantial needs.
Including clothing, transportation, shelter, childcare or food. Treatment may not be an individual’s
priority; it may simply be safe shelter. The case manager can effectively collaborate for the adolescent to
supportive residential housing. While meeting the clients basic need he or she will be more comfortable to
endure the path of recovery. Adolescent drug and treatment programs are also options upon discharge in
correlation to relapse prevention plans.
Referrals may be needed for agencies, group, community or professional entities, case managers must
continuously assess and evaluate the referral resources to ensure that they are beneficial and appropriate
to the clients’ needs, and outcomes. Discharge information should be clear; language specific and delivery
of information should be at the adolescents and family level of education. The culturally competent case
manager, can improve advocacy, be willing to accept others, understand culturally specific responses to
problems, have the ability to view the patient as an individual and not just a member of a group, and most
importantly have the ability of have self-awareness. Optimally achieving improved mental and psychological
health by helping adolescents meet academic requirements and acquiring a positive support system. The
willingness to an open mind can ultimately improve, motivate and provide opportunities for adolescents and case managers to be a productive part of society.
References
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Company.
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