2020 APNA Award for Innovation – Individual
Georgia L. Stevens, PhD, APRN, PMHCNS-BC
“I think I’ve always practiced from the perspective that I have so much to learn – from both the providers that I’m working with and from the consumers,” says Georgia L. Stevens, PhD, APRN, PMHCNS-BC, this year’s recipient of the APNA Award for Innovation – Individual. Her dedication to learning helped her identify a need and drove the creation of an innovative way to facilitate discharge planning and aftercare coordination for older adults with serious mental illness. “Dr. Stevens’ model across the state of Maryland has resulted in only a 5% re-hospitalization rate over more than 4 decades,” says Julie Carbray, who nominated Georgia for the award. “Her collaborative work across multiple agencies has addressed system-level challenges in service delivery for this vulnerable population.”
A private practice nurse prescriber and psychotherapist, as well as a Long Term Care Nurse Educator and Care Consultant for Behavioral Health System Baltimore, Georgia has dedicated her career to working with older adults with serious mental illness (SMI). She started her care coordination and discharge program in the 1980s. “It was a time when they said you couldn’t move people with SMI from hospitals or they would die,” she recalls. Georgia conducted research to better understand the challenges facing older adults with SMI as they re-integrated to their lives outside of inpatient settings. This research identified a pressing need for support in addressing the serious health co-morbidities in many adults with SMI as part of their whole health journey. Georgia understood that coordinating care for individuals with SMI after deinstitutionalization would require collaboration across services and providers.
Georgia has worked closely with community programs, nursing homes, and families to share education, resources, and monitor strategies with one goal in mind: ensuring that these individuals had access to the care they needed to thrive. As a result, she pioneered a dynamic care coordination program to address the health needs of each individual as they re-entered their communities. “It’s especially rewarding to see people be successful in the community and have the opportunity to have long term relationships,” says Georgia. “I follow people for life, so I get to build long term relationships with them – both the people leaving the hospitals and people who are providing direct care in the community.” And the results reflect Georgia’s tenacity and skill: a low re-hospitalization rate and a strengthened network of care within the community. As Carbray says, “She steps in to educate, monitor, and assure best coordination for these consumers…she has solved complicated consumer situations and system level challenges.”
“It’s especially rewarding to see people be successful in the community and have the opportunity to have long term relationships.”
Georgia has also developed training programs to secure the future of this work and support staff working with older adults with SMI. “She has created educational publications and videos to help mental health providers learn the best, innovative approaches to care,” says her colleague Barbara Warren. “Her energy and stamina are infectious.” As she designs these resources, Georgia stays focused on the needs of the providers directly serving this vulnerable population. “I’ve had a respect for frontline staff, the geriatric nursing assistants and techs, who are our eyes and ears,” she says. One such resource is a series of videos focusing on potential needs and issues in caring for older adults with SMI told from the perspectives of the direct care providers. Topics include abuse and neglect, tobacco dependence, stress management, younger residents in nursing homes, team conflict, and recognition of delirium.
When looking to the future of care coordination, Georgia encourages her psychiatric-mental health nursing colleagues to keep the spirit of collaboration close. “I think that we as PMH nurses are in the best position to really collaborate with other providers and with consumers: to facilitate them having a real recovery journey rather than an illness journey,” she says. “If you bring your passion and your humanity, actively listen, and empathize, you will have the capacity to work with people.”