Community-Based Psychiatric Nursing Care 1
The goal of the mental health delivery system is to help people who have experienced a psychiatric illness live successful and productive lives in the community and to ensure that consumers and families have access to timely and accurate information that promotes learning, self-care management, and health. Started that successfully transforming the mental health service delivery system rests on two principles: 1. Services and treatments must be consumer and family centered. 2. Care must focus on increasing consumers' ability to successfully cope with life's challenges, on facilitating recovery, and on building resilience. The report goes on to say that evidence shows that offering a full range of community-based alternatives is more effective than hospitalization and emergency department (ED) treatment. Many psychiatric nurses work in community-based settings, where they assume a broad range of responsibilities and engage in a variety of tasks and interventions (Kudless and White, 2007). In these settings they work with interdisciplinary teams and focus on prevention, care management, and recovery. Nurses at both the basic and advanced levels of education practice in the community where they engage with consumers and family members, empowering them to make decisions about their care. Consumers have noted that community mental health nurses increase their access to care, engage in positive relationships with them, and help them meet their health care needs (Elsom et al, 2007). Deinstitutionalization: At the patient level, deinstitutionalization refers to the transfer of a patient hospitalized for extended periods of time a community setting. At the mental health care system level, it refers to a shift in the focus of care from long-term institution to the community, accompanied by discharging long-term patients and avoiding unnecessary admissions. In reviewing the failures of this early attempt to move patients into community care, mental health experts agree that the following problems contributed to the lack of success: Poor coordination between state hospitals and community mental health centers. Underestimation of the support systems needed to enable people with mental illness to live in the community. Lack of knowledge about psychiatric rehabilitation. Shortage of professional trained to work this population in the community. 2
A systems model of care: A systems model of community mental health operates on the philosophy that all aspects of a person's life need to be cared for basic human needs, physical health needs, and needs for psychiatric treatment and rehabilitation if a person is to live successfully in the community. The focus is on developing a comprehensive system of care and coordinating needed services into and integrated package for persons with severe and disabling mental illnesses. Case Management: In implementing these systems, case management became the primary means for ensuring that the components were available to every person with a chronic mental illness who needed them. Components of a community support system include patient identification and outreach, mental health treatment, crisis response services, health and dental care, housing, income support and entitlement, peer support, family and community support, rehabilitation services, and protection and advocacy. (Figure 34-1). Case management involves linking the service system to the consumer and coordinating the service components so that the consumer can achieve successful community living. It focuses on problem solving to provide continuity of services and overcome problems of rigid systems, fragmented services, poor use of resources, and problems of inaccessibility. The six activities of case management are as follows: 1. Identification and outreach 2. Assessment 3. Service planning 4. Linkage with needed services 5. Monitoring service delivery 6. Advocacy In addition, core aspects and specific interventions related to clinical case management are listed in Table 34-1 3
At present, case management is an ambiguous concept without a clear base in any one provider group. Further, there are various models or types of case management, including full service, broker, therapist, intensive, peer based, social support, collaborative, community advocate, and problem focused-each with its own structure, purpose, and team composition. Questions about the effectiveness of the different types of case management and the recommended caseload of case managers remain unresolved. Assertive Community Treatment: Assertive Community Treatment (ACT) was developed in Wisconsin in the early 1970s as a program originally called Training in Community Living (TCL). It was created as a way to organize outpatient mental health services for patients who were leaving large state mental hospitals and were at risk for rehospitalization. ACT is a service delivery model, not a case management program. It was designed for people with the most challenging and persistent problems. The goal of ACT is recovery through community treatment and habituation. This model program provides a full range of medical, psychosocial, and rehabilitative services. The 10 principles of ACT are listed in Box 34-1. 4
ACT uses an interdisciplinary, team-oriented approach that typically includes 10 to 12 professionals (nurses, psychiatrists, social workers, activity therapists) who meet regularly to plan individualized care for a shared caseload of about 120 patients. Teams may include a person with a mental illness or a family member of a person with a mental illness. More than 75% of staff time is spent in the field providing direct treatment and rehabilitation. The services provided by ACT treatment team members are listed in Box 34-2. Psychiatric nurses are typically integral members of the ACT treatment team (McGrew et al, 2003). These teams function as continuous care teams who work with patients with serious mental illness and their families over time to improve their quality of life (chapter 14). In effect, ACT programs function as a communitybased "Hospital without walls," providing a high-intensity program of clinical support and treatment. 5
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Vulnerable Populations in the community: Homeless People with Mental Illness: About one third of the estimated 600,000 homeless people in the United States have a severe mental illness. However, only 1 in 20 persons with a a mental illness, as few as 5% to 7% need to be institutionalized. Most can live in the community with appropriate, supportive housing (Mojtabai, 2005). When homeless people with mental illnesses are given the opportunity to participate in treatment programs that address their needs for services in areas such as housing, health care, substance abuse, income support, and social support, many can be helped to find homes and achieve substantial improvements in their lives. Key components of this focused treatment approach include the following: Frequent and consistent staff contact through assertive outreach. Meeting the patient where the patient is, both geographically and interpersonally. Help with immediate survival needs, such as food, emergency shelter, and clothing. Gradual treatment through the development of trust. An emphasis on patient strengths Patient choice of services and the right to refuse treatment. The delivery of comprehensive services, including mental health and substance abuse treatment, medical care, housing, social and vocational services, and help in obtaining entitlements. Rural Mentally Ill People: They include insufficient access to crisis services, mental health and general medical clinics, hospitals, and innovative treatments. Rural residents also may face greater social stigma in regard to seeking mental health care, and basic community services such s transportation, electricity, water, and telephones that are important to providing health care may not be available. Rural residents are at significant risk for substance use disorders, mental illness, and suicide. For these reasons, mental health issues are among the most prominent health concerns being faced in rural areas. As a result, the following are true about residents with mental health needs: They enter care later in the course of their disease than their urban peers. They enter care with more serious, persistent, and disabling symptoms. They require more expensive and intensive treatment response. 7
Rural areas experience three additional problems. The first is the lack of mental health professional, including culturally competent or bilingual providers. The second is the fact that people in the United States have lower family incomes and are less likely to have health insurance benefits for mental health care. Finally, many ethical dilemmas arise when practicing in the community, and some of these are unique to the rural setting. When numbers of providers in isolated settings are limited, problems may arise because of overlapping social and professional relationships, altered therapeutic boundaries, challenges in protecting patient confidentiality, and differing cultural dimensions of mental health care. Incarcerated Mentally Ill people: In the United States about 80,000 patients are in psychiatric hospitals. In contrast, some 283,800 incarcerated persons are identified as having a mental illness (table 34-2). Thus the mentally ill segment represents 16% of the inmate populations of state and local jails, or more than three times the number of people in psychiatric hospitals throughout the United States. A result of the effect of prison life on inmates is the alarmingly high rate of suicides. Suicides is the leading cause of death in inmates, accounting for more than one half the deaths occurring while inmates are in custody. Almost all who attempt suicide have a major psychiatric disorder. More than one half of the victims were experiencing hallucinations at the time of the attempt. Clearly, the presence of severely mentally ill persons in jails and prisons is an urgent problem. These individuals are often poor, uninsured, disproportionately members of minority groups, and living with co-occurring substance abuse and mental disorders. Some programs are attempting to deal with this problem in various part of the United States. A community model for services (Figure 34-2) has been developed that includes methods for preventing incarceration of people with mental illness and intervening effectively when such a person is jailed. This model is based on the formation of a community board and includes both preventive and postrelease interventions. 8
Psychiatric Care in Community Settings: Primary Care Settings: Most people seek help for their mental health problems from their primary care provider. Thus primary care settings may be the most important point of contact between patients with psychiatric problems and the health care system. The role of the primary care provider is even more important for older adults and patients from racial and ethnic minorities. However, a majority of patients with mental illness are not treated effectively in the primary care setting. The first step in addressing this issue is the use of effective screening measures in primary care. The U.S. Preventive Services Task Force recommends the following (AHRQ, 2006): Screening adults for depression in clinical practices that have systems in place to ensure accurate diagnosis, effective treatment, and follow-up Screening and behavioral counseling interventions to reduce alcohol misuse by adults, including pregnant women in primary care settings. Recent research has shown that one- or two-item screening tools are effective in identifying those at risk for substance use or depressive disorders (Table 34-3) 9
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May studies have assessed strategies to improve the delivery of mental health care in primary care settings. Much of this work has been done in the area of depression because it is one of the most common disorders seen in the general medical setting and because effective treatments are available for depression. The most promising intervention is the implementation of collaborative care programs. Collaborative Care, collaborative care models have two key elements. The first is systematic care management most often done by a nurse to facilitate case identification, coordination of a treatment plan, patient education, close follow-up, and monitoring of progress. This can be done in the primary care setting or by telephone. The second elements is consultation among the primary care provider, case manager, and a mental health specialist. Research has shown that collaborative care models for depression improve clinical outcomes, employment rates, functioning, and quality of life and that they are cost-effective (Gensichen et al, 2006; Unutzer et al, 2006). Another framework that nurses can use for behavioral counseling in primary care is the 5A's: Assess Ask about a person's behavioral health risk and factors affecting one's choice of future goals. Advise- Give clear, specific, and personalized behavior change advice, including information about personal health harms and benefits. Agree- Collaboratively select appropriate treatment goals based on the patient's interest in and willingness to change the behavior. Arrange- Schedule follow-up contacts (in person or by telephone) to provide ongoing support, including referral to a specialist if needed. Nurses can play a pivotal role in integrating the mental health and physical care of patients in primary care settings. Emergency Department Psychiatric Care: Emergency departments (EDs) cannot deny treatment, and therefore they have become the safety net for patients who do not have access to care or the resources to go to another type of facility. With substance use disorders and mental illness contributing tot many other illnesses, EDs have seen and increasing number of patients who require interventions for these problems. Patients who have attempted suicide are most often seen in the ED. Psychiatric Services in the Emergency Department: Many tertiary care, acute care hospitals have psychiatric services available in the ED. These services have evolved from crisis intervention to diagnostic and treatment services, often with on-site treatment and referral to community services. 11
However, nurses and other clinicians working in EDs tend to focus less on theses disorders than on physical illnesses and injuries. The many reasons for this include time constraints, lack of confidence in intervening effectively, reimbursement issues, an bias and stigma bout psychiatric care. Home Psychiatric Care: Home psychiatric care is available to a broad segment of the population. Factors contributing to the development of this treatment setting include the following: Continued trend of deinstitutionalization. Growth of managed care, which focuses on cost, outcomes, and earlier hospital discharges. Advocacy by consumer groups to find less restrictive and more humane ways of delivering care to people with mental illness. Psychiatric home care programs are changing rapidly in response to the increased number of people with psychiatric illnesses living in the community and the competitive health care market. Perhaps the best reason to advocate for psychiatric home care is that it is a humane and compassionate way to deliver health care and supportive services. Home care reinforces and supplements the care provided by family members and friends and maintains the recipient's dignity and independence-qualities that are all too often lost in even the best institutions. The advantages of home care in relation to inpatient treatment involve its ability to serve as the following: An alternative to hospitalization by maintaining a patient in the community A facilitator of an impending hospital admission through preadmission assessment. An enhancement of inpatient treatment plan A way to shorten inpatient stays while keeping the patient engaged in active treatment. A part of the discharge planning process by assessing potential problems and issues. Examples of other gains obtained by psychiatric home care include its outreach capacity and emphasis on patient participation, responsibility, autonomy, and satisfaction. 12
Reimbursement Issues: Medicare guidelines do not provide very specific information on psychiatric nursing services that are covered on home visits. They do require that the patient meet all of the following criteria: Be homebound Have a diagnosed psychiatric disorder Require the skills of a psychiatric nurse. Context of Home Care: Psychiatric home care nursing provides unique challenges and opportunities to the nurse. In an impatient clinic or office setting, the provider has the control and power that come with ownership. The patient is a guest, and the nurse is the host. In the home setting the nurse is the guest and the patient sets the rules. This raises four key issues for the nurse: Cultural competence, flexibility in boundary setting, trust, and safety. Cultural competence. Awareness of the patient's ethnic and cultural background is critical to effective care in all settings. The nurse is exposed to the patient's culture, and the patient will observe the nurse's reaction in these surroundings. It is important that the nurse also have an understanding of one's own cultural background and the prejudices related to socioeconomic status, gender, family structure, and ways of dealing with emotion emanating from that background. Selfawareness gives the nurse the ability to step back from a judgmental stance and ask whether a certain behavior, opinion, or way of coping stands in the way of the patient's ultimate health. Boundary issues. Closely related to cultural issues are that differences in boundary issues. In the home setting it may be appropriate for the nurse to sit and share a cup of tea with the patient or eat a piece of cake. If the patient's culture is one that sees hospitality as connected closely to the sharing of food and refusal of food is thought of as an affront, then being willing to share in this ritual can build trust in the relationship between the nurse and patient. Trust. The psychiatric home care nurse must consider many different factors when planning and implementing nursing care. Unlike nursing practice in the hospital or outpatient mental health center, psychiatric home care nurses have little control over their patients' environments. It is therefore essential to establish trust in the initial evaluation home visit. Trust then becomes a vital part of the nurse-patient relationship as the patient and nurse work together to solve problems and achieve goals. For example, the nurse trusts the patient to be home at scheduled visits, take medications, and participate fully in all aspects of the plan of care. The patient trusts the nurse to be reliable, clinically knowledgeable, competent, and caring. 13
Safety. Strategies must be identified for dealing with suicidal or aggressive behavior. In this way, home health nursing does have its limitations. The nurse and patient must work together to develop and acceptable plan. If the situation becomes unsafe, the nurse must leave the home. Patients' families, caregivers, and other community resources should be urged to notify the police or take the patient to the hospital for and evaluation if the patient becomes dangerous. Nursing Activities. Nursing interventions in the home include assessment, teaching, medication management, administration of parenteral injections, venipuncture for laboratory analysis, and skilled management of the care plan. All these interventions are recognized as reimbursable skilled nursing services by Medicare. Psychiatric home care nurses provide many other skilled nursing services. They act as case mangers, coordinating an array of services, including physical therapy, occupational therapy, social work, and community services, such as home-delivered meals, home visitors, and home health aides. They collaborate with all the patient's health care providers and often facilitate communication among members of the multidisciplinary team. Forensic Psychiatric Care: Forensic psychiatric nursing is defined as a subspecialty of nursing that has as its objective assisting the mental health and legal systems in serving individual who have come to the attention of both. It is gaining momentum nationally and internationally. Forensic psychiatric nursing has two very different and sometimes conflicting goals. First is the goal of providing individualized patient care. Second is the goal of providing custody and protection for the community. The forensic focus for nursing is the therapeutic targeting of any aspect of the patient's behavior that links the offending activity and psychiatric symptomatology. As such, the forensic nurse functions as a patient advocate; a trusted counselor; an agent of control; and a provider of primary, secondary, and tertiary health care interventions to this vulnerable population. Interventions include risk assessment, crisis intervention, rehabilitation, suicide prevention, behavior management, sexoffender treatment, substance abuse treatment, and discharge planning. Settings and Roles. Most forensic psychiatric nurses work in the public sector under state departments of mental health or in psychiatric units in jails, prisons, and juvenile detention centers. However, forensic nurses are also found working in the following areas (IAFN, 2007): Interpersonal violence Public health and safety Emergency/trauma nursing Patient care facilities Police and corrections, including custody and abuse. 14
The scope of responsibility of forensic nurses can be quite broad, depending on the area of practice. Forensic nurses can practice in the ED, critical care setting, coroner's office, or correctional facility. One specific role is that of the sexual assault nurse examiner (SANE). This is a nurse who has received special training to provide care to the victim of sexual assault. 15