Community-Based Psychiatric Nursing Care

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Community-Based Psychiatric Nursing Care
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• 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. Successful transforming
  the mental health service delivery system rests
  on two principles
• Services and treatments must be consumer and
  family centered.
• Care must focus on increasing consumers' ability
  to successfully cope with life's challenges, on
  facilitating recovery, and on building
  resilience.

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• The reports shows that offering a full range of
  community-based alternatives is more effective
  than hospitalization and emergency department
  (ED) treatment.

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• 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.

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• 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).

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Deinstitutionalization

• At the patient level, deinstitutionalization
  refers to the transfer of a patient hospitalized
  for extended periods of time to 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.

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• 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 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 professionals trained to work this
  population in the community.

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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.

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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).

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• 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

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• Identification and outreach
• Assessment
• Service planning
• Linkage with needed services
• Monitoring service delivery
• Advocacy
• In addition, core aspects and specific
  interventions related to clinical case management
  are listed in Table 34-1

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• 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.

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Assertive Community Treatment

• Assertive Community Treatment (ACT) was developed
  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.

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• 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.

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• 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.

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• 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 community-based "Hospital
  without walls," providing a high-intensity
  program of clinical support and treatment.

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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.

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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.

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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.

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• 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.

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• 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.

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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.

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• 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.

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• 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.

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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)

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• 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)

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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.

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• 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

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• 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.

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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.

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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.
• 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.

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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.

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• 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.

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• 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.

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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.

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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.

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• 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. Self-awareness 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.

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• 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.

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• 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.

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• 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.

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• 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.

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• 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.

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• 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.

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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.

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• 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,
  sex-offender treatment, substance abuse
  treatment, and discharge planning.

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• 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.

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• 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.