Mental Health Care Settings

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Mental Health Care Settings

• Rebecca Sposato MS, RN

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The Stats

• Ambulatory care
• Number of ambulatory care visits (physician
  offices, outpatient centers, and emergency
  departments) with mental disorders as primary
  diagnosis 58.2 million
• Hospital inpatient care
• Number of discharges with mental disorders as
  first-listed diagnosis 2.4 million
• Average length of stay for mental disorders 7.1
  days
• Nursing home care
• Number of residents with mental disorders
  996,000
• Percent of residents with mental disorders 67
• (http//www.cdc.gov/nchs/fastats/mental.htm,
  2011)

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Diagnostic and Statistic Manual for Mental Health
Disorders-IV

• Describes the main features and specific criteria
  for mental illness
• Multi-Axis System
• Axis 1 - Clinical Conditions (ex. depression)
• Axis II - Personality and Intellectual Disorders
  (ex. borderline personality)
• Axis III - Medical Conditions ( ex. Diabetes)
• Axis IV Psychosocial or environmental problems
  (homeless, estranged from family)
• Avis V Global Functioning (100-0)

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Global Assessment of Functioning

• 100 no symptoms, well-adjusted and content with
  life, can take care of problems, close and
  meaningful relationships
• 75 Symptoms mildly affect quality of life,
  problems occasionally emerge, socially awkward
• 50 Symptoms impair quality of life, conflict
  with peers, legal/employment issues
• 25 Symptoms impair basic life skills, at risk
  for danger to self/others, impaired communication
• 1 Hurts self/others, absent life skills unable
  to address or communicate basic needs

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Mental Health Professionals

• Registered Nurse-
• care for patient and unit
• Advance Practice Mental Health Nurse/Clinical
  Specialist-
• Graduate level education and clinical
• Ensure protocols and staff training are up to
  date and comply with regulation
• Consult for complicated patients
• Nurse Practitioner-
• Manages the physical health and needs of patients

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Mental Health Professionals

• Clinical Psychologist-
• Graduate level education and clinical training
• Evaluate patients, conduct mental health tests
• Direct individual and group counseling
• Psychiatrist medical doctor
• Prescribes medications and ECT
• Referrals for therapy and counseling
• Determines admission/discharge
• Advocates for legal status

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Mental Health Professionals

• Case Managers/Social Workers
• Undergraduate and graduate education
• Liaisons for patients to obtain and maintain
  social services, financial aid, outpatient care
• Therapist /Counselors
• conduct treatment sessions, education, counsel
  groups, addiction management, rehabilitation
  services
• Mental Health Technicians
• Assist patients under nursing supervision

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Dorothea Dix (1802-1887)

• Originally a school teacher who in 1841 became a
  reformer for treatment of the mentally ill
• Within 10 years visited gt300 jails and gt500
  almshouses
• Advocated for mentally ill persons to be removed
  from jails/almshouses and be placed in public
  hospitals

By 1880, lt1 of prison population were the
mentally ill
http//www.pbs.org/wgbh/pages/frontline/shows/asyl
ums/special, 2011
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Deinstitutionalization

• gt80 Reduction in state psychiatric facilities
  for the community level
• Contributors
• 1950s anti-psych meds
• 1960s civil rights values
• 1965 Medicare/Medicaid
• Kennedy/Carter passed laws stipulating community
  programs
• Consequences
• Advent of outpatient mental health centers and
  programs
• Increase mental illness in homeless and prison
  populations and ED visits

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Community Based Mental Health

• Biopsychosocial Assessment
• Family/Friend resources
• Ability to obtain/maintain housing, food,
  hygiene, income, employment
• Adhere with outpatient mental health treatment,
  sobriety, medication schedule, MD appointment
• Plan B for mental illness symptoms

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Community Based Mental Health

• Admission/Observation for crisis
• Partial Hospital Programs
• Psychiatric home care
• Assertive Care Treatments
• Community Mental Health Care Centers
• MD or counselor office level care
• Support Groups

• Most Acute
• Least Acute

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Levels of Preventions

• Primary maintain the mental health of person and
  population.
• Educate teens about drugs/alcohol
• Secondary screen and intervene for impaired
  mental health
• Detox center
• Tertiary recover and rehabilitate towards mental
  health
• Support groups for alcoholics

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Inpatient Admission

• Majority of patients enter mental health care
  through the emergency room
• Self Referral
• Friend/Family
• Professional
• Criteria
• Imminent harm to self
• Imminent harm to other
• Gravely disabled in care of basic needs

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Types of Admission

• Voluntary
• patient complies and consents with inpatient
  status
• Patient may choose to leave prior to completion
  of therapy regimen
• Involuntary
• Patient may not leave facility
• 72hr Mental Health Hold initiated by police,
  Clin. Psych, MD, SW, LPC, APN, BSN (1yr in
  mental health)
• Short Term Certification up to 60 days
• Long Term Certification up to 90 days
• Legal Guardian/Ward of the State

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Inpatient Protocols

• Suicide Precautions and Elopement Precautions
• Levels of Restriction
• Day passes (overnight passes void inpatient
  status)
• Unaccompanied on grounds
• Accompanied by staff
• Restricted to unit
• Line of sight
• Seclusion
• Restrained
• Inventory Belongings
• No weapons, pills, powders, open liquids, cords,
  strings, belts, plastic bags, sharp objects

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Rights of Mental Health Patients

• Additional levels of confidentiality
• Exceptions
• 1. warning a third party of intended harm by
  patient
• 2. reporting abuse of a vulnerable person
• Right to stay informed/involved in treatment
• Right to contest care/provider
• Right to humane conditions, recreation, social
  interaction, vote, enter contracts

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References

• Centers for Disease Control (2011)
  www.cdc.gov/nchs/fastats/mental.htm,
• Diagnostic and Statistic Manual for Mental
  Disorders - IV Text Revision
• Public Broadcasting Service Frontline (2011)
  www.pbs.org/wgbh/pages/frontline/shows/asylums