1. Describe community-based psychiatric treatment settings. 2. Compare and contrast models of community-based psychiatric care and the role of the nurse. 3. Assess the needs of vulnerable psychiatric populations living in the community. Many patients with mental health problems are not treated effectively in the primary care setting. About 50% of mental health problems are not identified or treated in primary care, and about two thirds of primary care providers reported that they could not get outpatient mental health services for their patients (Cunningham, 2009; Ong and Rubenstein, 2009; Machado and Tomlinson, 2011). Federally funded community health centers have increased their specialty mental health offerings, but this is not sufficient to meet the need (Wells et al, 2010). The other side of the problem is equally compelling. People with serious mental illness have more difficulty in obtaining a primary care provider and experience greater barriers to medical care than the general population. The result is that they die 25 years earlier than the general population (Bradford et al, 2008; Green et al, 2010). Truly integrated care needs to be a two-way street that includes the following: • People in primary care settings who have behavioral health problems are identified and treated in primary care settings if possible. • People in behavioral health care settings who need routine primary care are identified and treated in the behavioral health setting if possible. Behavioral health service delivery in the primary care setting can reach many people who otherwise would not receive behavioral health intervention. It also provides a level of expertise regarding diagnosis and intervention for problems not generally seen in the medical setting, resulting in increased knowledge and skill in detection and treatment of behavioral health problems within the medical community. Primary care services for those who are mentally ill also can result in better quality of care for these patients (Canters for Disease Control and Prevention, 2011; Kilbourne et al, 2011). An important step in addressing this issue is the use of effective screening measures in primary care (Neushotz and Fitzpatrick, 2008; Oleski et al, 2010). The U.S. Preventive Services Task Force (2010) recommends the following: • 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 Research has shown that one- or two-item screening tools are effective in identifying those at risk for substance use or depressive disorders (Table 34-1). Because these questions can be answered in seconds, they can be asked during routine visits. A variety of screening tools can be used in primary care (Gilbody et al, 2007; Bernstein et al, 2009; Gaynes et al, 2010; Katzelnick et al, 2011). Nurses should incorporate these screening tools in their practice. TABLE 34-1 A framework that nurses can use for behavioral counseling in primary care is the Five A’s: • Assess: Ask about a person’s behavioral health risk and factors affecting his or her choice of future goals. • Advise: Give clear, specific, and personalized behavioral 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. • Assist: Help the person achieve agreed-on goals by acquiring the skills, confidence, and support for change. • Arrange: Schedule follow-up contacts (in person or by telephone) to provide ongoing support, including referral to a specialist if needed. Boarding is the practice of maintaining patients in the ED while waiting for psychiatric services to be available. Significant psychiatric bed shortages, increasing demand for psychiatric services, and lack of adequate funding for psychiatric services create the need for this unfortunate practice. Boarding frequently lasts more than 24 hours and sometimes days. It may result in safety and quality issues for all ED patients and can have a negative impact on staff workload and morale. Providing psychiatric consultants, having a separated area within the ED, and creating a separate psychiatric ED are suggested improvement strategies (Bender et al, 2008; Alakeson et al, 2010). • A way to provide care that removes the need for patient travel • A way to assess and treat in the patient’s own living setting • 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 through integration of home issues in the 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 E-therapy is the use of electronic media and information technologies to provide services for participants in different locations. E-therapy can be used to provide education, assessment, diagnosis, treatment engagement, direct treatment, and aftercare services. Providers can give and receive training and supervision using electronic forms of communication (Cleary et al, 2008; Center for Substance Abuse Treatment, 2009). This includes graduate programs in psychiatric nursing (Delaney et al, 2011). E-therapy can be one solution to the shortage of mental health providers for children and adolescents (Ellington and McGuinness, 2011). Text messaging, which is popular among youth, can provide other opportunities (Box 34-5). • Text-based forms of communication include e-mail, chat rooms, text messaging, and listservs. • Non–text-based forms include telephone and videoconferencing. Patient reaction has been positive, with patients usually being more honest with their responses and often expressing a preference for the computer-administered assessments of sensitive areas such as suicide, alcohol and drug use, sexual behavior, or human immunodeficiency virus (HIV)–related symptoms (Lieberman and Huang, 2008; Wolford et al, 2008).
Community-Based Psychiatric Nursing Care
Treatment Settings
Primary Care Settings
PROBLEM
QUESTIONS
POSSIBLE RESPONSES
POSITIVE SCREEN
Alcohol
When was the last time you had more than four (for women) or five (for men) drinks in 1 day?
1. Never
2. In the past 3 months
3. More than 3 months ago
In the past 3 months
Alcohol or drugs
In the last year:
1. Have you ever drunk alcohol or used drugs more than you meant to?
2. Have you felt you wanted or needed to cut down on your drinking or drug use?
Yes or no
Yes to either question
Depression
During the past 2 weeks:
1. Have you often been bothered by feeling down, depressed, or hopeless?
2. Have you often been bothered by little interest or pleasure in doing things?
Yes or no
Yes to either question
Emergency Department Psychiatric Care
Home Psychiatric Care
Virtual Mental Health Care
You may also need
Community-Based Psychiatric Nursing Care
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