Community-Based Psychiatric Nursing Care



Community-Based Psychiatric Nursing Care


Gail W. Stuart





People live, love, and learn in communities, and most mental health care is provided in the community. The goal of the health care delivery system is to create competent and mentally healthy communities and to help people who have experienced a psychiatric illness live successful and productive lives in the community.


Psychiatric nurses work in community-based settings, where they assume a broad range of responsibilities. In these settings, they work with interprofessional teams and focus on prevention, care management, and recovery. Nurses at 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.




Treatment Settings


Primary Care Settings


Most people seek help for their mental health problems from their primary care provider. 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 (Lyness et al, 2009). The three most common problems seen in primary care are depression, anxiety, and substance abuse.


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).


These system problems have given rise to discussions about the integration of behavioral health care in the primary care setting, and general medical care in the behavioral health care setting. The goal of integrated services is improved health outcomes and decreased costs. Nurses could play a prominent role in an integrated primary care setting (Weiss et al, 2009).


Truly integrated care needs to be a two-way street that includes the following:



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:



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.



Other important aspects of care in the primary care setting involve improving patients’ self-management skills through medication management, psychoeducation, supporting clinicians’ decision making through the use of practice guidelines, and facilitating access to specialty mental health care.


Many 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.


A framework that nurses can use for behavioral counseling in primary care is the Five A’s:



Although mental health and physical conditions are highly interconnected, mental health and physical care delivery systems are separated in many ways that block the delivery of the most effective care. Nurses can play a pivotal role in integrating the mental health and physical care of patients in primary care settings.




Emergency Department Psychiatric Care


The use of emergency department (ED) services in general hospitals by psychiatric patients has reached crisis levels. Because EDs cannot deny treatment, they have become a safety net for patients who do not have access to care or the resources to go to another type of facility. Time constraints, training, risk, and legal concerns contribute to most psychiatric ED visits resulting in an inpatient admission. With substance use disorders and mental illness contributing to many other illnesses, EDs have seen an increasing number of patients who require interventions for these problems.


About 2 million people visit EDs for mental disorders each year, with an additional 1.3 million ED visits related to alcohol and drug problems. Estimates of the number of ED patients with alcohol problems range from 15% to more than 40%. These estimates do not include visits that result from diseases and injuries related to substance use or mental health problems, nor do they reflect the number of ED patients who are affected by these health problems.


Patients who have attempted suicide are most often seen in the ED. Unfortunately, many of these patients and their families often feel punished or stigmatized by the ED staff. Many homeless people and patients with chronic mental illness also use the ED as a primary source of health care because they do not have access to other resources.


Providing safe and effective care for psychiatric patients in EDs can be challenging. Overcrowding, noise levels, and chaotic conditions may trigger a worsening of the patient’s condition. Another safety concern is access to dangerous items. A study conducted by the Emergency Nurses Association (ENA) found that only 19% of EDs had space dedicated to mental health care (Howard, 2006).


Patients also present to the ED for medical clearance before psychiatric admission. There are no standard protocols for medical clearance, and demands for this service can be the source of conflict between emergency and psychiatric providers (Reeves et al, 2010). The gaps between psychiatric and emergency care in the current health care system create serious problems for patients and staff alike.


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).


Some acute care hospitals have dedicated 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 behavioral health problems than on physical illnesses and injuries. The reasons for this include time constraints, lack of knowledge about how to screen and intervene effectively, reimbursement issues, and bias and stigma about psychiatric care (Nadler-Moodie, 2010).


Despite these issues, screening and interventions specifically tailored to the ED are emerging and can be used by nurses working in that setting. For example, screening and brief intervention for alcohol problems in the ED have been demonstrated to be effective in decreasing consumption in hazardous and harmful drinkers and in treatment engagement in dependent drinkers. EDs are, therefore, a prime setting for nurses to intervene to address the behavioral health problems of patients.




Employee Assistance Programs


Employee assistance programs (EAPs) are worksite-based programs designed to help identify and resolve behavioral, health, and productivity problems that may affect employees’ well-being or job performance. Their focus is wide ranging, covering alcohol and other drug abuse; physical and emotional health; and marital, family, financial, legal, and other personal concerns. As such, they are important points of access to behavioral health care.


EAPs have developed from being primarily alcoholism assessment and referral centers to being specialized behavioral health programs. Many cost-effectiveness studies document the value of EAPs in providing workplace education, skill development, and policy and environmental changes. Comprehensive EAPs have six major components:



EAPs are a rich community-based setting on which other services may be added to promote access to mental health and substance abuse treatment.



Home Psychiatric Care


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. Although changes in Medicare home health reimbursement have limited the growth of psychiatric home care, these programs have proven to be effective in meeting the needs of the psychiatric patient in a cost-effective manner. Psychiatric home care is a natural fit for the psychiatric nurse.


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.


Psychiatric home care programs receive and refer patients from the entire community’s general medical and mental health care services (Box 34-1). Psychiatric home care ranges from serving as an alternative to hospitalization, to functioning as a single home visit for the purposes of evaluating a specific issue, to providing treatment in the home. The advantages of psychiatric home care is that it can provide the following:




Examples of other advantages include its outreach capacity and emphasis on patient participation, responsibility, autonomy, and satisfaction. An excellent example of psychiatric home care is the Nurse Home-Visiting Program for mothers with depression (Box 34-2).




Psychiatric homebound status is different from medical homebound status. Medicare guidelines require that the patient meet all of the following criteria:



In determining psychiatric homebound status, a useful definition is a patient who is unable to independently and consistently access psychiatric follow-up. This definition is broad enough to include a person who is physically healthy and mobile but too depressed to get out of bed. It also includes patients with agoraphobia and patients with psychotic thinking processes who are vulnerable in the community. Box 34-3 lists some conditions that may make a patient psychiatrically homebound.



Psychiatric home care is a subspecialty that calls for a nurse with certain kinds of skills, education, and experience. Box 34-4 outlines Medicare requirements for psychiatric nurses practicing in the home setting.




Psychiatric home care nursing provides unique challenges and opportunities for the nurse. In an inpatient 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 issues of cultural competence and safety for the nurse.



Cultural Competence


Awareness of the patient’s ethnic and cultural background is critical to effective care in all settings, but nowhere is it more critical to treatment outcome than in the home care setting. The nurse is exposed to the patient’s culture, and the patient will observe the nurse’s reaction in these surroundings.


Ways of addressing members of the family, views of health and mental illness, the role of the nurse and health care providers in general, and the importance of alternative therapies are a few of the issues that vary across cultures. All these differences must be considered by the nurse planning care with the patient in the home. Recognition and use of the patient’s cultural beliefs in delivery of nursing care can positively influence the patient’s participation in recovery.


It is important that the nurse have an understanding of his or her own cultural background and the possible 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.


Closely related to cultural issues are the 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, being willing to share in this ritual can build trust in the relationship between the nurse and patient.





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 managers, 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.



CLINICAL EXAMPLE


Sonia, a 49-year-old woman, was referred by a managed care company to psychiatric home care after a 2-week inpatient stay at a local psychiatric hospital. She had a long history of psychiatric admissions for stabilization of her schizophrenia. Most hospitalizations were preceded by the patient’s noncompliance with her medication schedule and follow-up care at the mental health center.


Sonia lived with her sister and elderly mother in a small row house in the Hispanic section of a large city. The family’s native language was Spanish; they spoke English as a second language and understood some written English. Sonia’s sister was the family’s caregiver. She cared for their bedridden mother and helped with Sonia’s care.


Sonia’s sister could not understand why Sonia would be all right for long periods and then become “crazy” and not listen. Sonia agreed to psychiatric nursing visits but initially would not agree to treatment at the mental health center. Paranoia was a major component of her illness. Other barriers were financial concerns, a lack of knowledge about her illness, and cultural and language issues.


The psychiatric nurse’s plan of care included educating the patient and her sister on the disease process, signs and symptoms of relapse, the importance of continued medical care, medication actions and side effects, and correct administration of the prescribed medication. As her care progressed and Sonia became stable, the nurse helped the patient and her sister make and attend a follow-up appointment at the mental health center. Sonia was discharged from home care and agreed to go to the mental health clinic for her follow-up medical care.


Psychiatric home care nurses make appropriate referrals to community agencies and help their patients access community resources independently. They educate families and patients, provide supportive counseling and brief psychotherapy, promote health and prevent illness, and document everything in detail so that their agency can be reimbursed for the services they provide.




Virtual Mental Health Care


Mental health care need not be limited to a geographic location. Technology, including computers and mobile phones, have opened up a world of possibilities for expanding place-bound caregiving opportunities.


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).


In terms of access to services, online counseling may benefit people who are isolated in rural areas and underserved. Treatment providers can make themselves more available to those in need compared with providers administering face-to-face treatment. For example, e-therapy services can be found in rural clinics, military programs, correctional facilities, community mental health centers, nursing homes, home health care settings, and hospitals (Dwight-Johnson 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).



E-therapy can be text-based or non–text-based communication. Each form of communication has its advantages and disadvantages, which should be taken into account when determining the best methods for the targeted population.



Telepsychiatry connects people by audiovisual communication and is one means of providing expert health care services to patients distant from a source of care. It is suggested for the diagnosis and treatment of patients in remote locations or where psychiatric expertise is scarce. Research suggests that psychiatric consultation and short-term follow-up can be as effective when delivered by telepsychiatry as when provided face to face (García-Lizana and Muñoz-Mayorga, 2010).


When used with established ethical guidelines, computers offer a reliable, inexpensive, accessible, and time-efficient way of assessing psychiatric symptoms, implementing treatment guidelines, and providing care (Borzekowski et al, 2009). Computer-administered versions of clinician-administered rating scales are available for the assessment of a number of psychiatric illnesses, including depression, anxiety, obsessive-compulsive disorder, and social phobia.


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).


Feb 25, 2017 | Posted by in NURSING | Comments Off on Community-Based Psychiatric Nursing Care
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