What if you, your friend, or a family member needed psychiatric treatment or care? What would you do or recommend? Figure 4-1 presents a continuum of psychiatric mental health care that may help you to make a decision. Movement along the continuum is fluid and can go in either direction. For example, patients discharged from acute hospital care or a 24-hour supervised crisis stabilization unit (most acute level), may need intensive services to maintain their initial gains or to “step down” in care. Failure to follow up in outpatient treatment increases the likelihood of rehospitalization and other adverse outcomes. Patients may pass through the continuum of treatment in the reverse direction; that is, if symptoms do not improve, a lower-intensity service may refer the patient to a higher level of care in an attempt to prevent total decompensation (deterioration of mental health) and hospitalization.

FIG 4-1 The continuum of psychiatric mental health treatment.

The section that follows discusses care settings from least restrictive to most intensive. The notion of least restrictive interventions and settings is the foundational concept surrounding the care continuum. Ideally, the care setting will change to best address a patient’s individual needs at any given moment, “meeting the patient where they are.”

Outpatient psychiatric mental health care

Primary care providers

Individuals with depression may notice that they don’t really want to talk on the phone with friends, they’ve let their bedroom deteriorate to the point of being condemnable, nothing seems to be fun, their weight has crept up, and the ability to sleep is abysmal. These persons may wonder if they’re seriously sick and may decide to see a primary care provider. In fact, psychiatric illness is often first detected during a primary care visit even though it is not usually the main reason the patient had scheduled the appointment.

In the example above, it is likely that these persons would make an appointment with complaints of fatigue or insomnia. Also, conditions such as cardiovascular disease, diabetes, menopause, and chronic pain are complicated by psychiatric conditions such as depression and anxiety and therefore warrant frequent psychiatric assessment. Ideally, primary care providers treat the patient as a whole and not just for specific conditions. Primary care providers recognize that psychiatric illness can be manifested by physical symptoms and also realize that psychiatric disorders can intensify preexisting conditions.

Registered nurses in primary care can maximize their effectiveness by using therapeutic communication, conducting thorough assessments, and providing essential teaching. Using therapeutic communication, such as listening, can help patients feel comfortable talking about their psychiatric symptoms so that they can be relayed to the primary care provider and therefore receive appropriate treatment. Assessing the patient’s physical health concerns provides an opportunity to explore any mental health symptoms that the patient has not mentioned or maybe even recognized. Since many psychiatric disorders are discovered in the primary care setting, it is an ideal time to screen and provide teaching about mental health and any psychiatric medications patients receive. This teaching can make the difference between success and failure for medication continuation.

Once the problem is identified, patients may be apprehensive about starting new medications and understanding them. Most importantly, if they know that many side effects are short-term, they may put up with them rather than discontinuing the medication prematurely. Proper education on why they are taking a medication, how it works, and the possible side effects (which ones are short-term and which ones are more serious) will likely make it easier for them to agree to continued treatment. It is also important to teach patients about their mental illness and its trajectory so that they can keep their provider informed of any changes in symptoms, whether they are getting better or worse.

The vignette in the next column demonstrates how a registered nurse working in a primary care setting can assist in the assessment and education of a patient with a psychiatric illness.

VIGNETTE

Jayden Miller is a registered nurse at a primary care office where he works with a nurse practitioner. He greets his next patient, Mr. Newton, whom he has known for years and with whom he has established a solid rapport. He notices that even though Mr. Newton is pleasant, his affect is dull, and his voice is soft. He responds with vague, short answers, and has had poor eye contact, which is not usually how he acts. Mr. Newton reports that within the past year he has experienced increased fatigue, no enjoyment of anything, a chronic body ache, and has been craving carbohydrates uncontrollably.

After documenting his findings Jayden leans forward slightly on his stool and states in a caring tone, “Mr. Newton, I’ve known you for a while, and the change in your behavior has me concerned. Is there anything going on in your life that you’d like to talk about?” Mr. Newton hesitates but then tells Jayden that he was demoted at work last year and that he hasn’t felt right since then.

The nurse practitioner assesses Mr. Newton and diagnoses him with major depressive disorder after ruling out possible medical conditions. He is prescribed fluoxetine (Prozac) 20 mg daily, educated about his diagnosis and new medication and provided with written material to take home. He is also given a list of referrals for therapy and support groups. After the visit, Jayden documents the education and Mr. Newton’s response.

Specialty psychiatric care providers

Although some primary care providers feel comfortable in treating common psychiatric illnesses such as uncomplicated depression, they may feel less comfortable when depression becomes suicidal or disorders are more severe. For more efficient, comprehensive psychiatric care, patients are directed to a specialized care provider. This is someone whose practice focuses solely on psychiatric care, such as an advanced practice psychiatric nurse (nurse practitioner or clinical nurse specialist), psychiatrist, psychologist, social worker, and a variety of licensed therapists.

Specialized care providers can provide numerous services, such as prescribing medications, practicing individual psychotherapy (“talk” therapy), and leading group therapy. This type of provider is ideal for people looking for treatment specifically for their problem because these providers can have sub specialties they treat as well. An example of that would be a provider who specializes in working with war veterans with post traumatic stress disorder.

How does someone find one of these providers? One of the first steps is to inquire with a local care organization such as a primary care office, hospital, clinic, or therapy practice. Other ways include networking with peers, seeking help through support organizations, or contacting one’s insurance company for a list of covered providers.

Patient-centered medical homes

The Affordable Care Act (Health Affairs, 2010) outlines the concepts of patient-centered medical (health) homes and suggests the co-location of primary and specialty care in community-based mental health settings. The integration of primary care and behavioral health care is a common-sense approach that eliminates much of the stigma of seeking specialty care for psychiatric disorders.

Comprehensive and holistic care addresses mental and physical needs, supports acute and chronic illness interventions, and emphasizes prevention and wellness. This care requires a diverse team, including advanced practice nurses, physicians, physician assistants, nurses, social workers, pharmacists, nutritionists, care coordinators, and educators. Typically this team is in the same physical location; however, in some areas, especially rural areas, a virtual team linked electronically may serve the same purpose.

Patient-centered care in the health home refers to a whole-person orientation. It is an atmosphere of respect for the individual and family’s unique culture, preferences, and values. It supports individual choices about how active a person is in organizing and managing his or her own health care. Central to patient-centered care is that patients and families are core members in developing a plan of care. The underlying values of the medical home include clear communication among patients and families, the home itself, and members of the health care system.

Outside services such as specialty care, home health care, hospitalization, and community services are coordinated through the patient-centered health homes. Coordination becomes especially important when changes are being made in care sites, such as when patients are discharged from the hospital.

Accessibility to service is central to this model. Imagine a system with shorter waiting time for urgent care, expanded clinical hours, and 24/7 telephone or electronic access to real people on the care team. The use of health information technology is also an essential aspect of this care (Meyers et al., 2010). Electronic health records will undoubtedly help these centers of care fully reach their potential.

Quality and quality improvement are key goals for patient-centered medical homes. This is accomplished through the use of evidence-based practice and clinical tools to guide decision making. Measuring patient experiences and patient satisfaction provides information by which improvements can be made. Publicly sharing the information gained from these quality improvement activities demonstrates a transparent commitment to quality.

Community mental health centers

Community mental health centers were created in the 1960s and have since become the mainstay for those who have no access to private mental health care (Drake & Latimer, 2012). The range of services available at such centers varies, but generally they provide emergency services, adult services, and children’s services. Common treatments include medication administration, individual therapy, psychoeducational and therapy groups, family therapy, and dual-diagnosis (mental health and substance abuse) treatment. A clinic may also be aligned with a psychosocial rehabilitation program that offers a structured day program, vocational services, and residential services. Some community mental health centers have an associated intensive psychiatric case management service to assist patients in finding housing or obtaining entitlements.

Community mental health centers also utilize multidisciplinary teams. The psychiatric mental health nurse may carry a caseload of 60 patients, each of whom is seen one to four times a month. The basic level nurse is often supervised by an advanced practice registered nurse (APRN). Patients are referred to the clinic for long-term follow-up by inpatient units or other providers of outpatient care at higher intensity levels. Patients may attend the clinic for years or be discharged when they improve and reach desired goals.

The following vignette illustrates part of a typical day for a nurse in a community mental health center.

VIGNETTE

Allen Morton is a registered nurse at a community mental health center. He is on the adult team and carries a caseload of patients diagnosed with chronic mental illness. An advanced practice registered nurse supervises him. His responsibilities include responding to crisis calls, seeing patients for regular assessment, administering medications, leading psychoeducation groups, and participating in staff meetings.

Today Allen’s first patient is Mr. Enright, a 35-year-old man diagnosed with schizophrenia who has been in treatment at the clinic for 10 years. During their 30-minute counseling session, Allen assesses Mr. Enright for any exacerbation of psychotic symptoms (he has a history of grandiose delusions), eating and sleep habits, and social functioning in the psychosocial rehabilitation program that he attends 5 days a week, and today he presents as stable. Allen gives Mr. Enright his long-acting injectable (LAI) antipsychotic medication and schedules a return appointment for a month from now, reminding him of his psychiatrist appointment the following week.

Allen also leads a co-leads a medication group along with a social worker. This group consists of seven patients with chronic schizophrenia who have been attending biweekly group sessions for the past 5 years. Today, as Allen leads the group discussion, he asks the group to explain relapse prevention to a new member. He teaches significant elements, including adherence with the medication regimen and healthy habits. As group members give examples from their own experiences, he assesses each patient’s mental status. At the end of the meeting, he gives members appointment cards for the next group session.

Psychiatric home care

Psychiatric home care was defined by Medicare regulations in 1979 as requiring four elements: (1) homebound status of the patient, (2) presence of a psychiatric diagnosis, (3) need for the skills of a psychiatric registered nurse, and (4) development of a plan of care under orders of a physician. Other payers besides Medicare also authorize home care services, but most follow Medicare’s guidelines.

Homebound refers to the patient’s inability to leave home independently to access community mental health care because of physical or mental conditions. Patients are referred to psychiatric home care following an acute inpatient episode—either psychiatric or somatic—or to prevent hospitalization. The psychiatric mental health nurse visits the patient one to three times per week for approximately 1 to 2 months. Although this is the ideal situation, some home care responsibilities are managed by caseworkers while the nurse’s focus is more on the initial setup of treatment and medication adherence. By going to the patient’s home, the nurse is better able to address the concerns of access to services and adherence with treatment. With the growing number of older adults being treated in the community for psychiatric and medical issues, the role of psychiatric home care is becoming even more important.

Family members or significant others are closely involved in most cases of psychiatric home care. Because many patients are older than 65, there are usually concurrent somatic illnesses to assess and monitor. The nurse acts as a case manager, coordinating all specialists (e.g., physical therapist, occupational therapist, and home health aide) involved in the patient’s care, and is often supervised by an APRN team leader who is always available by telephone.

Boundaries become important in the home setting. Walking into a person’s home creates a different set of dynamics than those commonly seen in a clinical setting. It may be important for the nurse to begin a visit informally by chatting about patient family events or accepting refreshments offered. Continuity of care in this type of situation can increase the level of comfort and has been shown to decrease levels of depression and anxiety (D’Errico & Lewis, 2010). There is great significance to the therapeutic use of self in such circumstances to establish a level of comfort for the patient and family; however, nurses must be aware of the boundaries between a professional relationship and a personal one. (See the vignette at the top of the next column.)

VIGNETTE

Emma Castillo is a registered nurse employed by a home care agency in a large rural county. She visits patients living in a radius of 50 miles from her home and has daily telephone contact with her supervisor. She stops by the office weekly to drop off paperwork and attends a team meeting once a month. The team includes her team leader, other field nurses, a team psychiatrist consultant, and a social worker. Emma chooses to make her visits from 8:00 am until 3:30 pm and then completes her documentation at home.

Emma spends an hour with Mr. Johnson, a 66-year-old man with a diagnosis of major depression after a stroke. His primary care physician referred him because of suicidal ideation. Emma has met with Mr. Johnson and his wife 3 times a week for the past 2 weeks. He denies suicidal ideation, plan, or intent and has been adherent to his antidepressant regimen. Today, she teaches the couple about stress-management techniques. Case-management responsibilities for Mr. Johnson include supervision of the home health aide, who helps him with hygiene, and coordination with the physical and occupational therapists who also treat him.

Assertive community treatment

Assertive community treatment (ACT) is an intensive type of case management developed in the 1970s in response to the oftentimes hard to engage, community-living needs of people with serious, persistent psychiatric symptoms and patterns of repeated hospitalization for services such as emergency room and inpatient care (Wright-Berryman, McGuire, & Salyers, 2011). Patients are referred to ACT teams by inpatient or outpatient providers because of a pattern of repeated hospitalizations with severe symptoms, along with an inability to participate in traditional treatment. ACT teams work intensively with patients in their homes or in agencies, hospitals, and clinics—whatever settings patients find themselves in. Creative problem solving and interventions are hallmarks of care provided by mobile teams. The ACT concept takes into account that people need support and resources after 5:00 pm; teams are on call 24 hours a day.

ACT teams are multidisciplinary and typically composed of psychiatric mental health registered nurses, social workers, psychologists, advanced practice registered nurses (APRNs), and psychiatrists. One of these professionals (often the registered nurse) serves as the case manager and may have a caseload of patients who require visits three to five times per week; the case manager is usually supervised by an APRN or psychiatrist. Length of treatment may extend to years, until the patient is ready to accept transfer to a more structured site for care.

The following vignette illustrates a typical day for a psychiatric mental health registered nurse on an ACT team.

VIGNETTE

Maria Rodriguez is a nurse who works on an ACT team at a large inner-city, university-based medical center. She had five years of inpatient experience before joining the ACT team, and she works with two social workers, two psychiatrists, and a mental health worker. She is supervised by an APRN.

One of her two-hour home visits is to Ms. Abbott, a 53-year-old single woman with a diagnosis of schizoaffective disorder and hypertension. She lives alone in a senior citizen building and has no contact with family. The ACT team is now the payee for her Social Security check. Today, Maria will take Ms. Abbott to pay her bills and to her primary care provider. Ms. Abbott greets Maria warmly at the door, wearing excessive makeup and inappropriate summer clothing. With gentle encouragement, she agrees to wear warmer clothes. She gets irritable when Maria points out that she has not taken her morning medications. Observing the change in behavior and medication non adherence, Maria plans to return the following day to complete a follow-up assessment. By monitoring closely, she hopes to avoid a full decompensation that would require more intensive intervention.

Partial hospitalization programs

Partial hospitalization programs (PHPs) offer intensive, short-term treatment similar to inpatient care, except that the patient is able to return home each day. Typically, programs offer 5-6 hours per day utilizing individual and group psychotherapy treatment. The primary goals are symptom improvement, safety, education on clinical conditions, and medications and coping strategies. Referrals come from inpatient or outpatient providers. This level of care is designed to divert from an inpatient admission or a ‘step-down’. The average length of stay is approximately 1 to 2 weeks, depending on the program, and the multidisciplinary team consists of at least a psychiatrist, registered nurse, and social worker.

Other outpatient venues for psychiatric care

Mobile mental health units have been developed in some service areas. In a growing number of communities, mental health programs are collaborating with other health or community services to provide integrated approaches to treatment. A prime example of this is the growth of dual-diagnosis programming at both mental health and substance abuse clinics.

Telephone crisis counseling, telephone outreach, and the Internet are being used to enhance access to mental health services. Although face-to-face interaction is still preferred, the new forms of treatment through technology, such as telepsychiatry, have shown immense patient satisfaction and no evidence of complications (Garcia-Lizana & Munoz-Mayorga, 2010). Access and overall health outcomes are expected to improve as models of care that include telehealth and other innovative practices advance.

Prevention in community care

A distinct concept in the health care literature is that of treatment based on a public health model that takes a community approach to prevention. Primary, secondary, and tertiary prevention are levels at which interventions are directed. Primary prevention occurs before any problem is manifested and seeks to reduce the incidence, or rate of new cases. There is evidence (Brenner et al., 2010) that primary prevention may prevent or delay the onset of symptoms in genetically or otherwise vulnerable individuals. Although controversial, there is support for pharmacotherapy combined with cognitive-behavioral therapy for people at high risk for psychotic disorders such as schizophrenia. Coping strategies and psychosocial support for vulnerable young people are effective interventions in preventing mood and anxiety disorders.

Secondary prevention is also aimed at reducing the prevalence, or number of new and old cases at any point in time, of psychiatric disorders. Early identification of problems, screening, and prompt and effective treatment are hallmarks of this level. According to the Institute of Medicine (Katz & Ali, 2009), this level of prevention is the secondary defense against disease. While it does not stop the actual disorder from beginning, it may delay or avert progression to the symptomatic stage.

Tertiary prevention is the treatment of disease with a focus on preventing the progression to a severe course, disability, or even death. Tertiary prevention encompasses the term “rehabilitation,” which aims to preserve or restore functional ability. In the case of treating major depression, the aim is to avoid loss of employment, reduce disruption of family processes, and prevent suicide.

Outpatient and community psychiatric mental health care

Psychiatric mental health nursing in the outpatient or community setting requires strong problem-solving and clinical skills, cultural competence, flexibility, solid knowledge of community resources, and comfort in functioning more autonomously than acute care nurses. Patients need assistance with problems related to individual psychiatric symptoms, family and support systems, and basic living needs, such as housing and financial support. Community treatment hinges on enhancing patient strengths in the daily environment, making individually tailored psychiatric care imperative. Treatment in the community permits patients and their support systems to learn new ways of coping with symptoms or situational difficulties. The result can be one of empowerment and self-management for patients.

Psychiatric mental health nurses may be the answer to transforming an illness-driven and dependency-oriented system into a system that emphasizes recovery and empowerment. Nurses are adept at understanding the system and coordinating care. They “can work between and within systems, connecting services and acting as an important safety net in the event of service gaps”(American Psychiatric Nurses Association [APNA] et al., 2007).

Over the past 30 years—with advances in psychopharmacological and psychosocial interventions—psychiatric care in the community has become more sophisticated, with a continuum of care that provides more settings and options for people with mental illness. The role of the outpatient or community psychiatric mental health registered nurse has grown to include service provision in a variety of these treatment settings, and nursing roles have developed outside traditional treatment sites.

For example, psychiatric needs are well known in the criminal justice system and the homeless population. Individuals suffering from a serious mental illness tend to cycle through the correctional systems and generally comprise more than 50% of the incarcerated population (Dumont et al., 2012). The nurse’s role is not only to provide care to individuals as they leave the criminal justice system and re-enter the community, but also to educate police officers and justice staff in how to work with individuals entering the criminal system.

The percentage of homeless persons with serious mental illness has been estimated to be more than 26%, and it is speculated that the lack of mental health agencies has led to a greater number of homeless young adults (U.S. Department of Housing and Urban Development, 2011). The challenge to psychiatric mental health nurses is in making contact with these individuals who are outside the system but desperately in need of treatment.

Biopsychosocial assessment

Assessment of the biopsychosocial needs and capacities of patients living in the community requires expansion of the general psychiatric mental health nursing assessment (refer to Chapter 7). To be able to plan and implement effective treatment, the nurse must also develop a comprehensive understanding of the patient’s ability to cope with the demands of living in the community.

Key elements of this assessment are strongly related to the probability that the patient will experience successful outcomes. Problems in any of these areas require immediate attention because they can seriously impair the success of other treatment goals:

• Housing adequacy and stability: If a patient faces daily fears of homelessness, it is not possible to focus on other treatment issues.

• Income and source of income: A patient must have a basic income—whether from an entitlement, a relative, or other sources—to obtain necessary medication and meet daily needs for food and clothing.

• Family and support system: The presence of a family member, friend, or neighbor supports the patient’s recovery and, with the patient’s consent, gives the nurse a contact person.

• Substance abuse history and current use: Often hidden or minimized during hospitalization, substance abuse can be a destructive force, undermining medication effectiveness and interfering with community acceptance and procurement of housing.

• Physical well-being: Factors that increase health risks and decrease life span for individuals with mental illnesses include decreased physical activity, smoking, medication side effects, and lack of routine health exams.

Individual cultural characteristics are also very important to assess. For example, working with a patient who speaks a different language from the nurse requires the nurse to consider the implications of language and cultural background. The use of a translator or cultural consultant from the agency or from the family is essential when the nurse and patient speak different languages (refer to Chapter 5).

Treatment goals and interventions

Treatment goals and interventions are patient-centered and are therefore negotiated rather than imposed on the patient. To meet a broad range of needs, community psychiatric mental health nurses must approach interventions with flexibility and resourcefulness. The complexity of navigating the mental health and social service funding systems is often overwhelming to patients. Not unexpectedly, patient outcomes with regard to mental status and functional level have been found to be more positive and were achieved with greater cost effectiveness when the community psychiatric mental health nurse integrates case management into the professional role.

Differences in characteristics, treatment outcomes, and interventions between inpatient and community settings are outlined in Table 4-1. Note that all of these interventions fall within the practice domain of the basic level registered nurse.

TABLE 4-1

CHARACTERISTICS, TREATMENT OUTCOMES, AND INTERVENTIONS BY SETTING

OUTPATIENT/COMMUNITY MENTAL HEALTH SETTING	INPATIENT SETTING
Characteristics
Intermittent supervision	24-hour supervision
Independent living environment with self-care, safety risks	Therapeutic milieu with hospital/staff supported healing environment
Treatment Outcomes
Stable or improved level of functioning in community	Stabilization of symptoms and return to community
Interventions
Establish long-term therapeutic relationship.	Develop short-term therapeutic relationship.
Develop comprehensive plan of care with patient and support system, with attention to sociocultural needs and maintenance of community living	Develop comprehensive plan of care, with attention to sociocultural needs of patient and focus on reintegration into the community
Encourage adherence with medication regimen.	Administer medication.
Teach and support adequate nutrition and self-care with referrals as needed.	Monitor nutrition and self-care with assistance as needed.
Assist patient in self-assessment, with referrals for health needs in community as needed.	Provide health assessment and intervention as needed.
Use creative strategies to refer patient to positive social activities.	Offer structured socialization activities.
Communicate regularly with family/support system to assess and improve level of functioning.	Plan for discharge with family/significant other with regard to housing and follow-up treatment.

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Feb 3, 2017 | Posted by admin in NURSING | Comments Off

Outpatient psychiatric mental health care

Primary care providers

Nurse Key

Fastest Nurse Insight Engine

Settings for psychiatric care

Settings for psychiatric care

Continuum of psychiatric mental health care

Specialty psychiatric care providers

Patient-centered medical homes

Community mental health centers

Psychiatric home care

Assertive community treatment

Partial hospitalization programs

Other outpatient venues for psychiatric care

Prevention in community care

Outpatient and community psychiatric mental health care

Biopsychosocial assessment

Treatment goals and interventions

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