Psychiatric Emergency Care
The Community Mental Health Centers Act of 1963 man- dated that communities make the necessary provisions for psychiatric emergency care. It was believed that accessible emergency services were needed to provide crisis interven- tion, to prevent unnecessary hospitalizations, and to attempt to decrease chronicity of and dependence on institutional care. At that same time, providing these critical support ser- vices placed additional pressure on communities because of the increased population of chronically mentally ill clients residing outside institutions. Jails were often inappropriate, psychiatrists were either overburdened or uncooperative, and mental health centers operated only during regular busi- ness hours.
Community mental health administrators and clinicians responded either by establishing an emergency clinic at the local mental health center or by contracting with a general hospital in the same community to provide emergency care on a 24-hour-per-day basis. Since that time, other methods of providing psychiatric emergency care have included the use of mobile crisis units and crisis residence units. Crisis residence units provide short-term (usually fewer than 15 days) crisis intervention and treatment. Clients receive 24-hour-per-day supervision.
Because of the psychiatric client’s increasing reliance on these emergency services in the last decade, hospitals have assumed a key role in providing and managing crisis inter- vention and psychiatric emergency care. Hospitals often func- tioned as the “revolving door” between clients and the mental health services network, focusing on crisis stabilization ser- vices. People who use community-based emergency services most commonly tend to be young, unemployed veterans of the mental health system and either chronically mentally ill or chronic substance abusers.
The psychiatric emergency room is often located in a separate room or a specially allocated section of the hospital emergency department. The triage staff may include members of several psychiatric disciplines: psychiatric nurses, social workers, mental health counselors, and marriage and family therapists. The primary focus is on crisis stabilization through the therapeutic interview and immediate mobilization of available community- and client-centered resources and sup- port systems. A nurse practitioner or clinical nurse specialist may supervise the triage area. The nurse may have a collab- orative agreement with a consulting psychiatrist to prescribe necessary psychotropic medication or to support admission to TABLE 8.1
Examples of Creative Community-Based Mental Health Programs
Type of Program Description of Program Goal of Program
Nurse–family partnership Located in 270 communities in 23 states; nurses visit high-risk pregnant women
Teach positive parenting and coping skills School-based mental health Located in Dallas, Texas; formed by a school principal
and physician; nurses and counselors visit students
Identify mental health problems of students Tailor classroom activities to meet specifi c needs Improving Mood & Provid-
ing Access to Collaborative Treatment (IMPACT)
Located in California; consists of a mental health professional and medical team
Identify depression in older adults
Care for the homeless Located in California Identify the homeless
Provide safe housing Engage them in care
Suicide prevention Located in the U.S. Air Force Encourages personnel to seek help for emo- tional pain and trauma
Provides education and training regarding stress management
SOURCE: Hoppel, A. M. (2003). Mental health system failing Americans, government report says. Clinician News, 7(2), 7–8.
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CHAPTER 8 Continuum of Care 91
Residential Treatment Programs
Clients with a diagnosis of chronic schizophrenia, a severe affective disorder, borderline personality disorder, and mental retardation are viewed as individuals who benefi t from par- ticipation in residential treatment programs. The goals of these programs are to improve self-esteem and social skills, promote independence, prevent isolation, and decrease hospitaliza- tion. In many communities, residential placements are a key element in the services provided by CMHC advisory boards.
Indeed, residential placements have become one of the lead- ing areas of program expansion in the care of the psychiatric client. Numerous clients now are able to leave an LTC facility or psychiatric hospital for another structured living situation.
Historically, the fi rst community program of this type, called Tueritian House, was established in New York City shortly after World War II. Today there are thousands of innovative residential treatment programs throughout the United States.
Examples of such programs are included in Box 8-2.
Each type of residential treatment program offers different support services. The services provided include shelter, food, housekeeping, personal care and supervision, health care, individual or group counseling, vocational training or employ- ment, and leisure and socialization opportunities. Staffi ng for these residential programs ranges from professional psychiat- ric staff present at all times in the facility to provide support and supervision, to staff only on call for crisis intervention and stabilization. Continued research into these programs has led many community mental health experts to conclude that they are a successful means of therapeutic support and intervention and are particularly effective with the chronically mentally ill client.
Children or adolescents may benefi t from placement in therapeutic group homes or community residence programs.
This setting usually includes 6 to 10 children or adolescents per home. The home may be linked with a day-treatment pro- gram or specialized educational program. Family support ser- vices such as parent training or a parent support group may also be offered.
a psychiatric inpatient unit. The staff who provide these critical services must be knowledgeable and skillful in the areas of psy- chiatric assessment, including the administration of a complete mental status examination; application of crisis intervention theories; individual and family counseling; and use of resources in the specifi c community that can provide emergency hous- ing, fi nancial aid, and medical and psychiatric hospitalization.
Day-Treatment Programs
Day-treatment programs are also known as day hospital or partial hospitalization programs. The fi rst day-treatment pro- gram in North America was established in Montreal, Canada, shortly after the end of World War II. Day-treatment programs are usually located in or near the CMHC or in an inpatient treatment facility such as a psychiatric hospital. The programs usually provide treatment for 30 to 90 days, operating for 6 to 8 hours per day, 5 days a week. Most of these programs can accommodate up to 25 persons. These persons are not dys- functional enough to require psychiatric hospitalization, but need more structured and intensive treatment than traditional outpatient services alone can provide. These programs gener- ally provide all the treatment services of a psychiatric hospital, but the clients are able to go home each evening.
Day-treatment programs are usually supervised by a psy- chiatrist and staffed by psychologists, social workers, psychiatric nurses, family therapists, activity therapists, and mental health counselors. Multidisciplinary assessments usually include a physical examination; a complete psychiatric evaluation; psy- chological, educational, and nursing assessments; a substance abuse assessment; and a psychosocial history. A treatment plan, which is usually formulated within 10 days of admission to the program, is reviewed weekly by the multidisciplinary treatment team. Examples of day-treatment program interven- tions are listed in Box 8-1.
Day-treatment programs have been successful, as evi- denced by the increase in the number of programs in com- munities. Clients participating in day-treatment programs have fewer hospitalizations, a decrease in psychiatric symptoms, more successful work experiences, and better overall social functioning in the community.
Examples of Day-Treatment Program Interventions
Family therapy—multifamily groups
•
Client and family education
•
Individual therapy
•
Group therapy
•
Therapeutic education or vocational training
•
Drug and alcohol education
•
Recreational therapy
•
Expressive therapies (eg, art, movement,
•
psychodrama)
BOX 8.1 Examples of Residential Treatment Program Group homes:
• Halfway houses, therapeutic com- munity homes
Personal care homes:
• Boarding homes, congre-
gate care facilities, social rehabilitation residen- tial programs
Foster homes:
• Domiciliary care, group foster homes, transitional care facilities
Satellite housing:
• Apartment clusters, transitional residences, independent living with aftercare support
Independent living:
• Lodgings, single-room occu-
pancy with therapeutic support BOX 8.2
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92 UNIT II Special Issues Related to Psychiatric–Mental Health Nursing
limitations that cause severe isolation and major depression.
The second population is the chronically mentally ill who require long-term medication and ongoing supportive coun- seling. Such clients are often diagnosed with schizophrenia, bipolar illness, depression, or a schizoaffective disorder. The third population consists of clients in need of crisis interven- tion and short-term psychotherapy.
Aftercare and Rehabilitation
When clients are discharged from a psychiatric hospital, CMHCs provide support and rehabilitation for the client. Many of these clients require only minimal support, with weekly or biweekly individual or family therapy and medication evalua- tion. Most of these clients, however, represent the chronically mentally ill population. They experience repeat hospitaliza- tions and require diverse support functions from the treatment team at the CMHC. Therapeutic services provided by most CMHCs are highlighted in Box 8-3.
One of the most effective and novel approaches com- munity mental health care providers use is the Programs for Assertive Community Treatment (PACT), also referred to as ACT. PACT is a service-delivery model that provides com- prehensive, locally based treatment to clients with serious and persistent mental illnesses. Unlike other community-based programs, PACT is not a case-management program that con- nects individuals to mental health, housing, or rehabilitation agencies or services. It provides highly individualized services directly to consumers. The key features include treatment of the psychiatric disorder (eg, psychopharmacology, individual supportive therapy, mobile crisis intervention), rehabilitation (eg, behaviorally oriented skill teaching, supported employ- ment, support for resuming education), and support services (eg, legal and advocacy services, fi nancial support, transporta- tion). This approach has been described as a hospital without walls. The goal of this integrated program is to help clients with schizophrenia and related disorders, such as depression or substance abuse, stay out of psychiatric hospitals and live independently. Available 24 hours a day, 7 days a week, the program provides professional staff to meet clients where they live and provide at-home support at whatever level is needed to solve any problem. PACT has signifi cantly reduced hospi- tal admissions and improved both functioning and quality of life for those it serves (National Alliance for the Mentally Ill [NAMI], 2005).
Other community programs have developed and been successful. Warner-Robbins (2003) describes a community program in Oceanside, California, that helps incarcerated women transition from prison to society. Welcome Home Ministries began in 1996 as a result of the need to provide aftercare to released incarcerated clients who spoke of depri- vation, poverty, emotional and physical abuse, drug addiction, and repeated incarceration. Volunteers visit clients in prison.
Clients also are provided with transportation to a preferred destination when released from jail, and are given the oppor- tunity to attend monthly meetings to support and encourage one another.
Psychiatric Home Care
With the increased emphasis on community mental health in the 1960s, programs were established to treat the psychiatric client at home with a visiting nurse providing care. An early project in Louisville, Kentucky, had clients with acute schizo- phrenia living at home with their families. A public health nurse or a nurse from the local Visiting Nurses Association visited these clients at least weekly. The nurse’s role was to conduct a psychiatric assessment, dispense medication, and provide individual and family counseling. In addition, a psychiatrist evaluated the home client every few months.
During the 1970s, psychiatric home care programs declined as the focus increasingly centered on day-treatment and resi- dential treatment programs. However, in the late 1980s, the concept of psychiatric home care was revitalized as community resources became scarcer. Psychiatric home care can fi ll the gap in the mental health continuum of care by providing nurs- ing resources as adjunctive to outpatient treatment.
The advantages of home care are well known and include cost-effectiveness, client satisfaction, and decreased disrup- tion of relationships with family and friends. Home care also presents a signifi cant opportunity for psychiatric nurses to pro- mote client independence in the home environment by assess- ing functional abilities or self-care tasks and incidental abilities such as medication management, housekeeping, and manag- ing fi nances (Sanders, 2001).
The age of clients receiving psychiatric home care can vary. Any individual who has had a chronic psychiatric illness for at least 2 years may apply for Medicare or Medicaid health care coverage. Therefore, clients may be children, adolescents, adults, or elderly persons.
Independent psychiatric nurse practitioners who have con- tracts with insurance companies or who are providers for Medi- care and Medicaid can provide psychiatric services in the home environment. Medicare and Medicaid have made provisions to use a billing code that indicates that a house call was made.
The Health Care Financing Administration has established the following criteria for the provision of psychiatric home care services:
1. A psychiatrist must certify that the client is homebound.
2. The client must have a Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR) psychiatric diagnosis that is acute or an acute exacerba- tion of a chronic illness.
3. The client must require the specialized knowledge, skills, and abilities of a psychiatric registered nurse.
Richie and Lusky (1987) defi ne the major features of psychiatric home care as the provision of comprehensive care, ongoing interdisciplinary collaboration, and accountability to client and community. They have identifi ed three major client popu- lations that use this community service. The fi rst group is the elderly who do not have a history of chronic mental illness, but who are experiencing acute psychological and developmental problems. A common client in this group is an elderly per- son who lives alone and is experiencing increasing physical
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CHAPTER 8 Continuum of Care 93
time. As the population for whom they care grows and ages with an increase in comorbid conditions, different skills may be needed or different roles may require emphasis. For example, the psychiatric nurse practicing in the community provides counseling, support, and coordination of care and health teaching. The role is comprehensive and challenging and requires adaptability and fl exibility considering each cli- ent’s age, diagnosis, and spiritual, cultural, and legal issues.
A nurse clinician with an advanced degree may function as a nurse–therapist employing individual, group, and family therapy. Prescriptive privileges may be allowed, depending on the state’s department of professional regulation. Many insur- ance companies, as well as government-funded Medicare and Medicaid programs, approve reimbursement for psychiatric nursing services provided in the home, in LTC facilities, or in community-based mental health settings.
To emphasize the need for a clear theoretical framework for the practice of community mental health nursing, Dr. Jeanne Miller (1981) described two areas of concern to community mental health nurses. The fi rst concern was the attempt by nurses to improve the quality of direct client care through means such as primary nursing, psychiatric home care, and case man- agement. At the same time, community mental health nurses