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Community-Based
Psychiatric Nursing Care
 The goal of the mental health delivery system is to help
people who have experienced a psychiatric illness live
successful and productive lives in the community and to
ensure that consumers and families have access to timely
and accurate information that promotes learning, selfcare management, and health. Successful transforming
the mental health service delivery system rests on two
principles:
1. Services and treatments must be consumer and family
centered.
2. Care must focus on increasing consumers' ability to
successfully cope with life's challenges, on facilitating
recovery, and on building resilience.
The reports shows that offering a full range of
community-based alternatives is more effective than
hospitalization and emergency department (ED)
treatment.
Many psychiatric nurses work in communitybased settings, where they assume a broad range
of responsibilities and engage in a variety of tasks
and interventions (Kudless and White, 2007). In
these settings they work with interdisciplinary
teams and focus on prevention, care management,
and recovery.
Nurses at both 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. Consumers have noted that community
mental health nurses increase their access to care,
engage in positive relationships with them, and
help them meet their health care needs (Elsom et
al, 2007).
Deinstitutionalization:
At the patient level, deinstitutionalization refers to the
transfer of a patient hospitalized for extended periods
of time to a community setting. At the mental health
care system level, it refers to a shift in the focus of
care from long-term institution to the community,
accompanied by discharging long-term patients and
avoiding unnecessary admissions.
 In reviewing the failures of this early attempt to move patients
into community care, mental health experts agree that the
following problems contributed to the lack of success:
• Poor coordination between hospitals and community mental
health centers.
• Underestimation of the support systems needed to enable
people with mental illness to live in the community.
• Lack of knowledge about psychiatric rehabilitation.
• Shortage of professionals trained to work this population in the
community.
A systems model of care:
 A systems model of community mental health operates on the
philosophy that all aspects of a person's life need to be cared
for – basic human needs, physical health needs, and needs for
psychiatric treatment and rehabilitation – if a person is to live
successfully in the community.
 The focus is on developing a comprehensive system of care
and coordinating needed services into and integrated package
for persons with severe and disabling mental illnesses.
Case Management:
 In implementing these systems, case management became the
primary means for ensuring that the components were
available to every person with a chronic mental illness who
needed them.
 Components of a community support system include patient
identification and outreach, mental health treatment, crisis
response services, health and dental care, housing , income
support and entitlement, peer support, family and community
support, rehabilitation services, and protection and advocacy.
(Figure 34-1).
 Case management involves linking the service
system to the consumer and coordinating the service
components so that the consumer can achieve
successful community living. It focuses on problem
solving to provide continuity of services and
overcome problems of rigid systems, fragmented
services, poor use of resources, and problems of
inaccessibility. The six activities of case management
are as follows:
1.
2.
3.
3.
4.
5.
Identification and outreach
Assessment
Service planning
Linkage with needed services
Monitoring service delivery
Advocacy
 In addition, core aspects and specific interventions
related to clinical case management are listed in
Table 34-1
At present, case management is an ambiguous
concept without a clear base in any one provider
group.
Further, there are various models or types of case
management, including full service, broker, therapist,
intensive, peer based, social support, collaborative,
community advocate, and problem focused-each with
its own structure, purpose, and team composition.
Questions about the effectiveness of the different
types of case management and the recommended
caseload of case managers remain unresolved.
Assertive Community Treatment:
Assertive Community Treatment (ACT) was
developed in the early 1970s as a program originally
called Training in Community Living (TCL). It was
created as a way to organize outpatient mental health
services for patients who were leaving large state
mental hospitals and were at risk for
rehospitalization.
ACT is a service delivery model, not a case
management program. It was designed for people
with the most challenging and persistent problems.
The goal of ACT is recovery through community
treatment and habituation.
This model program provides a full range of
medical, psychosocial, and rehabilitative services.
The 10 principles of ACT are listed in Box 34-1.
 ACT uses an interdisciplinary, team-oriented approach that
typically includes 10 to 12 professionals (nurses, psychiatrists,
social workers, activity therapists) who meet regularly to plan
individualized care for a shared caseload of about 120 patients.
 Teams may include a person with a mental illness or a family
member of a person with a mental illness. More than 75% of
staff time is spent in the field providing direct treatment and
rehabilitation. The services provided by ACT treatment team
members are listed in Box 34-2.
Psychiatric nurses are typically integral members of
the ACT treatment team (McGrew et al, 2003). These
teams function as continuous care teams who work
with patients with serious mental illness and their
families over time to improve their quality of life
(chapter 14). In effect, ACT programs function as a
community-based "Hospital without walls,"
providing a high-intensity program of clinical
support and treatment.
Vulnerable Populations in the community:
 Homeless People with Mental Illness:
 About one third of the estimated 600,000 homeless people in
the United States have a severe mental illness. However, only
1 in 20 persons with a a mental illness, as few as 5% to 7%
need to be institutionalized. Most can live in the community
with appropriate, supportive housing (Mojtabai, 2005).
 When homeless people with mental illnesses are given the
opportunity to participate in treatment programs that address
their needs for services in areas such as housing, health care,
substance abuse, income support, and social support, many can
be helped to find homes and achieve substantial improvements
in their lives.
Key components of this focused treatment approach include the
following:
 Frequent and consistent staff contact through assertive
outreach.
 Meeting the patient where the patient is, both geographically
and interpersonally.
 Help with immediate survival needs, such as food, emergency
shelter, and clothing.
 Gradual treatment through the development of trust.
 An emphasis on patient strengths
 Patient choice of services and the right to refuse treatment.
 The delivery of comprehensive services, including mental
health and substance abuse treatment, medical care, housing,
social and vocational services, and help in obtaining
entitlements.
Rural Mentally Ill People:
They include insufficient access to crisis services,
mental health and general medical clinics, hospitals,
and innovative treatments. Rural residents also may
face greater social stigma in regard to seeking mental
health care, and basic community services such s
transportation, electricity , water, and telephones that
are important to providing health care may not be
available.
Rural residents are at significant risk for
substance use disorders, mental illness, and
suicide.
For these reasons, mental health issues are among the
most prominent health concerns being faced in rural
areas. As a result, the following are true about
residents with mental health needs:
• They enter care later in the course of their disease than their
urban peers.
• They enter care with more serious, persistent, and disabling
symptoms.
• They require more expensive and intensive treatment
response.
 Rural areas experience three additional problems.
o The first is the lack of mental health professional, including culturally
competent or bilingual providers.
o The second is the fact that people in the United States have lower family
incomes and are less likely to have health insurance benefits for mental
health care.
o Finally, many ethical dilemmas arise when practicing in the community,
and some of these are unique to the rural setting.
 When numbers of providers in isolated settings are limited,
problems may arise because of overlapping social and
professional relationships, altered therapeutic boundaries,
challenges in protecting patient confidentiality, and differing
cultural dimensions of mental health care.
Incarcerated Mentally Ill people:
In the United States about 80,000 patients are in
psychiatric hospitals. In contrast, some 283,800
incarcerated persons are identified as having a mental
illness (table 34-2). Thus the mentally ill segment
represents 16% of the inmate populations of state
and local jails, or more than three times the
number of people in psychiatric hospitals
throughout the United States.
 A result of the effect of prison life on inmates is the alarmingly
high rate of suicides. Suicides is the leading cause of death
in inmates, accounting for more than one half the deaths
occurring while inmates are in custody. Almost all who
attempt suicide have a major psychiatric disorder. More than
one half of the victims were experiencing hallucinations at the
time of the attempt.
 Clearly, the presence of severely mentally ill persons in jails
and prisons is an urgent problem. These individuals are often
poor, uninsured, disproportionately members of minority
groups, and living with co-occurring substance abuse and
mental disorders.
Some programs are attempting to deal with this
problem in various part of the United States. A
community model for services (Figure 34-2) has been
developed that includes methods for preventing
incarceration of people with mental illness and
intervening effectively when such a person is jailed.
This model is based on the formation of a community
board and includes both preventive and postrelease
interventions.
Psychiatric Care in Community Settings:
 Primary Care Settings:
 Most people seek help for their mental health problems from
their primary care provider. Thus 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. However,
a majority of patients with mental illness are not treated
effectively in the primary care setting.
 The first step in addressing this issue is the use of effective
screening measures in primary care. The U.S. Preventive
Services Task Force recommends the following (AHRQ,
2006):
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.
Recent research has shown that one- or two-item
screening tools are effective in identifying those at
risk for substance use or depressive disorders (Table
34-3)
 May 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.
 Collaborative Care, collaborative care models have two key
elements. The first is systematic care management most often
done by a nurse to facilitate case identification, coordination of
a treatment plan, patient education, close follow-up, and
monitoring of progress. This can be done in the primary care
setting or by telephone.
The second elements is consultation among the
primary care provider, case manager, and a mental
health specialist. Research has shown that
collaborative care models for depression improve
clinical outcomes, employment rates, functioning,
and quality of life and that they are cost-effective
(Gensichen et al, 2006; Unutzer et al, 2006).
Another framework that nurses can use for behavioral
counseling in primary care is the 5A's:
 Assess – Ask about a person's behavioral health risk and
factors affecting one's choice of future goals.
 Advise- Give clear, specific, and personalized behavior 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.
 Arrange- Schedule follow-up contacts (in person or by
telephone) to provide ongoing support, including referral to a
specialist if needed.
Nurses can play a pivotal role in integrating the mental health and
physical care of patients in primary care settings.
Emergency Department Psychiatric Care:
Emergency departments (EDs) cannot deny
treatment, and therefore they have become the safety
net for patients who do not have access to care or the
resources to go to another type of facility.
With substance use disorders and mental illness
contributing tot many other illnesses, EDs have seen
and increasing number of patients who require
interventions for these problems.
 Patients who have attempted suicide are most often seen in the ED.
Psychiatric Services in the Emergency Department:
Many tertiary care, acute care hospitals have
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 theses disorders than on physical
illnesses and injuries.
The many reasons for this include time constraints,
lack of confidence in intervening effectively,
reimbursement issues, an bias and stigma bout
psychiatric care.
Home Psychiatric Care:
Home psychiatric care is available to a broad segment
of the population. Factors contributing to the
development of this treatment setting include the
following:
• Continued trend of deinstitutionalization.
• Growth of managed care, which focuses on cost,
outcomes, and earlier hospital discharges.
• Advocacy by consumer groups to find less restrictive
and more humane ways of delivering care to people
with mental illness.
 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.
 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.
 The advantages of home care in relation to inpatient treatment
involve its ability to serve as the following:
• 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 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.
 Examples of other gains obtained by psychiatric home care
include its outreach capacity and emphasis on patient
participation, responsibility, autonomy, and satisfaction.
Reimbursement Issues:
Medicare guidelines do not provide very specific
information on psychiatric nursing services that are
covered on home visits. They do require that the
patient meet all of the following criteria:
Be homebound
Have a diagnosed psychiatric disorder
Require the skills of a psychiatric nurse.
Context of Home Care:
Psychiatric home care nursing provides unique
challenges and opportunities to the nurse. In an
impatient 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 four key issues
for the nurse:
Cultural competence, flexibility in boundary
setting, trust, and safety.
 Cultural competence. Awareness of the patient's ethnic and
cultural background is critical to effective care in all settings.
The nurse is exposed to the patient's culture, and the patient
will observe the nurse's reaction in these surroundings.
 It is important that the nurse also have an understanding of
one's own cultural background and the prejudices related to
socioeconomic status, gender, family structure, and ways of
dealing with emotion emanating from that background. Selfawareness 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.
Boundary issues. Closely related to cultural issues are
that 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, then
being willing to share in this ritual can build trust in
the relationship between the nurse and patient.
Trust. The psychiatric home care nurse must consider
many different factors when planning and
implementing nursing care. Unlike nursing practice in
the hospital or outpatient mental health center,
psychiatric home care nurses have little control over
their patients' environments. It is therefore essential to
establish trust in the initial evaluation home visit.
Trust then becomes a vital part of the nurse-patient
relationship as the patient and nurse work together to
solve problems and achieve goals. For example, the
nurse trusts the patient to be home at scheduled visits,
take medications, and participate fully in all aspects
of the plan of care. The patient trusts the nurse to be
reliable, clinically knowledgeable, competent, and
caring.
Safety. Strategies must be identified for dealing with
suicidal or aggressive behavior. In this way, home
health nursing does have its limitations.
The nurse and patient must work together to develop
and acceptable plan. If the situation becomes unsafe,
the nurse must leave the home. Patients' families,
caregivers, and other community resources should be
urged to notify the police or take the patient to the
hospital for and evaluation if the patient becomes
dangerous.
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 mangers,
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.
Forensic Psychiatric Care:
Forensic psychiatric nursing is defined as a
subspecialty of nursing that has as its objective
assisting the mental health and legal systems in
serving individual who have come to the attention
of both. It is gaining momentum nationally and
internationally.
Forensic psychiatric nursing has two very different
and sometimes conflicting goals. First is the goal of
providing individualized patient care. Second is the
goal of providing custody and protection for the
community.
The forensic focus for nursing is the therapeutic
targeting of any aspect of the patient's behavior
that links the offending activity and psychiatric
symptomatology.
As such, the forensic nurse functions as a patient
advocate; a trusted counselor; an agent of control;
and a provider of primary, secondary, and tertiary
health care interventions to this vulnerable
population. Interventions include risk assessment,
crisis
intervention,
rehabilitation,
suicide
prevention, behavior management, sex-offender
treatment, substance abuse treatment, and
discharge planning.
Settings and Roles. Most forensic psychiatric nurses
work in the public sector under state departments of
mental health or in psychiatric units in jails, prisons,
and juvenile detention centers.
 However, forensic nurses are also found working in the following areas
(IAFN, 2007):
 Interpersonal violence
 Public health and safety
 Emergency/trauma nursing
 Patient care facilities
 Police and corrections, including custody and abuse.
The scope of responsibility of forensic nurses can be
quite broad, depending on the area of practice.
Forensic nurses can practice in the ED, critical care
setting, coroner's office, or correctional facility. One
specific role is that of the sexual assault nurse
examiner (SANE). This is a nurse who has received
special training to provide care to the victim of sexual
assault.