week 2 mental health treatment settings

Chapter 4: Treatment Settings

Learning Objectives

  • By the end of this lesson, learners will be able to:

    • Describe the continuum of mental health care and the shift from institutional to community treatment.

    • Identify major outpatient, inpatient, and emergency psychiatric treatment settings.

    • Differentiate levels of care intensity (outpatient, intensive outpatient/partial hospitalization, inpatient).

    • Explain primary, secondary, and tertiary prevention in mental health care.

    • Describe the role of the psychiatric nurse in coordinating care, safety, and recovery across settings.

Background

  • 1860s to 1950s:

    • Asylums have roots in the Civil War era; individuals were treated in large asylums.

    • 1950s: Introduction of the first antipsychotic medication which revolutionized mental health treatment.

  • 1960s:

    • Medicare and Medicaid initiated with a lack of funding for psychiatric care, leading to significant changes in the care landscape.

  • 1999:

    • The Olmstead Decision facilitated deinstitutionalization, promoting a shift to community-based care.

  • 2016 Statistics:

    • A notable decrease in state psychiatric hospitals from 322 in 1950 to 195 in 2019, reflecting a current system that offers both outpatient and inpatient settings along a continuum of care.

Outpatient Care Settings

  • General Information:

    • Most mental health care occurs outside of hospitals, incorporating various providers and models.

  • Types of Providers:

    • Primary Care Providers: Often the first point of contact for mental health concerns.

    • Specialized Psychiatric Care Providers.

  • Patient-Centered Medical Homes (PCMHs):

    • Focus on team-based coordinated care, encompassing the following aspects:

    • Patient-centered approach

    • Comprehensive care

    • Coordination of care

    • Improved access

    • Systems approach aimed at achieving better access and whole-person care.

Outpatient Psychiatric Mental Health Care

  • Community-Based Residential Support:

    • Long-term supportive housing available for mental health clients.

  • Assertive Community Treatment (ACT):

    • Provides mobile, intensive, multidisciplinary care in the community for clients dealing with severe and persistent mental health issues.

  • Intensive Outpatient Programs (IOP):

    • Clients live at home, attending the facility approximately 3-5 days a week. This is less intensive compared to Partial Hospitalization Programs (PHP).

  • Inpatient Psychiatric Units:

    • Provide a 24/7 hospital stay for patients.

  • Other Outpatient Venues for Psychiatric Care:

    • Telepsychiatry, which allows for remote psychiatric consultations.

Emergency Care

  • Comprehensive Emergency Service Model:

    • Features dedicated psychiatric space and staff; often affiliated with a full-service emergency department (ED) in a hospital or medical center.

  • Hospital-Based Consultant Model:

    • There is no dedicated space or separate staffing; psychiatric staff may be on-site or on-call for the ED.

  • Mobile Crisis Team Model:

    • Provides field stabilization and assessment to de-escalate situations.

Case Study: Edgar

  • Edgar is a soldier who recently returned from a war zone, experiencing what he describes as depression. The initiation of care begins with his primary care physician, largely due to encouragement from his wife, Annie, who is concerned about his emotional state.

    • Edgar’s physician seeks help from the psychiatric nurse during a team meeting when he feels Edgar may require care beyond his expertise.

Prevention in Outpatient Care

  • Primary Prevention:

    • Prevention strategies that occur before any problem appears. It aims to reduce the rate of new cases.

  • Secondary Prevention:

    • Involves the early identification of issues, screening, and providing prompt and effective treatment. For example, noticing mood changes and referring to therapy.

  • Tertiary Prevention:

    • Focuses on treatment aimed at preventing the progression of an existing condition, closely linked to rehabilitation processes.

Knowledge Check

  • Scenario: A community health counselor conducts a workshop for first-time parents on coping with stress and emotional changes following childbirth.

    • This represents primary prevention as it aims to equip parents before issues arise.

Objectives

  • Describe the nurse's role in outpatient psychiatric settings.

  • Identify the primary types of inpatient care and their respective functions.

Outpatient Psychiatric Nursing

  • Nurses require the following competencies:

    • Strong problem-solving and clinical skills.

    • Cultural competence to effectively serve diverse populations.

    • Flexibility to adapt to varying patient needs.

    • Comprehensive knowledge of community resources.

    • Autonomy in promoting recovery and ensuring continuity of treatment.

Discussion: Needs of Outpatients

  • Key considerations when working with a patient transitioning from inpatient services to outpatient community-based services include identifying potential obstacles that might affect the success of ongoing treatment.

Audience Response Questions

  • Scenario: After a suicide attempt, Edgar requests his belt for personal use. Appropriate nurse responses should address safety protocols:

    • “Your belt is locked in the business office for safekeeping, along with all your other valuables.”

    • “For safety reasons, hospitalized clients are not allowed to keep certain personal possessions.”

    • “I cannot provide your belt, but I will help you get some pants with an elastic waistband.”

    • “I will ask the psychiatric technician to get your belt for you.”

Case Study: Edgar (Post-Hospitalization)

  • Following his hospital discharge, Edgar aims to “start again,” recognizing major depression as a chronic issue. He and Annie have decided to join a support group for veterans and their families focusing on PTSD and major depression. Furthermore, they have enrolled in a yoga class together, reflecting on shared interests and optimism for the future.

Strong Close

  • The evolution of mental health care emphasizes that treatment is no longer confined to hospitals; instead, it spans a continuum of care that begins in the community. Treatment intensifies only as necessary, depending on patients' safety and symptom severity, enabling movement across outpatient services, intensive programs, emergency care, and inpatient hospitalization as required.

Homework

  • Task: Select a population and identify the best treatment setting and level for prevention.

Asynchronous Next Steps

  • Recommended: Review treatment settings and concepts related to the continuum of care discussed in lecture materials.

Reflection

  • Considerations to reflect on: What strategies or concepts helped differentiate between primary, secondary, and tertiary prevention?