MENTAL HEALTH MENTAL HEALTH CARE SETTINGSCARE SETTINGS

Rebecca Sposato MS, RN

The StatsThe StatsAmbulatory care

◦ Number of ambulatory care visits (physician offices, outpatient centers, and emergency departments) with mental disorders as primary diagnosis: 58.2 million

Hospital inpatient care◦ Number of discharges with mental disorders as

first-listed diagnosis: 2.4 million◦ Average length of stay for mental disorders:

7.1 daysNursing home care

◦ Number of residents with mental disorders: 996,000

◦ Percent of residents with mental disorders: 67%

◦ (http://www.cdc.gov/nchs/fastats/mental.htm, 2011)

Diagnostic and Statistic Diagnostic and Statistic Manual for Mental Health Manual for Mental Health Disorders-IVDisorders-IVDescribes the main features and

specific criteria for mental illness Multi-Axis System

◦Axis 1 - Clinical Conditions (ex. depression)

◦Axis II - Personality and Intellectual Disorders (ex. borderline personality)

◦Axis III - Medical Conditions ( ex. Diabetes)◦Axis IV – Psychosocial or environmental

problems (homeless, estranged from family)

◦Avis V – Global Functioning (100-0)

Global Assessment of Global Assessment of FunctioningFunctioning100: no symptoms, well-adjusted and

content with life, can take care of problems, close and meaningful relationships

75: Symptoms mildly affect quality of life, problems occasionally emerge, socially awkward

50: Symptoms impair quality of life, conflict with peers, legal/employment issues

25: Symptoms impair basic life skills, at risk for danger to self/others, impaired communication

1: Hurts self/others, absent life skills unable to address or communicate basic needs

Mental Health Mental Health ProfessionalsProfessionalsRegistered Nurse-

◦care for patient and unitAdvance Practice Mental Health

Nurse/Clinical Specialist-◦Graduate level education and clinical◦Ensure protocols and staff training are

up to date and comply with regulation◦Consult for complicated patients

Nurse Practitioner-◦Manages the physical health and

needs of patients

Mental Health Mental Health ProfessionalsProfessionalsClinical Psychologist-

◦Graduate level education and clinical training

◦Evaluate patients, conduct mental health tests

◦Direct individual and group counselingPsychiatrist: medical doctor

◦Prescribes medications and ECT◦Referrals for therapy and counseling◦Determines admission/discharge◦Advocates for legal status

Mental Health Mental Health ProfessionalsProfessionalsCase Managers/Social Workers –

◦Undergraduate and graduate education◦Liaisons for patients to obtain and

maintain social services, financial aid, outpatient care

Therapist /Counselors◦conduct treatment sessions, education,

counsel groups, addiction management, rehabilitation services

Mental Health Technicians ◦Assist patients under nursing

supervision

Dorothea Dix (1802-1887)Dorothea Dix (1802-1887)Originally a school

teacher who in 1841 became a reformer for treatment of the mentally ill

Within 10 years visited >300 jails and >500 almshouses

Advocated for mentally ill persons to be removed from jails/almshouses and be placed in public hospitals

By 1880, <1% of prison population were the mentally illhttp://www.pbs.org/wgbh/pages/frontline/shows/asylums/

special, 2011

DeinstitutionalizationDeinstitutionalization >80% Reduction in state

psychiatric facilities for the community level

Contributors◦ 1950s: anti-psych meds◦ 1960s: civil rights values◦ 1965: Medicare/Medicaid◦ Kennedy/Carter passed

laws stipulating community programs

Consequences:◦ Advent of outpatient

mental health centers and programs

◦ Increase mental illness in homeless and prison populations and ED visits

Community Based Mental Community Based Mental HealthHealthBiopsychosocial Assessment

◦Family/Friend resources◦Ability to obtain/maintain housing,

food, hygiene, income, employment◦Adhere with outpatient mental

health treatment, sobriety, medication schedule, MD appointment

◦Plan B for mental illness symptoms

Community Based Mental Community Based Mental HealthHealth

Most Acute

Least Acute

Admission/Observation for crisis

Partial Hospital Programs

Psychiatric home care

Assertive Care Treatments

Community Mental Health Care Centers

MD or counselor office level care

Support Groups

Levels of PreventionsLevels of PreventionsPrimary: maintain the mental

health of person and population. ◦Educate teens about drugs/alcohol

Secondary: screen and intervene for impaired mental health◦Detox center

Tertiary: recover and rehabilitate towards mental health◦Support groups for alcoholics

Inpatient AdmissionInpatient AdmissionMajority of patients enter mental

health care through the emergency room◦Self Referral◦Friend/Family◦Professional

Criteria◦Imminent harm to self◦Imminent harm to other◦Gravely disabled in care of basic needs

Types of AdmissionTypes of AdmissionVoluntary:

◦patient complies and consents with inpatient status

◦Patient may choose to leave prior to completion of therapy regimen

Involuntary: ◦Patient may not leave facility

72hr Mental Health Hold: initiated by police, Clin. Psych, MD, SW, LPC, APN, BSN (1yr in mental health)

◦Short Term Certification: up to 60 days◦Long Term Certification: up to 90 days◦Legal Guardian/Ward of the State

Inpatient ProtocolsInpatient ProtocolsSuicide Precautions and

Elopement PrecautionsLevels of Restriction

◦ Day passes (overnight passes void inpatient status)

◦ Unaccompanied on grounds◦ Accompanied by staff◦ Restricted to unit◦ Line of sight◦ Seclusion◦ Restrained

Inventory Belongings◦ No weapons, pills, powders, open liquids,

cords, strings, belts, plastic bags, sharp objects

Rights of Mental Health Rights of Mental Health PatientsPatientsAdditional levels of confidentiality

◦Exceptions: 1. warning a third party of intended harm

by patient 2. reporting abuse of a vulnerable person

Right to stay informed/involved in treatment

Right to contest care/providerRight to humane conditions,

recreation, social interaction, vote, enter contracts

ReferencesReferences

Centers for Disease Control (2011) www.cdc.gov/nchs/fastats/mental.htm,

Diagnostic and Statistic Manual for Mental Disorders - IV – Text Revision

Public Broadcasting Service: Frontline (2011) www.pbs.org/wgbh/pages/frontline/shows/asylums