Chapter 4Psychiatric Mental Health Nursing in Acute

Care Settings

Inpatient Psychiatric CareAdmissions reserved for

SuicidalHomicidal orExtremely disabled in need of short-term acute

care

Funding Psychiatric Mental Health CarePrivate pay insuranceManaged care plans

Health maintenance organizations (HMOs)Preferred provider organizations (PPOs)Managed behavioral health care organizations

(MBHOs)MedicaidMedicare

Mental Health Funding LegislationPaul Wellstone and Peter Domenici Mental

Health and Addiction Equity Act of 2008Restricts insurance companies from requiring

higher co-payments or higher deductibles for mental health or substance abuse

Uninsured PatientsMedicare MedicaidSocial Security

Social Security Disability Income (SSDI)Supplemental Security Income (SSI)

Veterans Administration

Inpatient Psychiatric CareAdmission options

Direct admissionHospital emergency department

Criteria to justify admissionsDanger to self or others or unable to care for

basic needsVoluntary or involuntary

Patient RightsHospitalized patients retain their rights as

citizensObligation to balance patient's needs for

safety with patient's rights as a citizenMental health facilities have written

statements of patient's rights and applicable state laws

Multidisciplinary Treatment TeamMeet within 72 hours of patient's admissionMultidisciplinary treatment plan or clinical

pathway is guideline for patient’s care during hospital stay

Nursing CareAdmission assessmentEnsuring safetyPhysical health assessmentMilieu management

Nursing CareContinuedStructured group activitiesDocumentationMedication administrationMedication adherence

Nursing CareContinuedPain managementCrisis management

Medical crisesBehavioral crises

Preparation for discharge to community

Chapter 5Psychiatric Mental Health Nursing in

Community Settings

Community Mental Health Nursing Movement1963

Community Mental Health Centers Act (Kennedy)

Shift care from institution to the communityDeinstitutionalization

1960sFederal entitlement programsSocial Security DisabilitySupplemental Security IncomeMedicaidMedicareHousing assistanceFood stamps

Community Mental HealthNursing MovementContinued

ChallengesFew choices for outpatient treatmentLimited fundingMore clients than resourcesResistance of seriously mentally ill patients to

treatment1980s

Commission on Mental Health (Carter)

Roles and Functions of Community Mental Health Nurse Biopsychosocial assessment Negotiating flexible and resourceful

treatment goals and interventions Member of a multidisciplinary team Biopsychosocial Care Manager Promoting continuation of treatment Providing care in a variety of settings

Continuum of Psychiatric TreatmentMost acute treatment

(short-term)

Intensive outpatient treatment (usually short-term)

Transitional outpatient treatment (usually long-term)

Ongoing outpatient treatment (long-term)

Community SettingsPartial hospitalization program (PHP)

Intensive, short-term treatment with patient ableto return home each day Patients receive 5 to 6 hours of treatment dailyTypically 5 days a weekAverage length of stay 2 to 3 weeksMultidisciplinary team (psychiatrist, RN, and

social worker)

Community SettingsContinuedPsychiatric Home CareFour requirements

Homebound status of patientPresence of psychiatric diagnosisNeed for skills of RNPlan of care under physician

Community SettingsContinuedAssertive Community Treatment (ACT)

For clients with repeated hospitalizations, severe symptoms, or inability to participate in traditional treatment

Multidisciplinary team Work with patients in homes, agencies,

hospitals, or clinicsACT team provides support and resources; on

call 24 hours a day

Community SettingsContinuedCommunity Mental Health Centers

Emergency, adult, and children’s services for those

who have no access to private careProvideMedication administrationIndividual therapyPsychoeducational and therapy groupsFamily therapyDual-diagnosis treatment

Resolving Ethical DilemmasRole of nurse

Act in the best interests of the patient and society to the degree possible

Resources for consultationHospital ethics committeeAgency ethics consultantProfessional nursing organizationsState board of nursing

Barriers to Mental Health Treatment

Stigma associated with mental disordersScarcity of care in rural areasInability to afford health insuranceFragmented care for children and adults with

serious mental illnessHigh unemployment and disability among

seriously mentally illUndertreatment of older adults Lack of national priority for mental health