1. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 35Seriously and Persistently Mentally Ill, Homeless, or Incarcerated Clients

2. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Many behavioral disorders are complicated by the presence of chronic emotional, cognitive, and medical problems which pose significant challenges for patients, families, and their care management providers. Such complex behavioral illnesses, also termed Serious and Persistent Mental Illness (SPMI), are among the most complicated and difficult diseases to successfully treat. —Comprehensive Neuroscience, 2009

3. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins At any given time, there are many more people with untreated severe psychiatric illnesses living on America’s streets than receiving care in hospitals. —Nichols, 2008 Yesterday’s state hospitals have morphed into today’s jails and prisons. —Nasrallah, 2008

4. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Learning Objectives After studying this chapter, you should be able to Articulate the effect of a serious and persistent mental illness (SPMI) on the life of clients so affected Discuss the relationship between SPMI and the problems of homelessness and incarceration Explain how deinstitutionalization, transinstitutionalization, and lack of community services have contributed to the current problems of those with SPMI

5. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Learning Objectives (cont.) Describe the groups of individuals comprising the homeless population Identify those clients with SPMI at risk for incarceration Compare and contrast mental health and social service treatments for nursing-home residents, the homeless, and the incarcerated who are experiencing SPMI Articulate the impact of managed care on the mental health treatment and continuum of care of those with SPMI

6. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Learning Objectives (cont.) Discuss the effect of having a member with SPMI on the family Summarize important nursing assessments for the client with SPMI Determine nursing implementations that are important for a client with SPMI Construct a nursing plan of care for a client with SPMI

7. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Scope of SPMI Major depression, bipolar disorder, and schizophrenia account for four of the ten leading causes of disability. Factors such as substandard housing, unemployment or underemployment, poor nutrition, lack of preventive care, and limited access to medical care create severe stressors for individuals affected with mental illness. The physical health of individuals with SPMI is worse than the physical health of those without SPMI.

8. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Factors Related to the Current Problems of the SPMI Deinstitutionalization Transinstitutionalization Inappropriate use and lack of community services

9. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Categories of Seriously and Persistently Mentally Ill Nursing-home residents The homeless The incarcerated

10. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins The Homeless Risk factors for homelessness Special populations of the homeless –Children, adolescents, and young adults –Women –Elderly Hate crimes against the homeless

11. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins The Incarcerated Factors related to incarceration Clients at risk for incarceration –Clients with impulse control disorders –Clients with sexual disorders –Clients with substance-related disorders –Clients with bipolar disorders –Clients with personality disorders Risk for suicide among incarcerated clients

12. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins The Nursing Process Assessment Nursing diagnoses Outcome identification Planning interventions Implementation Evaluation

13. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Assessment Physical health status Current clinical symptoms Self-care abilities Current living situation Coping skills and support systems Compliance with medication Substance-abuse problems

14. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Nursing Diagnoses Interrupted family processes Ineffective health maintenance Imbalanced nutrition: more than body requirements Ineffective role performance Disturbed thought processes Chronic low self-esteem Hopelessness Impaired social interaction Ineffective coping Noncompliance (failure to take prescribed psychotropic medications or participate in long-term psychiatric treatment) Risk for violence: self- directed or other-directed violence Disturbed sensory perception (visual and/or auditory) Social isolation

15. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Outcome Identification Functional outcomes, especially social and occupational, are generally more important than symptomatic outcomes. Outcomes focus on the following: –Maintaining client safety –Establishing and maintaining client self-care –Establishing client trust and facilitating interaction with staff and peers –Decreasing delusional thinking and hallucinatory experiences –Increasing positive self-statements –Having the client agree to take prescribed psychotropic medications –Provision of family support when available

16. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Planning Interventions Planning nursing interventions is dependent on the following: The nurse’s ability to assess the client The nurse’s ability to establish and maintain a therapeutic relationship –Listen and communicate recognition and understanding

17. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Implementation Providing a safe environment Promoting physical health Providing medication management and education

18. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Implementation (cont.) Using cognitive–behavioral therapy –Orienting to reality –Promoting self-care –Enhancing self-esteem –Providing support National Empowerment Center

19. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Implementation (cont.) Employing the psychosocial rehabilitation approach –Clubhouse program Using the Assertive Community Treatment (ACT) model

20. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Implementation (cont.) Providing continuum of care –Integrated Model Program (IMPACT) –Respite care for the homeless –Welcome Home Ministries (WHM) –Concerns about continuum of care for homeless clients –Concerns about continuum of care for incarcerated clients –Concerns about managed care Educating the family

21. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Evaluation For clients with SPMI, care is ongoing and includes the provision of support necessary for community living. Care is successful if the client can avoid hospitalization and maintain community housing and support systems.

22. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Key Terms ACT model Clubhouse program Deinstitutionalization Empowerment Model of Recovery Hate crime Impulse control disorders Integrated Model Program (IMPACT) Mercy bookings Respite care for the homeless Serious and persistent mental illness (SPMI) Transinstitutionalization Welcome Home Ministries

23. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Reflection Reflect on your psychiatric nursing curriculum. Most curriculums address the issues of chronic mental illness but may not address psychosocial needs of the homeless or incarcerated client. ? Are the psychosocial needs of these clients included in the curriculum? If not, determine why. If they are addressed, are the nursing interventions realistic? Explain your answers.