1. MENTAL HEALTH CARE SETTINGS Rebecca Sposato MS, RN

2. The Stats Ambulatory 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 days Nursing 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)

3. Diagnostic and Statistic Manual for Mental Health Disorders-IV Describes 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)

4. Global Assessment of Functioning 100: 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

5. Mental Health Professionals Registered Nurse- ◦ care for patient and unit Advance 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

6. Mental Health Professionals Clinical Psychologist- ◦ Graduate level education and clinical training ◦ Evaluate patients, conduct mental health tests ◦ Direct individual and group counseling Psychiatrist: medical doctor ◦ Prescribes medications and ECT ◦ Referrals for therapy and counseling ◦ Determines admission/discharge ◦ Advocates for legal status

7. Mental Health Professionals Case 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

8. 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 ill http://www.pbs.org/wgbh/pages/frontline/shows/asylums/special, 2011

9. Deinstitutionalization >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

10. Community Based Mental Health Biopsychosocial 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

11. Community Based Mental Health 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

12. Levels of Preventions Primary: 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

13. Inpatient Admission Majority 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

14. Types of Admission Voluntary: ◦ 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

15. Inpatient Protocols Suicide Precautions and Elopement Precautions Levels 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

16. Rights of Mental Health Patients Additional 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/provider Right to humane conditions, recreation, social interaction, vote, enter contracts

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