1. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 03The Delivery of Mental Health Care

2. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins History of Mental Health Care Early civilizations –Few options to control symptoms –First institutions –Bizarre behavior led to outcasts –Asylums to house insane, prisoners, orphans –Cruel and inhumane treatment –Demons and Evil forces

3. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins History of Mental Health Care (Cont.) Beginning of change –Benjamin Rush (early 19th century) –Dorothea Dix (mid 19th century) Schoolteacher, questioned the treatment of both prisoners and individuals with mental illness Began effort to expose conditions and provoke legislation to help construct mental hospitals –Linda Richards (late 19th and early 20th century) –1913—beginning of psychiatric nursing as a specialty

4. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins History of Mental Health Care (Cont.) Twentieth century progress –National Mental Health Act of 1946 –Funds for research, nursing programs, and community support for those with mental illness –Trend toward community-based treatments –Psychotherapeutic drugs (1956) –Movement to deinstitutionalize clients

5. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Community-Based Care Federal legislation –Funding for diversified treatment methods Omnibus Budget Reform Act (OBRA) –Restrictions on nursing home placements Mental Health Act of 1983 –Patient rights National Mental Health Parity Act –Improved insurance benefits for mental health care

6. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Current Issues in Mental Health Care Cultural unpreparedness within the system Closing of inpatient units Growing demand for services Lack of access to health care/treatment Coverage of cost of care Lower socioeconomic status, lower educational levels, limited income

7. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Case Application 3.1 What additional information would you need to collect? What cultural issues may be a deterrent to available treatment for this client? What steps might you take to encourage treatment by health care professionals?

8. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Patient Bill of Rights Client has the right to –Be treated with dignity, concern, and respect –Expect quality care by competent professionals –Complete confidentiality within limits of law –Know the qualifications of professionals involved –Receive explanations of treatment and be involved in the planning of care

9. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Patient Bill of Rights (Cont.) Client has the right to –Refuse to be part of experimental therapy or treatment methods or medications –Understand the effects of prescribed medication –Treatment in least restrictive environment –Be involved in decision making about treatment options –Refuse treatment unless there is a court order

10. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Informed Consent Explanation of client rights and unit policies to the client/guardian from the agency Agency providing services is protected by getting a signed statement of understanding from the client –“Do No Harm” Explanation of insurance benefits or payment options

11. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Confidentiality Client’s right to prevent written or verbal communication from being disclosed without authorization Required by Nurse Practice Act HIPAA (2003) –Security procedures that protect the privacy and confidentiality of information –Client has the right to know what information is disclosed, to whom, and for what purpose

12. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Required Disclosure of Client Information Legally required that client information is disclosed May be shared with other team members if relevant to well-being or treatment –Intent to commit a crime –Duty to warn endangered individuals –Evidence of child abuse –Initiation of voluntary hospitalization –Infection by HIV

13. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Appeals and Complaints Clients have the right to be informed of –Means to channel complaints about their care or the professionals providing treatment –Procedure to follow to file a complaint to a professional board –Address of contact and procedure to appeal for payment decisions

14. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Seclusion and Restraint Seclusion—placement of a client in controlled environment to treat a clinical emergency Physical restraint—use of mechanical devices to provide limited movement by a client –Used to prevent harm to self or others and require careful monitoring Chemical restraint—use of medication to calm a client and prevent the need for physical restraint

15. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Nurse Accountability Responsibility for own actions Current licensure and educational requirements Institutional and government policies Documentation Client advocates Protect client

16. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Practice Settings for Mental Health Care Factors to consider –Least restrictive environment –Client’s history –Circumstances that led to the current admission Physician/Psychiatrist makes determination of inpatient vs outpatient treatment

17. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Inpatient Psychiatric Settings Voluntary commitment—client admitted based on willingness to comply with treatment program Involuntary commitment—person admitted to a psychiatric unit against his or her will –Order or protective custody is given by a court official

18. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Outpatient Mental Health Settings May include –Individual or group therapy –Marriage and family therapy –Psychological evaluation –Stress reduction and relaxation –Assessment for various mental disorders –Grief and loss support –Addictive behaviors and codependency therapy

19. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Nonpsychiatric Health Care Facilities Holistic care –Addresses the scope of human needs –Physical, psychosocial, cultural, and spiritual issues Variety of settings –Hospitals –Long-term care facilities –Home care –Hospices Nurses practice in a variety of nonspychiatric settings that provide an array of situations in which emotional and psychosocial needs of the client may emerge.

20. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Outpatient Health Care Settings For coping with the psychologic effects of physical illness –Powerlessness –Grief –Insecurity

21. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Acute Care for a Client with Dual Diagnosis Client with mental illness hospitalized for another medical condition Secondary mental illness must be considered in all aspects of care Altered psychologic state complicates compliance with treatment

22. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Correctional Facilities Characteristic behavior patterns –Manipulative, power seeking Mental health care issues –Real or perceived problems become means to seek special treatment –Substance abuse –Nurse may be the sole support system

23. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Tell whether the following statement is true or false. Early treatment of individuals with mental illness was inhumane and unjust.

24. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer True Rationale: Those with symptoms of mental illness were called “lunatics” and were treated cruelly. They were often treated as public spectacles or locked in cells. It was not until the early 19th century that Benjamin Rush advocated for improved conditions for the mentally ill.

25. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Which piece of legislation prevented the inappropriate placement of clients into nursing homes? A. National Mental Health Act of 1946 B. Americans with Disabilities Act (ADA) C. Omnibus Budget Reform Act (OBRA) D. Health Insurance Portability and Accountability Act (HIPAA)

26. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer C. Omnibus Budget Reform Act (OBRA) Rationale: OBRA (1987) was a further legislation of the 1982 Omnibus Budget Reconciliation Act, which provided funds to support the treatment of those with drug addictions and other mental disorders. The Omnibus Budget Reform Act prevented the inappropriate placement of clients with mental illness into nursing homes.

27. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Tell whether the following statement is true or false. A client receiving mental health care has a right to report a complaint against any professional involved in the treatment.

28. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer True Rationale: Not only does a client have the right to report a complaint, it is the responsibility of the health care team to provide the contact information to the client.

29. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Which of the following terms refers to the placement of a client in a controlled environment to treat a clinical emergency? A. Restraint B. Seclusion C. Outpatient care D. Voluntary commitment

30. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer B. Seclusion Rationale: Seclusion involves placing a client in a controlled environment when the client poses an immediate threat to himself or herself or others. Often this means placing a client inside a room with a locked door.

31. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins