Chapter 13-Creating Hospital and Community-base Therapeutic Environments

Deinstitutionalization
-Bringing mental health clients out of the hospital and into the community
-Began in the post World War II period
-Large public mental health hospitals were:
-Overcrowded and had fallen into disrepair
-Widely criticized for warehousing residents
-Phased-down
-Community mental health movement
-Reached its apex in 1960s
-Community mental health centers were constructed to provide acute care and
ambulatory services
Disturbing Trends
-Hospital care remained the main treatment for severely mentally ill clients
-Repeated readmissions
-Inadequate and inaccessible community resources
-New mentally ill populations (homeless, crack cocaine addicts, mentally ill criminal
offenders) were unable or unwilling to use provided services.
-There is an insufficient number of aftercare facilities (live-in facilities that serve as a
home base for those discharged from an inpatient facility) known as half-way homes.
Many who are discharged are not followed up sufficiently or often enough to ensure
successful adaptation to community living.
Therapeutic Environment in Hospital-Based Care
-Therapeutic environment is the purposeful use of people, resources, and events in the
clients immediate environment to:
-***Ensure safety
-Promote optimal functioning in ADLs
-Develop or improve social skills
-Enhance capacity to live independently in the community
-Unique roles for nurses:
-Provision of 24-hour care 365 days a year
-Influence on environment and client behavior
External factors:
-Privacy--the very nature of psychiatric hospitalization conflicts with the need for privacy.
Nurses must respect a clients privacy by keeping surveillance and monitoring to the
minimum necessary for client safety, honoring the confidentiality of personal information,
and maintaining routine social practices.

Chapter 13-Creating Hospital and Community-base Therapeutic Environments

-Autonomy--The ability of clients with mental disorders to carry out age-appropriate

roles may be significantly impaired, a therapeutic environment provides opportunities for
normal functioning according to each clients abilities.
-Safety--Mentally disordered clients may pose safety hazard to themselves or others.
Efforts to maintain client safety may deprive clients of privacy and autonomy.
-Group well-being--A clients behavior may be disruptive to the overall group. Nurses
may need to monitor or manage certain clients to maximize the common good. The
individuals privacy and autonomy may be violated when group well-being is considered
primary. Nurses must be sensitive to situations in which clashes occur.
Admission Criteria
-Overall effectiveness of functioning using DSM Axis V global assessment of functioning
scale determines the acuity of the illness. In most instances:
-Impairment in functioning must be in the 10-50 range to qualify for admission
-Admission of clients with active suicidal ideation, extreme psychotic and
delusional behavior, and acute withdrawal symptoms.
-All require intensive skill nursing care and case management
Therapeutic Environment Principles
Restrictiveness: Characterized by the--Physical environment--location of facility, security, options for behavior control
(seclusion, restraints, quiet time). Physical restrictiveness is ranked according to
the degree of interference with client dependence. The physical structure of
institutions--locked doors, communal living arrangements, and limited access to
community resources interferes with client freedom of movement and
individuality.
-Psychological environment--staff and client backgrounds, behavior, attitudes and
values
-Social environment--rules and regulations that govern the operation of the
setting and treatment standards for managing client behavior.
Orienting Client and Family: Inform clients about all aspects of the therapeutic
environment. Encourage clients and family to verbalize their concerns and questions
about what to expect during the treatment experience.
-Orient and educate client, family, and significant others about hospitalization and
treatment by reviewing the clinical problems, treatments, and behavioral
outcomes that are the focus of hospitalization or treatment in the facility

Chapter 13-Creating Hospital and Community-base Therapeutic Environments

-Engage clients, family, and significant others in the treatment process by

encouraging them to identify personal goals and participate in evaluating the
course of treatment.
Safety and the Structural Environment:
-Evaluate whether security is sufficient
-Assess the advantages and necessity of security
-Assess whether the security has any detrimental impact
-Consider whether the security advantages could be accomplished through some other
intervention that does not have detrimental impact. Implement alternative steps to
seclusion and restraint whenever possible.
-Re-evaluate structural controls implemented for specific reasons to determine whether
they are no longer relevant and should be discontinued. Use reality-oriented resources
to contribute to a sense of normality.
Program Structure: composed of the schedule and expectations for client treatment and
participation. Nurses have a number of opportunities to communicate expectations and
to address issues that arise.
-Program rules--give all clients regulations of the setting either before or soon after
admission
-Community meetings--provide clients with opportunity to solve problems of conflicting
interests, experience cooperlation with others, share responsibility, and experience
leadership in group. The most common milieu-oriented group in long term facilities is the
community meeting. Community meetings function to:
-Welcome new members and discuss expectations
-Discuss aspects affecting quality of life such as cleanliness, privacy, radio and
television use, and other interpersonal problems and conflicts.
-Plan activities
-Client government--grant clients privileges for demonstrating certain behaviors in the
community living group. Client government provides opportunities for:
-Participation, corrective learning experiences, and development of new behavior
patterns.
-Feedback essential to increase insight and promote learning
Supportive Social Climate
-The opportunity and ability to form relationships with other clients and staff appears to
be the most significant factor in determining the success of the inpatient experience.

Chapter 13-Creating Hospital and Community-base Therapeutic Environments

-Influences on individual and group behavior:

-External sources such as professional practice standards, regulatory agencies,
and laws.
-Clients attitudes, beliefs, and behaviors, styles of interaction between people.
-Nursing routines that limit client self-care can be detrimental to the unit atmosphere,
signaling over involvement and loss of client autonomy.
Spirituality
-Use of spiritual beliefs of clients to enhance wellness and coping. Discussing beliefs
enables you to reassure clients who fear that their beliefs will be challenged or
minimized in a psychiatric environment.
-Strive to provide spiritual resources that are both culturally congruent and culturally
competent
-Nurses must also recognize and explore THEIR OWN BELIEFS in order to minimize
the impact of bias in their client interactions
Encouraging Partnership with Clients and Families
-It is important to recognize that you have the responsibility to teach clients how to
implement the principles of the therapeutic environment outside the treatment setting
when the client is away.
1)
Establish a daily schedule: routine helps clients keep on track and organize their
thinking and activities.
2)
Use positive communication skills: Give instructions or directions at clients level
of ability. This may include verbal prompting alone or with physical assistance, and
especially praising independent performance. Avoid criticism, argument, and negative
reinforcement.
3)
Identify and participate in support groups: identify signs of stress and community
supporters.
4)
Recognize illness relapse or exacerbation: develop plan for managing symptoms
and emergency behaviors.
Types of Treatment Programs
Hospital-based: (inpatient), used with clients with life-threatening diagnoses.
Community Mental Health Centers: (CMHCs)
-Services offered:
-Emergency services
-Medication management clinics

Chapter 13-Creating Hospital and Community-base Therapeutic Environments

-Psychoeducation groups
-Vocational rehabilitation
-Consultation services to hospitals, nursing homes, and primary care centers
-Other specialty services as determined by the population they serve (homeless
mentally ill clients, chemically dependent clients, elder clients)
Mobile Outreach Units:
-Mobile treatment teams go out into the community by car or on foot to deliver services
in whatever setting makes the client comfortable. Common treatment goals:
-Provide greater access to mental health care
-Increase medication adherence
-Prevent relapse and re-hospitalization
-Identify and assess community needs
-Facilitate entry into mental health system
-Emergency intervention or crisis prevention
-Satisfy requirements of court-ordered treatment
Assertive Community Treatment (ACT):
-Assertive programs have shown much promise in terms of service delivery to high-risk
groups and are believed to prevent psychotic relapse and re-hospitalization and reduce
arrests, emergency room visits, and homelessness of clients with severe and persistent
mental illness.
-Deliver service in clients own environment
-Team of 7-12 interdisciplinary professionals in mobile outreach capacity. Team
is believed to reduce stress and burnout of case managers
-National Alliance on Mental Illness (NAMI)-create guidelines and standards for
assertive community treatment teams.
Psychiatric Home Care
-There is a growing demand form psychiatric home care nursing because it is cost
effective alternative to hospitalization. Medicare, medicaid, and private insurance all
fund psychiatric home care at different levels.
-Medicare reimbursement requirements:
-Care is provided by qualified experienced psychiatric nurse.
-Client MUST be home bound and have a diagnosed psychiatric disorder
-Home care is more likely to be used for clients recently discharged from a psychiatric
hospital, the homebound elderly, persons with dementia, young adults with severe
mental illness, or clients who have an associated medical condition.

Chapter 13-Creating Hospital and Community-base Therapeutic Environments

Managed Mental Health Care

-Method for capping rate of increase in costs while ensuring access to services.
Impact on Inpatient Settings
-Goals are achieved through shorter, more intense stays--because of the need to
maximize value for the mental health consumer and to keep cost down through use of
available resources.
-Critical pathways--valuable tools for helping nurses deliver care within managed care
frameworks.
Impact on Primary Care Settings
-Alternatives to hosptialization and accelerated discharge to ambulatory care settings
create a demand for comprehensive and well-coordinated services in primary care
setting.
-Managed care sites can offer concentrations of primary care resources to meet client
needs.
-Psychiatric-mental health nurses: perform mental health assessments, monitor clients
who are severely and persistently mentally ill, and facilitate health-promotion groups.
-Triage services--triage involves determining the severity of the illness and the need for
immediate care in order to direct care and ensure the efficient use of medical and
nursing staff and facilities. Nurses act as gatekeeper--deciding who will use the system
and at what level of care.
-Employer-based (onsite) clinics--psychiatric mental health nurses might be asked to
serve as consultant, counseling at the site a day or two per week, or seeing clients
referred through the primary care providers in the employer-based clinic.
Unique Aspects of MCOs
Legal issues: Flexing of benefits. Authorization of out-of-plan services.
Treatment and Medication Adherence:
Unrealistic Member Expectations:
-The members entitlement expectation is the members understanding of the care he or
she expects to receive. Entitlement expectations often differ from the specific provisions
of the health plan contract.
-Health plan members often do not consider what type of mental health benefits they
have purchased until they are in crisis.

Chapter 13-Creating Hospital and Community-base Therapeutic Environments

-The following are examples of mental health services that are NOT included in typical
MCO plans:
-Psychiatric or substance abuse therapy on court order, unless plan approved as
medically necessary
-Psychological testing, except for diagnosis or treatment of psychiatric disorder
-Marriage counseling or treatment for stress, except when connected to
treatment for a DSM psychiatric disorder
-Smoking cessation, obesity treatment, weight reduction, aversion therapy,
custodial care (however now some plans DO cover these), autism, learning
disabilities, mental retardation, congenital disorders.
-Experimental treatment (psychosurgery, megavitamin therapy, codependence
therapy, or treatment for sexual addiction)
Continuity of Care:
-Customers can move from one level of care to the next while remaining in the same
delivery system.
-Possible seamless movement from one level of care to the next.
Ethics in Managed Mental Health Care
-4 guiding principles for ethical dilemmas:
-Act as a steward of societys scarce mental health care resources
-Recommend least costly treatment if ethically and medically sound
-Advocate for justice
-Discuss reimbursable parameters of care openly with clients.
Case Management
-Case management is one strategy that has evolved in response to the shift in focus
from inpatient to community care.
-Helps clients and caregivers make informed decisions
-Consider client needs, abilities, resources, and personal preferences
-Respect clients need for autonomy in making decisions regarding treatment
Case Manager Role
-Coordination of one episode of care across multiple care settings
-Integrate, coordinate, and advocate for services.
Gatekeeper and Facilitator
-As gatekeeper you serve as the clients initial contact for care and referrals

Chapter 13-Creating Hospital and Community-base Therapeutic Environments

-Helps clients and their caregivers make informed decisions, such as whether the client
needs hospitalization, based on client needs, abilities, resources, and personal
preferences.
-Nurses should:
-Complete physical assessment of illness-detection
-Prevent unnecessary hospitalization
-Treatment in least-restrictive settings
-Prevent duplication and fragmentation of services
Client Advocate
-Most fundamental aspect of the case manager role
-Negotiating complex mental health care systems
-Active involvement in treatment and planning
-Resolve conflicting needs of several parties which requires creativity and
flexibility
-Defend clients rights and responsibilities
Case Manager Challenges
-Assessment phase: trust, mutual support, and clear communication among team
members are necessary before you can implement case management services. Need
for clarification of case manager role.
-Planning phase: you can bring valuable information concerning benefits, limits, family
resources, expectations, and other pertinent data to the treatment planning table.
-Implementation phase: Objective consultant who takes holistic view, conflict resolution
and arbitration, and provide additional data or client education.
-Evaluation phase: Continuous monitoring of client response and progress.