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Keltner: Psychiatric Nursing, 5th Edition

Chapter 3: Continuum of Care
Chapter Focus
The continuum of care provides consumers with a wide range of treatment modalities to
assist the individual in achieving his or her optimal level of functioning. Entry into the
system is effected by suggestion of medical personnel, by laypersons who have contact
with the patient, or by self-referral, and can occur at any point on the continuum of
services. The initial role of the nurse and other professionals is to assess the individual’s
current level of functioning to direct the person to the appropriate resources that will
enhance quality of life and decrease fragmentation of care. Coordination of services for
the individual necessitates multidisciplinary collaboration. Additional referrals can be
made as the needs of the individual evolve. During treatment, the individual and care
providers develop specific problem-oriented outcomes based on objective data and
subjective self-reports. These outcomes are monitored continually and their achievement
becomes the basis for third-party reimbursement.
Psychiatric treatment must be cost-effective, occur in the least restrictive setting, and be
individualized and outcome-based. Managed care has influenced the care continuum in a
number of ways. Less money for mental health and addiction services has resulted in
closing inpatient beds and insufficient community treatment. Fewer inpatient beds and
short inpatient stays have created a need for intensive community treatment. Decreased
reimbursements for care and lack of parity for mental health and addiction services has
resulted in lack of access to care and lack of needed treatment and services.
Hospital-based care is reserved for patients who require 24-hour intensive supervision in
a secure environment as a result of being a danger to self or others, who are gravely
disabled and at risk for accidental harm, or who require medical evaluation or treatment
for toxic reactions or withdrawal from chemical substances. Length of stay is typically 3
to 5 days. Types of psychiatric units vary. A small hospital might have only one closed
(i.e., locked) inpatient unit that accepts all patients with all diagnoses. A larger hospital
might offer more options for specialized care, such as for children, adolescents, adults,
and older adults, or individuals who are or are not psychotic, or who are dealing with
addictions. The psychiatric intensive care unit has evolved as a setting for providing care
for clients who demonstrate at-risk behaviors such as suicide, assault, self-mutilation,
sexual acting out, arson, or escape. For all hospitalized patients, discharge planning
begins at admission and is conducted by the multidisciplinary mental health team.

Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.

assertive community treatment. home care. and planning. and advocacy. In community-based care. The nurse applies the nursing process in the community as the foundation for case management in areas of psychiatric rehabilitation. Implementation is holistic in scope and evaluation is ongoing. Inc. Assessment is comprehensive and serves as the basis for establishing nursing diagnoses. supportive. The nursing assessment must be direct. group homes. and integrated community treatment Developing a nurse-patient relationship in the community is challenging because of the decreased contact and time spent with the individual. The nurse assists the individual to apply information obtained in group to his or her own situation and teaches problem-solving skills. goal-oriented. the principles of milieu management are adapted in assessing agencies. Community-based nursing practice includes the following:  Traditional outpatient services  Partial programs and day treatment  Psychiatric home care  Community outreach programs  Residential services such as nursing homes. resource linkage. because nurses advocate and negotiate for services. the importance of taking them as prescribed. primary care. All rights reserved. and relevant to the individual’s needs. and helpful. an affiliate of Elsevier Inc. and boarding homes  Self-help groups  Intensive outpatient programs such as clubhouses and recovery-oriented programs  Programs providing case management. monitoring for medication effectiveness and the presence of side effects. outcome identification. consultation and liaison. and educating the patient and family about medications.. Psychiatric nurses offer valuable contributions to community-based care because of their ability to adapt the nursing process and psychotherapeutic management model of care to any setting. In community-based settings. Copyright © 2007 by Mosby. and comprehensive. The nurse emphasizes the importance of medication compliance in symptom management and control with the individual and family. the nurse is instrumental in obtaining the medication history. therapy. The emphasis of milieu management is helping the individual cope with immediate needs and with stressors and problems in his or her home or living environment.Instructor's Manual 3-2 Nurses are the only members of the multidisciplinary team who provide 24-hour care during the hospital stay. With regard to psychopharmacology. and private homes. and monitoring for side effects and signs of noncompliance. Milieu groups are problem-focused. . foster care. crisis intervention. empathetic. specific. it is highly essential for the nurse to teach the individual and caregiver or family about medications. programs. the individual needs to know that the nurse is caring. The nurse adapts care based on limitations of the environment and availability of resources. Nursing knowledge of reimbursement systems and budget restrictions is also helpful. No matter how sick the individual or what behaviors he or she is exhibiting. apartment living.

Chapter Outline Hospital-Based Care Teaching Strategies Continuum of care provides a wide range of treatment modalities to assist individual in achieving his or her optimal level of functioning Referral to system: medical personnel. Apply the nursing process to patients who are receiving care in the community. 2. Identify the various levels of care within the continuum of care. 4. insufficient community treatment  Decreased reimbursements  Shorter hospital stays  Less expensive types of treatment  Might determine which medications are prescribed Result: psychiatric treatment must be flexible. Inc. community members. this requires multidisciplinary collaboration. Understand the types of care that might be available in hospitals and in the community. outcomebased. an affiliate of Elsevier Inc.. Typical stay now 3 to 5 days. cost-effective. . individualized. All rights reserved. 3.  Coordinate services to decrease fragmentation of care. problem-oriented. Purpose and effects of managed care:  Fewer inpatient beds. individual patient Role of nurses and other professionals:  Assess current level of functioning and direct to appropriate resources. reduced from 4 to 6 weeks This has resulted in:  Changed purpose and goals of hospitalization Copyright © 2007 by Mosby. and occur in the least restrictive setting.  Develop specific problem-oriented outcomes with individual and monitor via objective data and self-report.Instructor's Manual 3-3 Key Terms case management continuum of care managed care Learning Objectives After reading this chapter. you should be able to: 1. Identify the role of the nurse in implementing the psychotherapeutic management model in hospital and community-based care.

.  Protect the acutely psychotic. who are at risk for accidental harm. Copyright © 2007 by Mosby. self-mutilation. escape)  Purpose: symptom and behavioral control so individuals can be transferred to treatment-oriented units. During shortened LOS. Inc. sexual acting out. Goals: assist individuals to attain initial stabilization and a safe level of functioning. Patients are more acutely ill and exhibit more psychopathology than in the past. for patients demonstrating high-risk behaviors (e. assess for appropriate referrals for aftercare. who are unable to meet basic needs. an affiliate of Elsevier Inc. necessitating 24Hospital-Based Care hour supervision in a secure setting Needed by the actively suicidal. typically 8 to 10 beds.  Provide intervention for behaviors dangerous to self or others. and those threatening others with harm Other purposes:  Protect the gravely disabled. Types of Hospital-Based Care Units accepting all diagnoses Specialized units:  Psychiatric intensive care unit (PICU). seclusion and restraint used more often on these units Discharge Planning Accomplished by interdisciplinary mental health team Putting It All Together Psychotherapeutic Management Nurse-Patient Relationship Nursing is the only discipline providing 24-hour care during hospitalization.g.  Provide thorough medical and psychiatric evaluation. arson.  Treat withdrawal from substances. All rights reserved.  Establish therapeutic relationship..  Treat toxic reactions to medications.. suicide.Instructor's Manual 3-4  Greater need for risk assessment before admission  Implementation of varied types of care  Changing staffing patterns  Increased patient acuity  Increased importance of discharge planning Purposes of Psychiatric Highest priority: safety for self and others.  Identify immediate needs. those who are selfmutilating. assault. nurses must:  Convey respect and maintain the dignity of the individual.

nursing homes Self-Help Groups Support groups run by members rather than mental health professionals. Nursing responsibilities:  Obtain medication history. foster care and boarding homes. ongoing treatment.  Educate patient and family regarding effects and side effects. including history of allergies. Inc. include group homes. All rights reserved. problems with side effects.. relevant to patient needs Nurse: assists individual to apply information obtained in groups to own situation. halfway houses.  Monitor medication effectiveness and presence of side effects.  Assess need for prn medication. serves individuals with severe mental illness or those with a combination of psychiatric and medical illness. teaches problem solving Clinics and private offices: frequency of visits varies with patient need. typically weekly to monthly Partial Programs and Day Treatment Appropriate for patients who require some supervision. usually meet weekly Intensive Outpatient ProgramsMore intensive than traditional outpatient services Clubhouse model: provides daytime work-organized Copyright © 2007 by Mosby. Milieu activities: emphasize helping the individual cope with immediate needs and with stressors in living environment Structured milieu includes groups that are problem-focused.  Provide holistic quality care. an affiliate of Elsevier Inc. evening. apartment living. present and past compliance. Psychiatric Home Care Needed for individuals who are homebound because of their illness or disability. .  Seek individual’s perspective on medication effectiveness.Instructor's Manual Psychopharmacology Milieu Management Community-Based Care Traditional Outpatient Services 3-5  Assess full range of client needs using multiple sources. home visits made by nurses from public and private home care agencies Community Outreach Include mobile crisis teams to reach homeless or transient Programs groups. neighborhood clinics to serve individuals who shun other community-based services Residential Services For individuals who need temporary or long-term housing.  Emphasize need for medication compliance in symptom management and control. and nursing care Schedule: might be 4 to 8 hours for 1 to 5 days/week Day. goal-oriented. structured activities.  Provide discharge planning. or night programs exist.

and professionals Case management model: coordinates services and resources needed by individual to live independently in the community Assertive Community Treatment Other Types of Intensive Service Primary Care Integrated Community Treatment Putting It All Together Psychotherapeutic Management Nurse-Patient Relationship Psychopharmacology Goal: prevent rehospitalization by providing comprehensive and cost-effective services A team of professionals assumes direct responsibility for providing services needed by the consumer 24/7 in settings where the consumer’s problems arise. family supports. developing collaborative relationships with patients. relationship Copyright © 2007 by Mosby. including but not limited to homeless shelters. All rights reserved. weekend. However. Psychopharmacologic medications might be prescribed. noncompliance is major cause of relapse and rehospitalization. side effects. focuses on health promotion. Care sought by some in primary care offices and clinics because of lack of knowledge about who can provide help and reduced access to care. Inc. families. Case managers are often nurses. housing Recovery model: provides consumer with control and responsibility for own life. . advanced practice nurses can assist the patient by implementing interventions related to coping. emphasizes consumer strengths and choices as well as collaboration and involvement with friends. Nurse and caregivers must know about medications prescribed and their importance. management of side effects. problem solving. behavioral management. evening. the streets. and other professionals is crucial for maintaining the continuum of care. an affiliate of Elsevier Inc.Instructor's Manual 3-6 activities focused on care and maintenance of the clubhouse. and substance-related problems. Nursing responsibilities: teach about medication effects. illness prevention. support for employment. and jails. and holiday leisure activities. and illness care Limited time spent with the individual and family in the community makes developing the nurse-patient relationship challenging. Model providing treatment for physical and mental health care in one location or clinic..

Implementation Calls for nurse to take a holistic approach. programs. spiritual. an affiliate of Elsevier Inc. medical needs and limitations. Nurse adapts principles of milieu management in assessing agencies. social. and problem-solving skills. mental. emotional. environmental. Outcome Identification and Planning and setting priorities are accomplished after Planning comprehensive assessment and establishment of nursing diagnoses. spiritual and religious needs and concerns. Inc.Instructor's Manual Milieu Management 3-7 between medication and symptom management. Use of the Nursing Process in the Community Assessment Comprehensive assessment performed by the nurse typically includes medication compliance and management. and determines which services in the continuum will meet patient needs in the least restrictive setting. vocational. social supports. family involvement. monitor for symptoms of side effects and early symptoms of noncompliance and intervene quickly. financial Evaluation Each intervention and overall patient status must be continually evaluated. All rights reserved. . coping abilities. and private homes.. recognizing and addressing the interconnectedness of factors in the patient’s life—physical. cognitive. Copyright © 2007 by Mosby. symptom management.