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CHAPTER IV
User Behavior Analysis
The entire analysis will focus on the two major users, the market and the
management. The market analysis which were categorized as to psychiatric
patients and substance abuse patients would be the main user and would include
recent demography.
Projected market will only compose the first half of the entire users. The
other half would be the management determined by the size of the clients.
Provisions mandated by the Department of Health will also be considered in
determining the management type and organizational structure of the nursing
home.

I.

Market Type Analysis


Categorization of mental disorders as well as substance abuse cases is vital

in identifying the types of patients suitable for the facility. Various mental conditions
will be discussed together with their corresponding therapeutic recommendations
to aid the markets continuous and long term care. Collated and evaluated annual
demographic counts of the projected market determines the size and facilities to
be provided for the users.

A. Projected Market
1. Post Psychiatric Patients

Once a patient is diagnosed with mental disturbance in a mental


hospital, appropriate treatments are delivered. Such facility provide
treatments to help patients acquire mental stability for a span of time or even
fully recover from the illness. Treatment may last from two weeks to three
months. When patients reached the maximum treatment duration, they are
discharged as per policy of the facility.

Post psychiatric patients may be discharged from the facility but that
does not mean that the patient have recovered from their disorder. After
patients leave their continuous treatment, monitoring of medication may not
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be as strict as that of the previous institution they are in. According to Don
Susano J. Rodriguez Memorial Mental Hospitals resident psychiatrist Dr.
Lalyn Marzan, chances of recurrence especially for those who are suffering
from chronic type of illness is inevitable. This cases often happens due to
various factors and are recorded in numerous case study reports.

The following are the psychiatric disorders with their corresponding


follow up treatments that the facility can continuously manage and support.
a. Psychotic Disorders

i.

Schizophrenia
Definition

Thought disorder that impairs judgment, behavior & ability to


interpret reality.

Symptoms must be present at least 6 months to be able to


make a diagnosis.

Risk Factors/Etiology

Men have an earlier onset, usually at 15 to 25 years of age.

Dopamine & abnormalities in Serotonin.

Many believe the family may be the cause of the patient's


schizophrenia. If the mother gives mixed messages, it is
called the double-bind theory.

There are families that are critical, intrusive, and hostile to the
patient. When this occurs, it has been linked to high rates of
relapse.

Schizophrenia may be viral in origin.

Schizophrenia is more prevalent in the low socioeconomic


status groups, either as a result of downward drift or social
causation.

Physical & Psychiatric Presenting Symptoms

Hallucinations (mostly auditory)

Delusions (mostly bizarre)

Disorganized speech or behavior

Catatonic behavior

Negative symptoms
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Usually experience social &/or occupational dysfunction

Physical exam usually unremarkable, but may find saccadic


eye movements, hyper vigilance, etc.1

Treatment

Hospitalization is recommended for either stabilization or


safety of the patient.

Antipsychotics (Atypical): To help control both positive and


negative symptoms.

If no response, consider using Clozapine

The

suggested

psychotherapy

will

be

supportive

psychotherapy
Types of Shizophrenia
Schizophrenia Paranoid Type

MC Type of Schizophrenia

Older patients (Onset is in their late twenties or thirties)


Best prognosis

Presenting Symptoms: Preoccupation with delusions


and/or hallucinations, usually involving grandeur or
persecution

Schizophrenia Disorganized Type

Presenting

Symptoms:

Disorganized

speech

and

behavior. Flat or inappropriate affect. Marked regression


to primitive disinhibited behavior (Bizarre Behavior).
Severe thought disorder. Poor contact with reality

Risk Factors: These patients tend to be younger than 25 "


Worst prognosis

Schizophrenia Catatonic Type

Presenting

Symptoms:

Psychomotor

Disturbances,

ranging from severe retardation to excitation. Extreme


negativism. Peculiarities of voluntary movements. Mutism
is very common

Nabeel Kouka, MD, DO, MBA, August 2009 New Jersey, USA, Psychiatry for Medical Students and Residents
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Complications: Medical care may be necessary because


of exhaustion, malnutrition, self- inflicted injury, or
hyperpyrexia2

Schizophrenia Residual Type

Symptoms: Absence of positive symptoms (delusions,


hallucinations, disorganized speech/behavior & catatonic
behavior)

Patients tend to have negative symptoms (Social


Withdraw, Flat Affect, and Occupational Dysfunction)

Schizophrenia Undifferentiated Type

Presenting Symptoms: Meet criteria for schizophrenia. Do


not meet criteria for other schizophrenia types

Other Psychotic Disorders


Schizophreniform Disorder (> 1 month but < 6 months)

Presenting Symptoms: Same as in Schizophrenia


(Hallucinations, Delusions, Disorganized speech, grossly
disorganized or catatonic behavior, Negative symptoms,
Social &/or Occupational dysfunction)

Difference from Schizophrenia: Symptoms are present > 1


month but < 6 months & most of the patients return to their
baseline level of functioning

Risk Factors: Many of these patients have affective


symptoms as compared with schizophrenics. Suicide is a
risk factor given that the patient is likely to have a
depressive episode after the psychotic symptoms resolve

Treatment
o Must

assess

whether

the

patient

needs

hospitalization, to assure safety of patient &/or


others
o Antipsychotic medication is indicated for a 3-6
month course
o Individual psychotherapy3

2
3

Ibid.
Ibid
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Schizoaffective Disorder

Presenting Symptoms: Mood Disorders (major depressive


episode, manic episode, or mixed episode) + Psychosis
(schizophrenia). Delusions or hallucinations for at least 2
weeks in the absence of mood symptoms

Prognosis:

Better

prognosis

than

patients

with

schizophrenia. Worse prognosis than patients with


affective (mood) disorders

Treatment: Must first determine whether hospitalization is


necessary.

Use

antidepressant

medications

&/or

anticonvulsants to control the mood symptoms. If these


are not effective, consider the use of antipsychotic
medications to help control the ongoing symptoms. Start
with treatment of the worst syndrome
Delusional Disorder

Presenting Symptoms: Non-bizarre delusions for at least


one month. No impairment in level of functioning.

Types include erotomanic, jealous, grandiose, somatic,


mixed, unspecified.

Risk Factors: Mean age of onset is about 40 years (better


prognosis). Seen more in women & most of these patients
are married and employed.

Associated with low socioeconomic status as well as


recent immigration.

Associated with conditions in either the limbic system or


basal ganglia

Treatment:

Antipsychotic

medications

&

Individual

psychotherapy
Brief Psychotic Disorder (> 1 day but < 1 month)

Presenting Symptoms: Same as in Schizophrenia

Difference from Schizophrenia: Symptoms are present > 1


day but < 1 month

Patient appears to be responding to internal stimuli


(Hearing Voices)

Risk

Factors:

Seen

most

frequently

in

the

low

socioeconomic status as well as in those who have


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preexisting personality disorders or the presence of


stressors.4

Treatment
o Hospitalization is warranted if the patient is acutely
psychotic
o Antipsychotics & short-term Benzodiazepines (for
Rx of agitation)

b. Mood Disorders

i.

Major Depressive Disorder (Major Depression)

Mood disorder that presents with at least a 2-week course


of symptoms that is a change from the patients previous
level of functioning

Must have depressed mood or anhedonia (absence of


Pleasure)

Risk Factors/Epidemiology

Women > Men (2:1) due to several factors, such as


hormonal differences

Onset is 40 years

Incidence is higher in those who have no close


interpersonal relationships

Neurotransmitters

abnormalities:

Serotonin,

Norepinephrine & Dopamine


o Serotonin metabolites (5 HOIAA) in suicide &
aggression

Other risk factors include family history, exposure to


stressors & behavioral reasons, such as learned
helplessness.

Presenting Symptoms

Depressed mood & Anhedonia (absence of Pleasure)


during most of the day

Typical Features (Vegetative Changes of Depression)


o (low) Appetite, Weight & Sleep (Insomnia)

Ibid
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o Psychomotor retardation or agitation


o Fatigue or loss of energy nearly every day
o Feelings of worthlessness or guilt
o Diminished ability to concentrate
o Recurrent thoughts about death. (Ask about
Suicide)

Atypical Features
o (high) Appetite, Weight & Sleep (Hypersomnia)

May Also Include Psychotic features: Worse prognosis

Physical Examination

Usually within normal limits

May find psychomotor retardation, such as slowing of


movements & speech

May also find evidence of cognitive impairment, such as


decreased concentration

Lab tests are not diagnostic but may find abnormal


Dexamethasone

Suppression

test

or

Thyrotropin-

Releasing Hormone test


Treatment

Must first (Ask about Suicide) & Secure the safety of the
patient

Antidepressants: Selective Serotonin Reuptake Inhibitors


(SSRI), Tricyclic Antidepressants (TCA) & Monoamine
Oxidase Inhibitors (MOI)

Electro-Convulsive Therapy (ECT) may be indicated if


patient is suicidal or worried about side effects from
medications

Individual Psychotherapy: To help the patient deal with


conflicts & sense of loss

Cognitive Therapy: To change the patients distorted


thoughts about self & world.

ii.

Bipolar Disorder

A mood disturbance in patient that experiences manic


symptoms for > 1 week & cause significant impairment in
his/her functioning level
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Risk Factors/Epidemiology

Men = Women

Onset in young adults & average age of about 30 years

More prevalent among High Socioeconomic status & who


didnt finish college

Considered to be the illness with the greatest genetic


linkage. (50-70%)

Coexisting disorders: Anxiety, Alcohol Dependence &


Substance Abuse

Presenting Symptoms

Abnormal or persistently elevated mood lasting > 1 week

High Self-esteem or grandiosity

Excessive involvement in activities & Distractibility

Psychomotor agitation & more talkative than usual

Flight of ideas

High Sexual activity

High in goal-directed activity

Physical Examination

Usually within normal limits

May find evidence of psychomotor agitation & pressured


speech

Treatment

Must assess patient safety to determine the need for


hospitalization.

Pharmacotherapy: Antimanic Mood Stabilizers (Lithium,


Carbamazepine & Valproic Acid), Benzodiazepines &
Antipsychotics in ER

Individual psychotherapy

Differential Diagnosis

Mental disorders: Schizophrenia & Personality Disorders

Medical disorders: CNS diseases, Hyperthyroidism &


Medications (Stimulants)5

Ibid.
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iii.

Dysthymic Disorder

A chronic mood disorder (mild Depression) characterized by


a depressed mood that lasts most of the time for > 2 years.
(Major depression - usually up to 1 year)

Risk Factors/Epidemiology

> In women who are < 64 years of age as well as in those


that are unmarried & young individuals from low-income
families

Coexisting disorders: Anxiety, Substance Abuse &/or


Borderline Personality

Treatment
o Hospitalization is usually not indicated in these
patients
o Long-term individual insight-oriented Psychotherapy
o SSRI, TCA or MOI6

Differential Diagnosis

Differential diagnosis is essentially the same as for major


depression

Must consider minor depressive disorder & recurrent brief


depressive disorder7

iv.

Cyclothymic Disorder

A chronic mood disorder (mild Bipolar II Disorder)


characterized by many periods of Depressed Mood & many
periods of Hypomanic Mood for > 2 years

Risk Factors/Epidemiology

6
7

Seen more frequently in women.

Family histories of bipolar disorder

It frequently coexists with borderline personality disorder

Alcohol & substance abuse are common

Ibid.
Ibid.
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Many of the patients have interpersonal and marital


difficulties

Treatment

Pharmacotherapy: Antimanic Mood Stabilizers (Lithium,


Carbamazepine & Valproic Acid)

Psychotherapy will focus on helping the patients gain insight


into their illness & how to cope with it

Differential Diagnosis

Medical: Seizures, substances & medications

Mental: Other mood disorders, personality disorders,


medications again

v.

Seasonal Affective Disorder

A mood disorder characterized by depressive symptoms


found during winter months & absent during summer months

Believed to be caused by abnormal melatonin metabolism


("MSH)

Treatment

Phototherapy or sleep deprivation8

c. Anxiety Disorders

Definition: Anxiety is a syndrome with Psychologic &


Physiologic components

Psychologic components
o Worry that is difficult to control
o Hypervigilance
o Restlessness
o Difficulty Concentrating
o Sleep Disturbance

Physiologic components
o Autonomic Hyperactivity
o Motor Tension

Ibid.
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Risk Factors/Etiology

Psychodynamic Theory

Anxiety occurs when instinctual drives are thwarted.

Behavioral Theory

Anxiety is a conditioned response to environmental stimuli


originally paired with a feared situation

Biologic Theory implicate

Various neurotransmitters (GABA, Norepinephrine &


Serotonin)

Various CNS structures (Reticular Formation & Limbic


System)

Presenting Symptoms

Excessive Nervousness

Fears

Sense of impending Doom

Irrational Avoidance of objects or situations

Anxiety Attacks

Physical & Psychiatric Examination

Mental Status: Hyper-arousal, ! Startle Reflexes, Timidity &


Worries

Physical Examination: Evidence of Autonomic Arousal &


Motor Restlessness

Diagnostic Tests

Evidence of medical conditions (Thyroid Problems) or


substances that cause anxiety disorders

Differential Diagnosis

Adjustment disorders with Anxious mood

Anxiety disorders (Generalized Anxiety disorder, panic


disorder, phobias & Post-Traumatic Stress Disorder)

Anxiety disorder due to general medical conditions (Thyroid


Problems)

Substance-induced Anxiety disorder9

Ibid.
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Treatment

i.

Psychotherapies (Behavioral Modification)

Pharmacotherapy: Antidepressants & Benzodiazepines

Panic Disorders

Definition

Recurrent unexpected Attacks of Intense Anxiety that


include marked physical symptoms, such as Tachycardia,
Hyperventilation, Dizziness, and Sweating

Risk Factors/Etiology

Have a Genetic Component

Associated w/ separations during childhood & interpersonal


loss in adulthood

Occur in response to Panicogens (i.e. Lactate, CO2,


Caffeine & Yohimbine)

Presenting Symptoms

Prevalence: 2% of the population

Occurs at a 1 to 2 male-to-female ratio

Onset: Often during the third decade

Course: Severity of symptoms may Wax & Wane and may


be associated with inter-current stressors

Duration: Attacks usually last a few minutes

Associated problems

Agoraphobia, Depression, Generalized Anxiety &


Substance Abuse

Treatment

Pharmacotherapy

Short term Treatment: Benzodiazepines (Alprazolam)

Long term Treatment: SSRI (Fluoxetine) &/or TCAs


(Imipramine)

Others: Clonazepam & MOI (Phenelzine)

Psychotherapy

Relaxation Training for panic attacks


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ii.

Systematic Desensitization for Agoraphobia10

Phobic Disorder

Definition

Irrational fear & avoidance of objects & situations

Presenting Symptoms

Agoraphobia

Fear or avoidance of open spaces from which escape


would be difficult in the event of panic attack (Public
Places, Transportation, Crowds)

More common in women

Often leads to severe restrictions on individuals travel


& daily routine.

Social Phobia

Fear of humiliation or embarrassment in either general


or specific social situations (e.g., Public Speaking,
Stage Fright)

Specific Phobia

Fear or avoidance of Objects or Situations other than


Agoraphobia or Social Phobia.

Involves

Animals

(Carnivores,

Spiders),

Natural

Environments (Storms), Injury (Injections) & Situations


(Heights, Darkness)
Treatment

Cognitive-Behavioral Therapies for phobias

Systematic Desensitization, Flooding & Assertiveness


Training

Pharmacotherapy

10
11

SSRI, Buspirone & B-Blockers (for Stage Fright)11

Ibid.
Ibid.
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iii.

Obsessive-Compulsive Disorder (OCD)

Definition

Characterized by recurrent Obsessions or Compulsions that


are recognized by the individual as unreasonable

Obsessions:
commonly

Anxiety-Provoking
concerning

&

Intrusive

Contamination,

Thoughts

Doubt,

Guilt,

Aggression & Sex

Compulsions: Peculiar Behaviors that reduce Anxiety via


Hand-Washing, Organizing, Checking, Counting & Praying

Risk Factors/Etiology

Associated with abnormalities of Serotonin metabolism

Presenting Symptoms

Symptoms usually Wax & Wane

Prevalence: 2% of population.

Occurs at a 1 to 1 male-to-female ratio ***

Onset: Insidious & occurs during childhood, adolescence or


early adulthood

Depression, other Anxieties & Substance Abuse are


common

Physical Examination

Chapped hands when hand-washing compulsion is present

Treatment

Pharmacotherapy: SSRI (Fluoxetine or Fluvoxamine) &


Clomipramine

Behavioral Psychotherapies: Relaxation Training, Guided


Imagery, Exposure,

Response Prevention, Thought Stopping Techniques &


Modeling12

iv.

Acute Stress Disorder & Post Traumatic Stress Disorder

Definition

12

Ibid.
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These disorders are characterized by Severe Anxiety


symptoms & follow a threatening event that caused feelings
of Fear, Helplessness or Horror

Acute Stress Disorder: Anxiety lasts < 1 month (but > 2


days)

Post-Traumatic Stress Disorder (PTSD): Anxiety lasts > 1


month

Risk Factors/Etiology

Traumatic events precipitate Acute Stress & Post Traumatic


Stress Disorders

Pre-morbid factors, such as personality traits &/or play an


uncertain role

Onset: May occur at any age 50% of cases resolve within 3


months

o Symptoms begin immediately after trauma, but may occur


after months / years

Three key symptom groups

Re-experiencing of the Traumatic Event

Dreams, Flashbacks or Intrusive Recollections

Avoidance of Stimuli associated with the trauma or numbing


of general responsiveness

Increased

Arousal:

Anxiety,

Sleep

disturbances

&

Hypervigilance

Anxiety, Depression, Impulsivity & Emotional Lability are


common

Survivor guilt - A feeling of irrational guilt about an event


sometimes occurs

Treatment

Counseling after a stressful situation to prevent PTSD from


developing

Group Psychotherapy with other survivors is helpful

Pharmacotherapy:

Antidepressants

(SSRI,

TCAs)

or

Benzodiazepines13

13

Ibid.
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v.

Generalized Anxiety Disorder

Definition

Excessive

&

poorly

controlled

Anxiety

about

life

circumstances (> 6 months)

Both Psychologic & Physiologic symptoms of Anxiety are


present

Risk Factors/Etiology

Genetic Predisposition for an anxiety trait

Presenting Symptoms

Prevalence: 5% of the population

Occurs > in Women at a 2 to 3 male-to-female ratio

Onset: Often during childhood, but can occur later

Course: Usually chronic, but symptoms worsen with stress

Associated problems: Depression, Somatic Symptoms &


Substance Abuse

Treatment

Behavioral

Psychotherapy:

Relaxation

Training

&

Biofeedback

Pharmacotherapy:

Venlafaxine,

Antidepressants,

Buspirone & Benzodiazepine14

d. Adjustment Disorders
Definition

Maladaptive Reactions to a psychosocial STRESSOR ***

Risk Factors/Etiology

Cause: environmental stressors having an effect on


functioning

14

Ibid.
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Risk that a stressor will cause an adjustment disorder


depends on an individuals emotional strength & coping
skills

Prevalence: Extremely common; all age groups

*** Onset: Within 3 months of the initial presence of the


stressor

*** Course: Lasts 6 months or less once the stressor is


resolved

Can become chronic if stressor continues & no ways of


coping with stressor

Associated Problems

Social

&

occupational

performance

deterioration

or

withdrawn behavior
Differential Diagnosis

Normal reaction to stress

Disorders that occur following stress

Post-Traumatic Stress Disorder (PTSD) - Severe Symptoms

Grief - Same symptoms as Adjustment Disorder, but


due to death

Major Depressive Disorder - Severe Symptoms

General Anxiety Disorder

Treatment

Supportive Psychotherapy

Pharmacotherapy: Anxiolytics or Antidepressants15

Patterns of care of a large sample of patients discharged after


short inpatient treatment are discussed in the light of the changes
introduced by the 1978 Mental Health Act in the Italian psychiatric care
delivery system. Three closely related issues are considered: 16

Use of psychiatric hospitalization.

15

Ibid.
Barbato A, Terzian E, Saraceno B, Montero Barquero F, Tognoni G. (1992 Jan 27) Soc Psychiatry Psychiatr Epidemiol.
From: http://www.ncbi.nlm.nih.gov/pubmed/1313602
16

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Relationships between inpatient and community treatment


before and after an admission episode.

Continuity of care.

The main findings are:

Great variability between services suggests that local factors


play an important role in determining the contents of care in
Italian post-reform psychiatry.

The relationship between inpatient and community services is


complex, partial integration being the most common picture.

Psychiatric hospitalization is the entry point into the care


system for a sizeable group of patients.

Continuity of care is achieved for half the patients, mostly with


diagnoses of severe mental disorders.

Subjects with a recent history of revolving door behavior or a


past history of mental hospital admission show the highest
likelihood

of

remaining

in

community

care

following

discharge.17

2. After Substance Abuse

"...the more treatment an addict receives, the better his or her


chances are of remaining sober."18
People would like to think that completing a drug rehab will "fix"
the addiction. However, the disease of addiction is incurable, but
manageable. It is imperative to have an after-care plan before
graduating from treatment. Relapse is a reality no matter how much one
thinks they have a handle on their disease and most likely occurs within
days of walking out of the facility to years. Most addicts and alcoholics
who relapse do so within the first 18 months. Some tools to consider

17Ibid.
18

http://www.projectknow.com/research/aftercare/#learn
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when building after- care plan is transitional- living, extended treatment,


and 12-step programs. Speaking with counselors, therapists, family
members and peers with a substantial amount of sobriety can help in
learning how to maintain recovery. It is best to build the after-care plan
before leaving the facility so the recovering addict can be prepared for
certain situations and know how to keep themselves safe.19
Substance use disorder (DSM II) is a generic term referring to
psychiatric disorder associated with regular use of substances that
affect the central nervous system. The behavioral changes resulting
from such disorders are generally viewed as socially desirable.
Pathologic use of centrally acting substances is divided into
categories of abuse and dependence (DSM III).

Misuse of substances must be present long enough for


pathologic pattern to be established for it be considered
substance abuse; sporadic excessive drug abuse is not
technically abuse. Formal diagnosis requires that the
following criteria exist for at least 1 month.20

The term dependence denotes here physiologic dependence,


which characterized by the presence of tolerance and
withdrawal. Dependence usually develop in individuals with a
pathologic pattern of use and its social consequences, but it
may occasionally occur in individuals who have not exhibited
a pathologic pattern, as in the case of a patient who becomes
dependent on a narcotic during a treatment of a medical
treatment.

Tolerance has developed when the same dose of


substance produces a decreases effect or when
increasing doses are necessary to produce the same
effect.

Withdrawal refers to the development of an abstinence


syndrome, which is specific to the substance in use
when it is withdrawn or dosage is decreased.

Addiction is a term used by many researchers to refer to


overwhelming involvement with seeking and using drugs or
alcohol and a high tendency to relapse after withdrawal. It is

19
20

Dr. Howard Samuels n.d. After Care Plan, http://www.thehillscenter.com/drug-rehab/what-to-do-after


Steven L. Dubovsky 1985 by Harwal Publishing Company, Media, Pennsylvania, Psychiatry
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therefore a quantitative description of the degree to which


drug use pervades an individuals life rather than a condition
that can be clearly defined. Insofar as total preoccupation with
a drug is a severe pattern of pathologic use, addiction may be
said to be a form of substance abuse as defined in section 1B.
While some practitioners feel that all addicted individuals are
physically dependent, many authorities state that it is possible
to be drug dependent and not be addicted in that ones life is
not organized around finding and using the drug. Conversely,
it may be possible to be addicted in the sense that drugseeking behavior is paramount in an individuals life without
that individual being physically dependent.21

i.

Transition

Sober/Transitional Living
A transitional living or sober living house can vary in

services, structure, dynamics, and capacity. Generally run by


a live-in manager, a structured house usually integrates drug
testing, curfews, meetings, and probation periods. Ask a lot of
questions when viewing or selecting the sober living; View it
as an extension of treatment, as safety should be number one.

Outpatient Care
This is a great tool for extending the benefits of

treatment.

Counseling,

group

and

individual

therapy,

medication management, and drug testing are usually offered.


Recovering addicts that don't have the benefit of living in a
sober/transitional living are highly recommended to utilize
outpatient care to extend their treatment.

Sober Coach/Companion
An excellent tool for chronic relapses, vulnerable

situations or unstable addicts in early recovery. Companions


assist individuals in achieving objectives through exploration
of problems and their ramifications, examination of attitudes
and feelings, consideration of alternative solutions, and aiding
in decision-making. Coaching basically help clients utilize

21

Ibid
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their resources to resolve problems and/or modify behaviors,


attitudes and values.

12-Step Programs
12-step

programs

are

available

for

addictive,

compulsive, or behavioral problems based on the 12-steps of


Alcoholics

Anonymous.

For

drug

addicts,

Narcotics

Anonymous meetings are available, as well as specific drug


12-step groups. These programs have proven successful for
addicts in recovery. With these programs an addict can find
anonymous support and tools from others walking the same
path.22
ii.

After Drug Rehab


Boredom can be an instant trigger for relapse. Since
addiction is a disease of the mind, "staying out of one's head"
and keeping active are suggested. The old way of living didn't
work. Knowing what to do after drug rehab, and how to have
fun in sobriety is very important. Sober friends, hobbies, and
choices can be fun and ensure a happy healthy way of life.23

iii.

Family Involvement
For family and friends of drug- or alcohol-addicted
individuals, addressing the addiction is one of the most
difficult aspects of helping the addicted person seek
treatment. Often, over time, daily family involvement has only
managed to enable the addict. Family members frequently do
not know how to bring up the issue of addiction therapy, and
opt to ignore the problem for fear of pushing their loved one
away during a confrontation or intervention.
These are legitimate concerns, and while families
should understand that approaching their loved one should be
a gentle and supportive process, they also need to
understand that most patients seek substance abuse
treatment because of positive family involvement and
intervention.24

22

Ibid

23

Ibid.
24 Ibid.
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After a Substance Abuse Treatment Program


There truly is no clear-cut end to the addiction therapy

process. Families struggling with the effects of their loved


ones drug and alcohol addiction should continually attend Al
Anon or Nar Anon meetings (perhaps both) on a regular basis
to continue a constructive program of support and ongoing
education.
Alcohol and drug addiction are both considered family
diseases, and family involvement with people combating
drug and alcohol addiction requires continual attendance at
these meetings during and after the formal inpatient or
outpatient addiction therapy session. Additionally, while these
meetings help individuals to understand the disease and how
to support someone they care about, they also assist friends
and family with their own emotional support during what is
most often an incredibly trying and stressful time. By
continuing to attend Al Anon and Nar Anon meetings, friends
and family of an addicted individual can continue to stay out
of the destructive cycle of enabling and codependency and
fully realize the benefits of addiction therapy.25

B. Market Demography
The following data are taken from Don Susano J. Rodriguez Memorial
Mental Hospitals record. The 2013 report was classified as to Inpatient,
Outpatient, and Patient Discharge. The succeeding demography were also
categorized as to type of disorder as well as the location where patients often
come from.
The collated reports also include first quarter of 2014s statistics of
psychiatric patients arranged according to sex and age. Analysis of the
following statistics will determine the size of the facility. Market size will be
based on the annual growth report of mental disorder and substance abuse
cases in the entire region.

25

Steven Gifford n.d., LICDC, LPChttp://psychcentral.com


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1.

Regional Psychiatric Demography

Don Susano J. Rodriguez Memorial Mental Hospital 2013


(Inpatient and Outpatient Records)
Date
Outpatient Department
Admission
Discharge
2013

Male

Female

Total

Male

Female

January

292

277

118

53

66

February

159

149

98

39

55

March

343

310

110

53

68

April

396

327

135

53

70

May

373

321

100

43

59

June

369

318

96

36

50

July

215

210

82

50

47

August

196

192

96

41

42

September

252

260

103

43

60

October

267

259

79

38

50

November

257

246

84

45

57

December

248

217

80

35

47

Total

3367

3086

1181

529

671

Table 1.0 Source: Don Susano J. Rodriguez Memorial Mental Hospital records officer

The figures presented in table 1.0 showed the outpatients, admitted, and
discharged mental patients for the entire 2013 in the whole Bicol region. The
census from Don Susano J. Rodriguez Memorial Mental Hospital had revealed that
male outpatients outnumbered female in general. Female though have a higher
discharge rate than admitted male patients.

Don Susano J. Rodriguez Memorial Mental Hospital 2013


(Classification According to Disorder)

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Mental Disorders

January

February

March

April

IPD

OPD

IPD

OPD

IPD

OPD

IPD

OPD

Schizophrenia, Undifferentiated
Type

21

68

19

65

23

67

70

Schizophrenia, Paranoid Type

24

72

24

59

25

73

36

Schizophrenia Residual Type

18

67

15

60

17

65

20

Schizophrenia

82

20

87

13

94

11

Bipolar Disorder MRE Manic with


Psychotic Feature

51

73

80

39

Substance Induced with Psychotic


Feature

70

Major Depression Disorder

25

Psychosis NOS

23

22

28

General Anxiety Disorder

11

Adjustment Disorder

Table 2.0 Source: Don Susano J. Rodriguez Memorial Mental Hospital records officer
Don Susano J. Rodriguez Memorial Mental Hospital 2013
(Classification According to Disorder)
Mental Disorders

May

June

July

August

IPD

OPD

IPD

OPD

IPD

OPD

IPD

OPD

Schizophrenia, Undifferentiated
Type

34

63

25

75

10

87

Schizophrenia, Paranoid Type

47

41

18

87

16

74

Schizophrenia Residual Type

15

12

14

94

13

88

Schizophrenia

13

45

16

100

19

94

Bipolar Disorder MRE Manic with


Psychotic Feature

35

13

16

12

Substance Induced with Psychotic


Feature

10

Major Depression Disorder

27

35

Psychosis NOS

14

General Anxiety Disorder

Adjustment Disorder

11

Table 2.1 Source: Don Susano J. Rodriguez Memorial Mental Hospital records officer

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Don Susano J. Rodriguez Memorial Mental Hospital 2013


(Classification According to Disorder)
Mental Disorders

September

October

November

December

IPD

OPD

IPD

OPD

IPD

OPD

IPD

OPD

Schizophrenia, Undifferentiated
Type

23

95

18

90

12

78

19

75

Schizophrenia, Paranoid Type

18

87

21

97

20

83

12

79

Schizophrenia Residual Type

15

68

16

87

15

80

10

81

Schizophrenia

12

126

19

122

26

85

28

101

Bipolar Disorder MRE Manic with


Psychotic Feature

10

31

32

14

76

17

53

Substance Induced with Psychotic


Feature

15

Major Depression Disorder

11

16

Psychosis NOS

22

10

13

General Anxiety Disorder

Adjustment Disorder

Table 2.2 Source: Don Susano J. Rodriguez Memorial Mental Hospital records officer
The tables above are sorted data of inpatients and outpatients according to
mental disorder in Don Susano J. Rodriguez Memorial Mental Hospital for the year
2013.

Don Susano J. Rodriguez Memorial Mental Hospital 2013


(Sorted According to District)
Province/District

January

February

March

April

IPD

OPD

IPD

OPD

IPD

OPD

IPD

OPD

District I

11

64

26

12

20

13

68

District II

10

74

30

95

83

District III

11

49

33

47

11

72

District IV

112

10

95

105

74

Iriga CIty

24

25

28

11

74

22

79

Naga City

17

70

21

12

94

15

92

Camarines Norte

12

62

16

29

11

65

11

74

Albay

10

57

23

23

56

15

65

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Sorsogon

11

40

12

14

16

64

12

62

Masbate

11

19

28

Catanduanes

26

Quezon

Table 3.0 Source: Don Susano J. Rodriguez Memorial Mental Hospital records officer
Don Susano J. Rodriguez Memorial Mental Hospital 2013
(According to District)
Province/District

May

June

July

August

IPD

OPD

IPD

OPD

IPD

OPD

IPD

OPD

District I

73

68

50

48

District II

76

70

53

50

District III

74

73

12

58

55

District IV

76

13

71

10

60

52

Iriga CIty

18

87

13

79

14

70

12

60

Naga City

13

80

83

60

62

Camarines Norte

11

65

16

76

48

53

Albay

15

59

63

45

50

Sorsogon

10

61

53

42

30

Masbate

33

28

Catanduanes

10

15

Table 3.1 Source: Don Susano J. Rodriguez Memorial Mental Hospital records officer
Don Susano J. Rodriguez Memorial Mental Hospital 2013
(According to District)
Province/District

September

October

November

December

IPD

OPD

IPD

OPD

IPD

OPD

IPD

OPD

District I

45

59

50

10

49

District II

10

42

52

13

49

12

46

District III

11

52

56

53

10

45

District IV

54

13

64

57

57

Iriga CIty

59

15

77

15

68

11

65

Naga City

47

11

66

63

13

53

Camarines Norte

52

57

63

55

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Albay

53

12

45

54

58

Sorsogon

28

47

31

30

Masbate

Catanduanes

Table 3.2 Source: Don Susano J. Rodriguez Memorial Mental Hospital records officer
The tables above are sorted 2013 data of inpatients and outpatient based
on district and province from the whole region.

Do n Su san o J. Rod r igu ez M em or ial M en tal Hosp ital 2013


(In p atien t an d Ou tp atien t Recor d s)
400
350
300
250
200
150
100
50
0

Male Outpatient

Female Outpatient

Total Inpatient

Male Discharge

Female Discharge

The graph above shows the sorting of outpatient according to male and
female, the total admitted patients, and male and female discharge rate. The
month of April have shown the peak of outpatients for both male and female.
Outpatients include recurring cases and psychiatric consultation.
In the same month, as observed in the graph, shows the highest admission
rate for both male and female patients. Together with the increase of patient
admission in the month of April is the peak of discharge rate for both male and
female patients as well.

Don Susano J. Rodriguez Memorial Mental Hospital 2014


(First Quarter Report)
OUTPATIEN
T

10-14

15-19

20-44

45-64

65+

Total

Gran
d
Total

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Month

January

22

19

114

109

121

117

31

25

292

277

569

February

11

81

64

61

67

159

149

307

March

33

39

152

135

132

119

18

12

343

310

700

April

11

30

36

121

112

108

96

21

23

291

275

566

May

20

25

112

104

84

49

27

25

249

237

486

June

22

17

137

122

90

62

27

28

279

220

528

5.5

4.
5

22.6
7

24.
5

119.
5

107.6
7

99.3
3

85

21.8
3

19.
5

268.8
3

244.6
7

Month

January

15

12

22

18

25

41

66

53

119

February

18

18

15

25

16

55

39

94

March

17

13

21

17

30

23

68

53

121

April

17

10

13

19

15

16

46

47

93

May

15

12

18

15

13

19

48

46

94

June

11

14

24

18

17

14

52

47

99

1.3
3

0.
5

15.5

11.
5

19.3
3

17

20.8
3

21.
5

0.0

0.0

55.83

47.5

AVERAGE
INPATIENT

AVERAGE

Table 4.0 Source: Don Susano J. Rodriguez Memorial Mental Hospital records officer
The table above is the 2014 first quarter data of inpatients and outpatient
according to gender. Statistics are also grouped with accordance to their
corresponding age bracket.
Do n Su san o J. Rod r igu ez M em or ial M en tal Hosp ital 2014
(Ou tp atien t Recor d )

May
March
January
0

65 and aboveyrs old

50

100

45 to 64yrs old

150

200

20 to 44yrs old

250
15 to19 yrs old

300
10 to 14 yrs old

The graph above shows the outpatient department market rate categorized
in their corresponding age brackets. The market have shown level increase from

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ages 15 to 19 until 44 to 64. With a total average of 227.17 cases, the peak of
outpatients came from ages 20 to 44 years old for both genders.

Do n Su san o J. R o d r igu e z M e m o r ial M e n tal Ho sp ital 2014


(In p atien t Recor d )
June
May
April
March
February
January
0

65 and above

10

20

45 to 64yrs old

30

40

20 to 44yrs old

50

60

15 to19yrs old

70
10 to 14yrs old

The graph above shows the inpatient department market rate categorized
in their corresponding age brackets. Same with the outpatient department, the
market have shown level increase from ages 15 to 19 until 44 to 64. And with a
total average of 42.33 cases, the peak of inpatients came from ages 45 to 64 years
old for both genders.

2.

Substance Abuse Demography


City Health Office (Naga City) Substance Abuse Records
2013

2012

2011

January

February

March

April

May

June

July

August

10

September

October

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November

December

Source: City Health Officer

City Health Office (Naga City) Substance Abuse Records


Age Range

Reported Case (2013)

13-16

17-20

20-25

15

26-30

18

41-50

Source: City Health Officer

The records provided by the city health office were limited due to
confidentiality. For the complete annual report, the August 2013 record shows that
the highest count of rehabilitation inpatient in DOH-Camarines Sur Treatment and
Rehabilitation Center. Based on the tables shown above, the 20-25 and 26-30 age
brackets have shown an increase in number of the total patients in the same
facility.

C. Related Case Study Reports


Psychiatric Case Study
A group of researcher in the psychiatric department of University
of Michigan conducted a study on what awaits discharged patients after
psychiatric treatment. The investigation showed that timely outpatient
follow-up after hospitalization may not reduce readmission or
substantially improve longer-term depression treatment, suggesting a
need for additional or more effective care processes.
The study have revealed that transitions between inpatient and
outpatient health care settings are associated with elevated risks of
adverse events and, therefore, are a focus of quality improvement
initiatives. After 30 days of discharge from a psychiatric hospitalization,
approximately 10%15% of patients are readmitted due to recurrence,
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and suicide rates are more than 100 times higher than in the general
population.
Homecare treatment after psychiatric hospitalization have vivid
effects in the reduction of incidence of hospital readmission. Continuous
aftercare had aided the risk of psychiatric adverse outcomes. The
National Committee for Quality Assurance, therefore, includes
outpatient mental health follow-up within seven days of discharge from
a psychiatric hospitalization as a quality measure in the Healthcare
Effectiveness Data and Information Set (HEDIS). To understand the
clinical utility of applying health system resources toward improving this
measure, it is important to assess whether timely outpatient mental
health follow-up corresponds with greater receipt of evidence-based
treatments or fewer adverse outcomes.
In 2008, the Veterans Health Administration (VHA) implemented
a policy mirroring this HEDIS quality measure. All patients discharged
from an inpatient mental health setting were required to have a followup outpatient contact within seven days. In 2009, VHA adopted this
measure as a quality indicator to evaluate its medical centers and
regional networks. These policy changes provide an opportunity to
evaluate whether improved performance in providing seven-day followup visits is associated with improvements in other care processes and
outcomes.
Prior research have demonstrated a spillover effect (also referred
to as a halo effect) of performance monitoring, suggesting that focused
improvement in one aspect of treatment may benefit other aspects of
care for the same disorder.26
In the period following discharge from hospital, psychiatric
patients are at high risk of readmission. Within the first 6 months,
readmission occurs for between 20 and 40% of patients (Caton et al,
1985; Boydell et al, 1991). In selected groups of patients the figure is
higher; over 50% of patients were readmitted within 6 months of a
course of electroconvulsive therapy (Robertson & Eagles, 1997). The
peak period of risk for readmission is within the first month (Naji et al,
1999). For long-stay psychiatric patients a similar pattern obtains, with
26

Paul N. Pfeiffer, M.D.; Dara Ganoczy, M.P.H.; Kara Zivin, Ph.D.; John F. McCarthy, Ph.D.; Marcia

Valenstein, M.D.; Frederic C. Blow, Ph.D. (2012) Psychiatric Services retrieved: http://ps.psychiatryonline.org/
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likelihood of readmission exhibiting a decaying curve over time, albeit


with a lower initial rate of returning to in-patient care (Rothbard et al,
1999).
Suicide data tend to mirror those for readmission. Rates of
suicide are high in the year after discharge, notably within the first 28
days (Goldacre et al, 1993; Geddes & Juszczak, 1995; Geddes et al,
1997; Sohlman & Lehtinen, 1999). Noting an increase in rates of postdischarge suicide among women from 1968 to 1992, Geddes and
Juszczak (1995) made a link with decreasing numbers of in-patient
beds. The National Confidential Inquiry into Suicide and Homicide
(Scottish Executive, 2001) found a peak of post-discharge suicides
within the first 2 weeks, when 8% of all suicides by community
psychiatric patients occurred. Eighty percent of this group died before
their first follow-up contact. These findings gave rise to the authors'
recommendations that all patients should be followed up within 1 week
of discharge (within 48 hours for patients who have been at high risk),
and that discharge should be preceded routinely by a joint case review
between in-patient and community teams, with this review including an
assessment of risk.
As reflected in the second confidential inquiry recommendation
above, it is often held that poor communication, notably between
healthcare professionals, is responsible for problems that arise around
the time of discharge. Certainly, with respect to the communication that
hospital specialists have with general practitioners (GPs), this criticism
is probably well founded.27
If GPs are to implement continuity and changes in care following
admission then they require information, accurately and promptly,
following a patient's discharge. Orrel and Greenberg (1986) found that
only 26% of GPs had received a brief communication about an in-patient
stay within 2 weeks of discharge. While it is straightforward to tailor
information to suit GPs' preferences by altering the format of the handwritten discharge letter (Walker et al, 1998), this information still has to
reach the GP. Once fears about confidentiality have been allayed, it is
to be hoped that electronic transmission will usually be used. Meanwhile,
we rely on patient transmission by hand. Although this can be

27

Ibid.
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augmented by posting a copy of the hand-written discharge summary


(Curran et al, 1992), patients are, perhaps surprisingly, usually quite
reliable in relaying this letter to their GP (Colledge et al, 1992; Naji et al,
1999). GPs are keener to be telephoned about their patients at the time
of discharge than hospital specialists might think (Sagar, 1990; Walker
& Eagles, 1994).
Poor information transfer at discharge does appear to increase
the likelihood of readmission (Olfson & Walkup, 1997) and one study
found that, after discharge, an alarming 90% of elderly patients were
receiving different medication regimes at home from those they had
been prescribed in hospital (Cochrane et al, 1992). Are efforts to
improve communication helpful in a patient's post-discharge care?
McInnes et al (1999) found that pre-discharge visits to the frail elderly
improved GP-hospital collaboration, were associated with increased
patient satisfaction and gave rise to greater use of community resources.
It is perhaps doubtful that this would transfer cost-effectively to
psychiatric settings. A randomized trial in Aberdeen (Naji et al, 1999) of
standard discharge procedure v. a package of enhanced communication
(GPs were telephoned; patients' appointments were arranged with GPs
before discharge; discharge letters were posted as well as handdelivered) indicated marginal benefit only. There was a trend towards
lower rates of readmission and patients had more consultations about
psychiatric issues with their GPs after discharge.28
Various clinical interventions have sought to ameliorate patients'
vulnerability in the post-discharge period. As with efforts to enhance
inter-professional communications, there is little evidence that these
have been successful.
The UK 700 trial recruited patients with psychosis, either at the
time of discharge from hospital, or when living in the community but
having been admitted during the preceding 2 years. The patients were
randomly assigned to standard or intensive case management, the latter
being similar in format to the Care Program Approach. Intensive case
management had no impact on suicidality (Walsh et al, 2001), nor on
either clinical status or social functioning (Burns et al, 1999). There was
no impact on likelihood of readmission (Burns et al, 1999). However, a

28

Ibid.
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similar study in London (Tyrer et al, 1995) found that closely monitored
community-based patients spent significantly longer in hospital. Tyrer et
al (1995) did find that loss to follow-up was less common in the closely
monitored group.Few studies have focused more specifically on the
post-discharge period. Sullivan and Bonovitz (1981) found that
subsequent out-patient attendance was improved by offering the first
appointment within 3 days of discharge. A nurse discharge coordinator
had no positive effect on readmission rates, on post-discharge wellbeing or on patient satisfaction ratings (Walker et al, 2000). As in Roy's
(2001) recent review, there have been no intervention studies of
representative cohorts of discharged patients to determine whether
suicidality can be influenced. Psychological autopsy studies, with all
their inherent flaws, can perhaps yield pointers towards clinical practices
that may reduce suicidality. King et al (2001) found that discontinuity of
contact was associated with post-discharge suicides in Wessex.
However, rates of key personnel on leave or leaving were said to be
1% in the control group and 5% in the suiciding patients. Given that the
average consultant psychiatrist is on leave for some 15% of the time,
this strongly suggests incomplete and selective recording.29
Currently, researchers know that psychiatric patients are
vulnerable in the post-discharge period, but they have no good evidence
to direct their efforts to improve the situation. Attempts to enhance interprofessional communication have the advantage of being very cheap
(Naji et al, 1999), which probably makes them worth pursuing despite
the tenuous evidence of effectiveness. The same cannot be said for
clinical packages of care in the post-discharge period, such as the predischarge meetings and rapid follow-up espoused by the National
Confidential Inquiry (Scottish Executive, 2001). As others have pointed
out (Marshall, 1996; Geddes, 1999), it is probably premature to
introduce such policies without an adequate evidence base. It seems
much more logical to conduct good research studies to determine
whether patients' vulnerability in the post-discharge period can indeed
be ameliorated and to design appropriate policies thereafter.30

29

Ibid.
Shona A. Walker, Senior Registrar and John M. Eagles, Consultant Psychiatrist (2002), Psychiatric Bulletin retrieved
from: http://pb.rcpsych.org
30

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II.

Management Type Analysis


As mentioned in the earlier part of this chapter, the facility will be comprised

of two type of users wherein the first half would be the client and the second part
is composed of the management staff. The analysis will discuss the following
management type as well as the roles and responsibilities of each staff member.
Management scale will also be scaled in proportion to the market size.

A. Management Type
1.

Administrative Order No. 147 S. 2004


Amending Administrative Order No. 70-A, Series 2002 re:
Revised Rules and Regulations Governing the Registration,
Licensure and Operation of Hospitals and Other Health Facilities
in the Philippines
a. Section 6. Definition: A hospital is a health facility for the
diagnosis, treatment and care of individuals suffering from
deformity, disease, illness or injury, or in need of surgical,
obstetrical, medical or nursing care. It is an institution where
there are installed bassinets or bed 24-hour use or longer by
patients in the management of deformities, disease, injuries,
abnormal physical, and mental conditions, and maternity
cases.
b. Section 7. Classification of Hospitals and other Health
Facilities: Hospitals and other facilities shall be classifies as
follows
Government or Private
Government Operated and maintained partially or
wholly by the national, provincial, city or municipal
government, or other political unit: or by any
department, division, board or agency thereof.31
Private Privately owned, established and
operated with funds through donation, by any
individual corporation, association or organization.
General or Special
General Provides services for all types of
deformity, disease, illness or injury.
Special Primarily engaged in the provision of
specific clinical care and management.
Service Capabilities

31

Department of Health, April 28, 2004 Philippines, Administrative Order No. 147 S. 2004
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32

Primary Care
o Non-departmentalizes
hospital
that
provides clinical care and management
on the prevalent diseases in the facility.
o Clinical Services include general
medicine, pediatrics, obstetrics, and
gynecology, surveying and anesthesia.
o Provide appropriate administrative and
ancillary services (clinical laboratory,
radiology, pharmacy)
o Provides nursing care for patients who
require intermediate, moderate and
partial category of surprised care for 24
hours or longer.
Secondary Care
o Departmentalized hospital that provides
clinical care and management on the
prevalent diseases in the locality, as well
as particular forms of treatment, surgical
procedure and intensive care,32
o Clinical services provided in Primary
Care, as well as specialty clinic care.
o Provides appropriate administrative and
ancillary services (clinical, laboratory,
radiology, and pharmacy)
o Nursing care provided on primary care,
as well as total and intensive skill care.
Tertiary care
o Teaching and training hospital that
provides clinical care and management
and the prevalent diseases in the locality,
as well as specialized forms of treatment,
surgical procedure and intensive care.
o Clinical services provided by in
secondary care, as well as subspecialty
clinical care.
o Provides appropriate administrative and
ancillary services (clinical laboratory,
radiology, pharmacy)
o Nursing care provided secondary care,
as well as continuous and highly
specialized critical care.
Infirmary A health facility that
provides emergency treatment
and care to the sick and injured,
as well as clinical care and
management to mothers and
newborn baby.
Birthing Home A health facility
that provides maternity services
on pre-natal and post-natal care,

Ibid
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normal spontaneous delivery, and


care of newborn baby.33
Acute Chronic Psychiatric Care
Facility A health facility that
provides
medical
services,
nursing care, pharmacological
treatment
and
psychosocial
intervention for mentally ill
patients
Custodial Psychiatric Care Facility
A health facility that provides
long-term care, including basic
human services such as food and
shelter, to chronic mentally ill
patients.34

With accordance to the Administrative Order no 147 s. 2004 of


Department of Health Philippines, the management would be privately
operated and would offer special treatment for specific clinical care and
management. The facility would fall under other health facilities and would
provide tertiary care service capabilities. Under the tertiary care, the
facility would comply with the staffing requirements of Acute-Chronic
Psychiatric Care Facility/Custodial Psychiatric Care Facility.

B. Organizational Mandate

Vision
The Filipino people with the highest level of mental health.
Mission
To promote mental health and prevent mental disorders through
advocacy, education, prevention, and best practice interventions for the
Filipino people.
Goals
To promote mental health and prevent mental disorders through
advocacy, education and information dissemination, and capability building;

33
34

Ibid
Ibid
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To provide best practice interventions for assessment, treatment,


and

rehabilitation

that

are

multi-disciplinary,

family-focused,

and

community-based;
To promote the conduct of research in mental health that will serve
as basis for policy and program development;
To collaborate and build alliances with government and nongovernment organization, local and international, for the advancement of
mental health.35

C. Organizational Structure

Gracedale Nursing Home Operational Assessment Final Report Table taken from
www.phcr.org

Organizational Chart taken from www.maristowhouse.co.uk

35

Philippine Mental Health Association, Inc, http://www.pmha.org.ph


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HIVE Organizational Chart

The organizational structure of the HIVE is based on existing nursing home


staffing chart. The organizational management of the facility was divided in
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accordance to the Department of Health personnel administration. The subgroups


were mainly Medical Service Department where physicians medical plans are
provided, the Nursing Service Department, where personal care are given, the
Ancillary Service Department, for continuous therapeutic services, and the
General Administrative Service Department, for overall clerical, maintenance,
dietary and housekeeping services.

D. Management Roles and Responsibilities

The

following

are

enumerated

management

staff

with

their

corresponding roles and responsibilities. Job descriptions are also provided


for each member of the organization. Descriptions were patterned from
existing facility type and provision given by the Department of Health,
Philippines.
1.

Owner
Means the individual, partnership, corporation, association or other

person who owns a facility. In the event a facility is operated by a person


who leases the physical plant, which is owned by another person, "owner"
means the person who operates the facility, except that if the person who
owns the physical plant is an affiliate of the person who operates the facility
and has significant control over the day-to-day operations of the facility, the
person who owns the physical plant shall incur jointly and severally with the
owner all liabilities.36

2.

Administrator
The nursing home administrator is appointed by the governing body.

Federal regulations require that a nursing home be supervised by an


administrator licensed by the state. The administrator is charged with
management of the facility. He/she is expected to administer the facility in
a manner that allows each resident to maximize physical, mental and
psychosocial well-being.37

36
37

Health Facilities and Regulation (210 ILCS 45/) Nursing Home Care Act, http://www.ilga.gov
Mark W. Swanson, O.D, 1998 243 N. Lindbergh Blvd., St. Louis, Optometric Care of Nursing Home Residents
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3.

Medical Director
The Certified Medical Director in Long Term Care recognizes the

dual clinical and managerial roles of the medical director. The CMD
credential reinforces the leadership role of the medical director in promoting
quality care and offers an indicator of professional competence to long term
care providers, government, quality assurance agencies, consumers, and
the general public.

Role 1Physician Leadership


The medical director serves as the physician
responsible for the overall care and clinical practice carried
out at the facility.

Role 2Patient Care-Clinical Leadership


The medical director applies clinical and administrative
skills to guide the facility in providing care.

Role 3Quality of Care


The medical director helps the facility develop and
manage both quality and safety initiatives, including risk
management.

Role 4Education, Information, and Communication


The medical director provides information that helps
others (including facility staff, practitioners, and those in the
community) understand and provide care.

Function 1Administrative
The medical director participates in administrative
decision making and recommends and approves relevant
policies and procedures.

Function 2Professional Services


The medical director organizes and coordinates
physician services and the services provided by other
professionals as they relate to patient care.

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Function

3Quality

Assurance

and

Performance

Improvement
The medical director participates in the process to
ensure the quality of medical care and medically related care,
including whether it is effective, efficient, safe, timely, patientcentered, and equitable.38

Function 4Education
The medical director participates in developing and
disseminating key information and education.

Function 5Employee Health


The medical director participates in the surveillance
and promotion of employee health, safety, and welfare.

Function 6Community
The medical director helps articulate the long-term care
facilitys mission to the community.

Function 7Rights of Individuals


The medical director participates in establishing
policies and procedures for assuring that the rights of
individuals (patients, staff, practitioners, and community) are
respected.

Function 8Social, Regulatory, Political, and Economic


Factors
The medical director acquires and applies knowledge
of social, regulatory, political, and economic factors that relate
to patient care and related services.

Function 9Person-Directed Care


The medical director supports and promotes persondirected care.39

38
39

The Nursing Home Medical Director: Leader and Manager, March 2011, http://www.amda.com/
Ibid.
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4.

Attending Physician
Means any doctor of medicine duly licensed to practice in the

Philippines, an active member in good standing of the Philippine Medical


Association and accredited by the Commission.40

Responsibility for Initial Patient Care. The attending


physician should:
o Assess a new admission in a timely fashion (based on
a joint physician-facility-developed protocol, and
depending on the individual's medical stability, recent
and previous medical history, presence of significant or
previously unidentified medical conditions, or problems
that cannot be handled readily by phone);
o Seek, provide, and analyze needed information
regarding a patient's current status, recent history, and
medications and treatments, to enable safe, effective
continuing

care

and

appropriate

regulatory

compliance;
o Provide appropriate information and documentation to
support the facility in determining the level of care for a
new admission;
o Authorize admission orders in a timely manner, based
on a joint physician-facility-developed protocol, to
enable the nursing facility to provide safe, appropriate,
and timely care; and
o For a patient who is to be transferred to the care of
another health care practitioner, continue to provide all
necessary medical care and services pending transfer
until another physician has accepted responsibility for
the patient.

Support Patient Discharges and Transfers. The attending


physician should:
o Follow-up with a physician or another health care
practitioner at a receiving hospital as needed after the
transfer of an acutely ill or unstable patient;

40

Book IV - Health, Safety and Social Welfare, http://www.dole.gov.ph


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o Provide whatever documentation or other information


may be needed at the time of transfer to enable care
continuity at a receiving facility and to allow the nursing
facility to meet its legal, regulatory, and clinical
responsibilities for a discharged individual; and
o Provide pertinent medical discharge information within
30 days of discharge or transfer of the patient.

41

Make Periodic, Pertinent On-Site Visits to Patients. The


attending physician should:
o Visits patients in a timely fashion, based on a joint
physician-facility-developed protocol, consistent with
applicable state and federal regulations, depending on
the patient's medical stability, recent and previous
medical history, presence of significant or previously
unidentified medical conditions, or problems that
cannot be handled readily by phone;
o Maintain progress notes that cover pertinent aspects of
the patient's condition and current status and goals.
Periodically, the physician's documentation should
review and approve a patient's program of care.
o Determine progress of each patient's condition at the
time of a visit by evaluating the patient, talking with staff
as needed, talking with responsible parties/family as
indicated, and reviewing relevant information, as
needed;
o Respond to issues requiring a physician's expertise,
including the patient's current condition, the status of
any acute episodes of illness since the last visit, test
results, other actual or high risk potential medical
problems that are affecting the individual's functional,
physical, or cognitive status, and staff, patient, or family
questions

regarding

the

individual's

care

and

treatments; and
o At each visit, provide a legible progress note in a timely
manner for placement on the chart (timely to be defined
by a joint physician-facility protocol). Over time, these
progress notes should address relevant information
41

Role of the Attending Physician in the Nursing Home, March 2003, http://www.amda.com
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about significant ongoing, active, or potential problems,


including reasons for changing or maintaining current
treatments or medications, and a plan to address
relevant medical issues. 42

Ensure Adequate Ongoing Coverage. The attending


physician should:
o Designate an alternate physician or appropriately
supervised midlevel practitioner who will respond in an
appropriate, timely manner in case the attending
physician is unavailable;
o Update the facility about his or her current office
address, phone, fax, and pager numbers to enable
appropriate, timely communications, as well as the
current office address, phone, fax and pager numbers
of designated alternate physicians or an appropriately
supervised midlevel practitioner;
o Help ensure that alternate covering practitioners
provide adequate, timely support while covering and
intervene with them when informed of problems
regarding such coverage;
o Adequately notify the facility of extended periods of
being unavailable and of coverage arranged during
such periods
o Adequately inform alternate covering practitioners
about patients with active acute conditions or potential
problems that may need medical follow-up during their
on-call time.

Provide Appropriate Care to Patients. The attending


physician should:
o Perform

accurate,

timely,

relevant

medical

assessments;
o Properly define and describe patient symptoms and
problems,

clarify

and

verify

diagnoses,

relate

diagnoses to patient problems, and help establish a


realistic prognosis and care goals;
o In consultation with the facility's staff, determine
appropriate services and programs for a patient,
42

Ibid.
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consistent with diagnoses, condition, prognosis, and


patient wishes, focusing on helping patients attain their
highest practicable level of functioning in the least
restrictive environment; 43
o In

consultation

treatments,

with

including

facility

staff,

ensure

that

rehabilitative

efforts,

are

medically necessary and appropriate in accordance


with relevant medical principles and regulatory
requirements;
o Respond in an appropriate time frame (based on a joint
physician-facility-developed protocol) to emergency
and routine notification, to enable the facility to meet its
clinical and regulatory obligations;
o Respond to notification of laboratory and other
diagnostic test results in a timely manner, based on a
protocol developed jointly by the physicians and the
facility, considering the patient's condition and the
clinical significance of the results;
o Analyze the significance of abnormal test results that
may reflect important changes in the patient's status
and explain the medical rationale for subsequent
interventions or decisions not to intervene based on
those results when the basis for such decisions is not
otherwise readily apparent;
o Respond promptly to notification of, and assess and
manage

adequately,

reported

acute

and

other

significant clinical condition changes in patients;


o In consultation with the facility staff, manage and
document ethics issues consistent with relevant laws
and regulations and with patients' wishes, including
advising patients and families about formulating
advance directives or other care instructions and
helping identify individuals for whom aggressive
medical interventions may not be indicated; and
o Provide

orders

that

ensure

individuals

have

appropriate comfort and supportive care measures as

43

Ibid.
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needed; for example, when experiencing significant


pain or in palliative or end-of-life situations; 44
o Periodically review all medications and monitor both for
continued need based on validated diagnosis or
problems and for possible adverse drug reactions. The
medication review should consider observations and
concerns offered by nurses, consultant pharmacists
and others regarding beneficial and possible adverse
impacts of medications on the patient.

Provide

Appropriate,

Timely

Medical

Orders

and

Documentation. The attending physician should:


o Provide timely medical orders based on an appropriate
patient assessment, review of relevant pre- and postadmission information, and age-related and other
pertinent risks of various medications and treatments;
o Provide sufficiently clear, legible written medication
orders

to

avoid

misinterpretation

and

potential

medication errors, such orders to include pertinent


information such as the medication strength and
formulation (if alternate forms available); route of
administration; frequency and, if applicable, timing of
administration;

and

the

reason

for

which

the

medication is being given;


o Verify the accuracy of verbal orders at the time they are
given and authenticate, sign and date them in a timely
fashion, no later than the next visit to the patient.
o Provide documentation required to explain medical
decisions, that promotes effective care, and allows a
nursing facility to comply with relevant legal and
regulatory requirements
o Complete death certificates in a timely fashion,
including all information required of a physician. 45

Follow Other Principles of Appropriate Conduct. The


attending physician should:
o Abide by pertinent facility and medical policies and
procedures

44
45

Ibid
Ibid.
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o Maintain a courteous and professional level of


interaction with facility staff, patients, family/significant
others, facility employees, and management
o Work with the medical director to help the facility
provide high quality care
o Keep the well-being of patients/residents as the
principal consideration in all activities and interactions.
o Be alert to, and report to the medical director and
other appropriate individuals as named through facility
protocol-- any observed or suspected violations of
patient/resident rights, including abuse or neglect, in
accordance with facility policies and procedures. 46

5.

Nurse Practitioner
Nurse Practitioners are registered nurses who have acquired the

formal education, extended knowledge base and clinical skills beyond the
registered nurse level to practice in an advanced role as direct health care
providers.
Nurse Practitioners are authorized to practice by the Board in a
specialty area via their registered nurse licensure and advanced practice
certification in a specialty area.
Nurse Practitioners utilize critical judgment in the performance of
comprehensive

health

assessments,

differential

medical

diagnosis

including ordering, conducting, and interpreting diagnostic and laboratory


tests, and the prescribing of pharmacologic and non-pharmacologic
treatments in the direct management of acute and chronic illness and
disease.47
6.

Clinical Nurse Specialist


Using the core competencies of advanced practice nursing to design,

implement, and evaluate programs of care to enhance patient outcomes,


particularly for complex patients and across systems of care.

46
47

Ibid.
Arizona State Board of Nursing, January 2009, http://www.azbn.gov
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CNS involvement in care delivery and planning depends on a


variety of factors, e.g. the assessed needs of patients and
learning needs of staff.

Leading

multidisciplinary

groups

in

designing

and

implementing innovative solutions that address system


problems and patient care issues.

Serving as a leader, consultant, mentor and change agent to


achieve quality cost-effective outcomes.48

Developing differential diagnoses and interventions to treat or


prevent illness.

Planning and implementing educational opportunities for


health professional staff, patients and communities.

7.

Pharmacist

The consultant pharmacist for a nursing home shall conduct a


drug regimen review for actual and potential drug therapy
problems in the nursing home and make remedial or
preventive clinical recommendations into the medical record
of every patient receiving medication. The consultant
pharmacist shall conduct the review at least monthly in
accordance with the nursing home's policies and procedures.

The consultant pharmacist shall report and document any


drug irregularities and clinical recommendations promptly to
the attending physician or nurse-in-charge and the nursing
home administrator.49

The consultant pharmacist shall report drug product defects


and adverse drug reactions.

The consultant pharmacist shall ensure that all known


allergies and adverse effects are documented in plain view in
the patient's medical record, including the medication
administration records, and communicated to the dispensing
pharmacy. The specific medications and the type of allergy or
adverse reaction shall be specified in the documentation.

The consultant pharmacist shall ensure that drugs that are not
specifically limited as, to duration of use or number of doses
shall be controlled by automatic stop orders. The consultant

48
49

AACN Statement of Support for Clinical Nurse Specialists, March, 2006, www.aacn.nche.edu
Nursing home pharmacy reports; duties of consultant pharmacist, 2003, http://www.ncga.state.nc.us
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pharmacist shall further ensure that the prescribing provider


is notified of the automatic stop order prior to the dispensing
of the last dose so that the provider may decide whether to
continue to use the drug.

8.

Nursing Director

The Director of Nursing assumes authority, responsibility, and


accountability for the delivery of nursing services in the facility.
In

collaboration

with

facility

Administration,

allocates

department resources in an efficient and economic manner to


enable each resident to attain or maintain the highest practical
physical, mental, and psychosocial well-being. Collaborates
with other departments, medical professionals, consultants,
and organizations, including government agencies and
advocacy groups, to develop, support and coordinate resident
care, related administrative functions, and to represent the
interests of the facility.

Develops, maintains, and implements nursing policies and


procedures that conform to current standards of nursing
practice, facility philosophy, and operational policies while
maintaining compliance with state and federal laws and
regulations.

Communicates and interprets policies and procedures to


nursing

staff,

and

monitors

staff

practices

and

implementation.

Participates in all admission decisions, and may visit


prospective residents before admission.

Participates in daily or weekly management team meetings to


discuss resident status, census changes, personnel, or
resident complaints or concerns.

Evaluates the work performance of all nursing personnel,


assists in the determination of wage increases, and
implements discipline according to operational policies.

Ensures delivery of compassionate quality care and nursing


supervision as evidenced by adequate services and staff
coverage on unit, absence of odors, general cleanliness,
prevention of pressure wounds, and apparent maintenance of
optimal resident functions.
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Demonstrates knowledge of and application of Key Clinical


Quality Indicators, and proactively monitors and implements
systems to achieve and/or surpass company thresholds.

Exercises overall supervision of resident assessments and


care plans.50

Reviews 24-hour report from every unit daily to monitor and


ensure timely, effective responses to significant changes in
condition,

transfers,

unexplained

injuries,

discharges,
falls,

use

behavioral

of

restraints,

episodes,

and

medication errors.

Collaborates

with

physicians,

consultants,

community

agencies, and institutions to improve the quality of services


and to resolve identified problems.

Coordinates nursing services with all other departments


including Therapy.

Oversees nursing schedules to assure they meet resident


needs and regulatory and budgetary standards.

Participates in the recruitment and selection of nursing


personnel and assures sufficient staff are hired.

Oversees and supervises development and delivery of inservice education to equip nursing staff with sufficient
knowledge and skills to provide compassionate, quality care
and respect for resident rights.

Proactively develops positive employee relations, incentives,


and recognition programs. Promotes teamwork, mutual
respect, and effective communication.

Participates

in

budget

development

for

the

nursing

department, and for medical, nursing, and central supplies.


Assures nursing staff properly charges out ancillaries used.

Helps the Administrator prepare staff for inspection surveys,


instructing staff on matters of conduct and disclosure, being
interviewed by inspectors, immediate corrections of problems
noted by surveyors, etc. Reviews and reinforces important
standards previously cited.

Participates in the preparation of the Plan of Correction


response to an inspection survey.

50

Job Description Director of Nursing, March 2004, http://www.ihca.org


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Communicates directly with residents, families, medical staff,


nursing

staff,

interdisciplinary

team

members,

and

Department Heads to coordinate care and services, promote


participation in care plans, and maintain a high quality of care
and life for residents.51

Promotes customer service and hospitality and responds to


and adequately resolves complaints or concerns from
residents or families about nursing services.

Monitors facility incidents and complaints daily to identify


those defined as unusual occurrences by State policy and
promptly reports such occurrences to Administrator/Executive
Director for appropriate action.

Monitors complaint reports daily for allegations of potential


abuse or neglect, or the loss or misappropriation of resident
property, and participates in these investigations.

Promotes compliance with accident prevention procedures,


safety rules, and safe work practices to prevent employee
injury and illness and control workers compensation costs.

Assures staff is trained in fire and disaster and other


emergency procedures, and evaluates performance during
drills.

Interacts courteously with residents, family members,


employees, visitors, vendors, business associates, and
representatives of government agencies.

Acts in an administrative capacity in the absence of the


Administrator.52

9.

Charge Nurse
In Skilled nursing Facilities, the Director of Nursing Services shall

designate as charge nurse for each shift a registered nurse, a licensed


practical nurse, or a licensed psychiatric technician nurse. Responsibilities
of the charge nurse shall include supervision of the total nursing activities
in the facility during his/her assigned tour of duty.53

51

Ibid.
Ibid.
53 Charge Nurse, http://aipp.afmc.org
52

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Responsibility for observation of work performance of aides in


delivery of direct care.

Administration of medication if there is no assigned


medication nurse.

Ordering medications from the pharmacy.

All direct observations of patients to observe and evaluate


physical and emotional status.

Delegate responsibility for the direct care of specific patients


to the nursing staff based on the need of the patients.

10.

Taking phone orders from physicians or dentists.

Giving shift report to the next shift.

Shift count of control drugs.

Dietary observations.54

Unit Supervisor
Manages and assumes 24-hour responsibility and accountability for

resident care on assigned unit. Manages the unit in accordance with policy
and procedure.

Assumes 24-hour responsibility and accountability for


resident care on assigned unit.

Ensures complete and prompt reporting of incidents with


follow-up as necessary to Administrator and Director of
Nursing.

Meets with all 3 shifts at least once per month.

Actively participates in committee/programs as directed by


Director of Nursing.

Participates in the development and implementation of new


policies and procedures based on identified needs.

Serves as MDS (Minimum Data Set) coordinator for assigned


unit and completes admissions MDS for each resident.55

Oversees resident care to promote the highest level of


physical, mental and psychosocial functioning possible for
assigned unit.

54
55

Ibid.
Champaign County Job Description, January, 2006, http://www.co.champaign.il.us
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Actively participates in the Quality Assurance process,


including attendance at Quality Assurance meetings and
submission of required reports.

Ensures that significant changes in resident condition are


communicated to the physician, family or responsible party.

Makes daily rounds on unit to ensure resident care needs and


environmental standards are met, this includes monitoring of
dining room during meal times.

Works

collaboratively

with

other

members

of

the

interdisciplinary care team to provide holistic care. Reviews


clinical records for completeness and accuracy as necessary.

Monitors, tracks, evaluates and reports infections for the unit.


Acts as a resource for nursing staff.

Reviews applications for admission to the unit with Director of


Nursing and Admissions Director. Works collaboratively with
Director of Nursing to identify and provide orientation and
continuing education for unit staff members.

Attends and actively participates in nursing supervisory


meetings.56

11.

Licensed Practical Nurse


Licensed practical nurses provide nursing care usually under the

direction of medical practitioners, registered nurses or other health team


members. They are employed in hospitals, nursing homes, extended care
facilities, rehabilitation centers, doctors' offices, clinics, companies, private
homes and community health centers. Operating room technicians are
included in this unit group.57

Provide nursing services, within defined scope of practice, to


patients based on patient assessment and care planning
procedures

Perform nursing interventions such as taking vital signs,


applying aseptic techniques including sterile dressing,
ensuring infection control, monitoring nutritional intake and
conducting specimen collection

56
57

Ibid.
Licensed Practical Nurse jobs Canada, Visa Bureau 2003-2014, http://www.visabureau.com
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Administer

medication

and

observe

and

document

therapeutic effects

Provide pre-operative and post-operative personal and


comfort care

Monitor established respiratory therapy and intravenous


therapy

Monitor patients' progress, evaluate effectiveness of nursing


interventions and consult with appropriate members of
healthcare team

Provide safety and health education to individuals and their


families.58

12.

Certified Nursing Assistant

Performs any combination of following duties in care of


patients in hospital, nursing home, or other medical facility,
under direction of nursing and medical staff: Answers signal
lights, bells, or intercom system to determine patients' needs.

Bathes, dresses, and undresses patients.

Serves and collects food trays and feeds patients requiring


help.

Transports patients, using wheelchair or wheeled cart, or


assists patients to walk.

Drapes patients for examinations and treatments, and


remains with patients, performing such duties as holding
instruments and adjusting lights.

Turns and repositions bedfast patients, alone or with


assistance, to prevent bedsores.

Changes bed linens, runs errands, directs visitors, and


answers telephone.

Takes and records temperature, blood pressure, pulse and


respiration rates, and food and fluid intake and output, as
directed.

Cleans, sterilizes, stores, prepares, and issues dressing


packs, treatment trays, and other supplies.59

58
59

Ibid.
Nurse Assistant Job Description, 1997-2013, careplanner.com
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13.

Physical Therapist
PTs examine each individual and develop a plan using treatment

techniques to promote the ability to move, reduce pain, restore function, and
prevent disability. In addition, PTs work with individuals to prevent the loss
of mobility before it occurs by developing fitness- and wellness-oriented
programs for healthier and more active lifestyles.

Diagnose and manage movement dysfunction and enhance


physical and functional abilities.

Restore, maintain, and promote not only optimal physical


function but optimal wellness and fitness and optimal quality
of life as it relates to movement and health.

Prevent

the

onset,

symptoms,

and

progression

of

impairments, functional limitations, and disabilities that may


result from diseases, disorders, conditions, or injuries.60

14.

Occupational Therapist
OTs provide intervention in many areas of occupation such as:

activities of daily living (ADLs) including bathing, dressing, grooming;


instrumental activities of daily living (IADLs) including home and financial
management, rest and sleep, education, work, play, leisure, and social
participation (AOTA, 2008). They also develop and implement health and
wellness programs to prevent injuries, maintain function, and improve
safety of residents. For example, OTs and OTAs can take a leadership role
in developing and implementing programs to educate clients on
compensatory techniques for low vision, customized exercise programs, or
strategies to prevent falls. Occupational therapy practitioners may also
consult with other staff within the facility or in the community on a variety of
topics related to increasing safe engagement in activities.61

15.

Speech Therapist
In a nursing home environment, diagnoses and treats speech and

language

problems,

and

engages

in

scientific

study of

human

communication. Evaluates speech and language skills as related to

60
61

Guide to Physical Therapist Practice, 2nd Edition (2003), http://www.apta.org


American Occupational Therapy Association [AOTA], 2008), http://www.aota.org
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educational, medical, social, and psychological factors. Plans, directs, or


conducts rehabilitative treatment programs to restore communicative
efficiency of individuals with communication problems of organic and nonorganic etiology. Requires a master's degree in speech-language pathology
and may require a certificate of clinical competence in speech-language
pathology (CCC). Expected to meet certain state licensing requirements.
Familiar with a variety of the field's concepts, practices, and procedures.
Relies on extensive experience and judgment to plan and accomplish goals.
Performs a variety of tasks. May lead and direct the work of others. A wide
degree of creativity and latitude is expected. Typically reports to a manager
or director.62

16.

Dentist
Dental hygienists are licensed oral health professionals specializing

in prevention and treatment of oral diseases, as well as protection of


patients' total health. Whether by administering a prophylaxis (tooth
cleaning) or taking X-rays, dental hygienists dentistry's advanced
defensive guards are often the first members of the dental team to treat
patients.63

17.

Optometrist
The role played as an optometric consultant in a nursing facility can

be as creative and unique as one desires. In the role of consultant, the


optometrist may be asked to assist the nursing home in developing policies
or to provide suggestions on ways to improve the function of residents other
than providing examinations. Optometrists certainly provide eye care
services to the residents, but many other areas of optometric expertise may
be needed. 64

18.

Finance Officer
The hospital CFO is assigned onsite financial responsibility for a. The

CFO administers, directs and monitors all hospital financial activities and
62

Speech and Language Pathologist - Nursing Home Job Description, http://swz.salary.com


Nayda Rondon, 2006-2014, Dental Hygienists: Helping You Maintain a Clean, Healthy Smile
http://www.yourdentistryguide.com
64 Mark W. Swanson, O.D, 1998 243 N. Lindbergh Blvd., St. Louis, Optometric Care of Nursing Home Residents
63

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keeps the hospital CEO and the hospital Board of Trustees informed of the
financial condition of the facility.65

19.

Cashier
Cashier receives cash payments tendered in person, makes change

and prepares and issues receipts; balances and maintains logs of daily
remittance claims by third party payers and electronic payments; processes
all payments and adjustments; balances and reconciles any differences of
electronic payments; posts third party payer adjustments; prepares daily
deposit for all hospital cash transactions, endorses checks for deposit;
researches all documents to verify appropriate payments, including
unknown patient payments; receives, maintains and releases patient
property in accordance with established procedures; compiles and reviews
periodic reports; performs routine filing and other clerical duties.66

20.

Billing Officer
The primary purpose of your job position is to assist in the day-to-

day accounting functions of the facility in accordance with current


acceptable accounting and cost reimbursement principles relating to health
care and the hospital operation as may be directed by the Administrator or
Controller.67

21.

Disbursing Officer

Responsible for providing accounting services to the assigned


unit to ensure accurate and timely finance and accounting
service delivery.

Performs routine tasks relevant to assigned section in


accordance to the finance & accounting policies and
procedures set by the business unit.

Coordinates with concerned departments or parties for


pending supporting documents follow-up, correction and
reconciliation of entries, and other related inquiries.

65

HealthTech Management Services, http://www.cahcare.com


Hospital Cashier, http://www.erie.gov
67 Office/Billing, http://www.anberryhospital.com
66

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Maintains and safe keeps pertinent files and documents for


audit references.

Prepares and processes Check and cash payments, Letter


Remittance (LR), and Debit Advice (DA), manually for
approval of authorized signatories as per Limits of Authority.

Posts all processed accounts payable transactions to check


tally with accounts receivables.

Monitors check accounts and the re-occurring monthly


payment from Accounting.

Conducts checks inventory to monitor usage and releases.

Processes cash advances, reimbursement, liquidation, and


transfer of funds representation.68

22.

Admission Officer
Reviews admitting department operations in a nursing home

environment. Ensures compliance with applicable standards. Oversees the


in-patient/out-patient functions, bed assignments, and completion of
preliminary paperwork for entering patients. Works with medical, nursing,
and accounting staff to ensure appropriate patient placement. Confirms that
all insurance benefits coverage meets standards of admission as dictated
by policy.69

23.

Social Service Director


The SSDs main responsibility will be to motivate all residents to

make healthy adjustments to the nursing facility, by their participation in


activities and social events. Informal counseling will be a part of the SSDs
job responsibilities and they will attempt to uncover any problems which
might be interfering with the residents socialization and participation in
home activities.70

24.

Budget Officer

Prepares the Annual Work and Financial Plan of the hospital.

Monitors and controls fund utilization in the hospital.

68Disbursement

Officer, 2010, http://www.home-harbor.com


Admissions Coordinator - Nursing Home Job Description, 2014, http://swz.salary.com
70 Job Description Social Service Director, http://elmbrookhomes.com
69

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Reviews and consolidates budget estimates of the different


units of the hospital.

Allocates available funds to hospital programs and projects


based on approved guidelines, policies and priorities.

Reviews

fiscal

documents

and

accounts

relating

to

disbursement of funds.

Reviews expense vouchers covering payments, vis--vis,


authorized allotments.

Serves as the hospitals liaison officer for budgetary matters.

Directs the preparation of requests for the reprogramming of


funds and corresponding changes in the work plan.

Plans and directs the realignment of hospital expenditures in


accordance with the appropriation reserves and quarterly
allotments by items and projects.71

25.

Social Worker

Makes assessment of economic and other resources of


patients and their families.

Performs casework service to patients referred with social,


emotional or environmental problems affecting their medical
situation.

Consults with other disciplines in the setting concerned and


directs the implementation, coordination and collaboration of
the MSS activities with other disciplines.

Mobilizes external resources to meet the medical needs of


patients.

Ensures the systematic documentation, reporting and


preparation of monthly reports.

26.

Performs other related functions as may be assigned.72

Dietary Supervisor
To provide or to serve safe, nutritious foods through careful planning,

wise procurement and proper preparation of the balance and satisfying


meals within the budgetary limits.73

71

Andy Geff E. Cepe, The Administrative Subsystems Functions, Policies and Relationships, http://tdh.doh.gov.ph
Ibid.
73 Ibid.
72

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27.

Food Service Worker

Shall assist in food preparation work such as:


o Peeling, washing and cutting of fruits and vegetables
o Weighing, cutting of meat, fish and poultry supplies

Shall apportion cooked foods for distribution in patients trays


and in wards.

Shall apportion raw food supplies for distribution to patients


receiving raw ration.

Shall collect, clean and return food containers and used trays
to the dietary after use.

Shall maintain orderliness and cleanliness in the Dietary


Service.74

28.

Cook

Prepares and cook menu items for hospitals in patients


especially those with modified diets and supervises food
service workers in the preparation and cooking in all hospital
categories.

Shall assist or give suggestions on menu planning and


preparation of duty schedules of subordinates.

Shall maintain sanitary standards in preparation, apportioning


and storage of foods.75

29.

Housekeeping/Laundry
Develop and maintain clean, safe and sanitary environment for

patients and hospital personnel. They also ensure adequate supply of clean
linens for patients and hospital units. 76

30.

Maintenance

Installation, operations and maintenance of electrical, mechanical


and communication equipment and allied facilities including buildings and
vehicles.77

74

Ibid.
Ibid.
76 Ibid.
77 Ibid.
75

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31.

Security
Ensure safety of hospital patients, facilities/properties and personnel,

maintain peace and order, and enforce hospital rules and regulations.78

78

Ibid.
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