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Community Care Objectives Review revolution of community mental health Define "community support system" Identify the levels of prevention on MI Describe roles of the nurse in community mental health care Evolution of the Care for the Mentally Ill
Chlopromazine Freud Managed Care Enlightenment Period Neurotransmitter Community Support System Dark Period Community Mental Health Act 18C 19C 20C-50's 60's 80's 90's ______________________________________________ The decade of the brain Humanistic Care Atypical antipsychotics Drug therapy Psychodynamic Theory Neurosurgery Partnership Psychopharmacology Landmarks in community mental health 1946 - Natl M H Act; 1949- NIMN 1955 MH Study Act 60's - Community Mental Health Centers Act; Deinstitutionalization case managers 70's - Community Support Program 80's Mental Health Systems Act 90's American Disabilities Act pt's rights 2000 Healthy people 2010; NAMI; NAMP National health goal; advocacy Healthy People 2010
18-1. Reduce the suicide rate. 18-2. ....adolescents 18-3. Reduce the proportion of homeless adults who have serious mental illness (SMI). 18-4. Increase the proportion of persons with serious mental illness (SMI) who are employed. 18-5. (Developmental) Reduce the relapse rates for persons with eating disorders, including anorexia nervosa and bulimia nervosa. Healthy People 2010 (cont'd)
18-6. (Developmental) Increase the number of persons seen in primary health care who receive mental health screening and assessment. 18-7. (Developmental) Increase the proportion of children with mental health problems who receive treatment. 18-8. (Developmental) Increase the proportion of juvenile justice facilities that screen new admissions for mental health problems. Healthy People 2010 (cont'd) 18-9. Increase the proportion of adults with mental disorders who receive treatment. 18-9a. aged 18 to 54 years with SMI. 18-9b. .....depression. 18-9c. ..... schizophrenia. 18-9d. ..... generalized anxiety disorder. Healthy People 2010 (cont'd) 18-10. (Developmental) Increase the proportion of persons with co-occurring substance abuse and mental disorders who receive treatment for both disorders. 18-11. (Developmental) Increase the proportion of local governments with community-based jail diversion programs for adults with SMI. 18-12. Increase the number of States and the District of Columbia that track consumers' satisfaction with the mental health services they receive. Healthy People 2010 (cont'd) 18-13. (Developmental) Increase the number of States, Territories, and the District of Columbia with an operational mental health plan that addresses cultural competence. 18-14. Increase the number of States, Territories, and the District of Columbia with an operational mental health plan that addresses mental health crisis interventions, ongoing screening, and treatment services for elderly persons. Commonly adopted patient's right To treatment using the least restrictive alternative/environment To confidentiality To freedom from restraints and seclusion To access to personal belongings To daily exercise, to have visitors, to use of telephone, writing materials, & uncensored mail. Community Support System A network of caring and responsible people committed to assisting a vulnerable population to meet its needs and develop its potential without becoming unnecessarily isolated or excluded from the community. Goals of community support system Improve the competence of the client daily living Alleviate the symptoms Use various therapeutic constructs Improve outcomes Install hope Active participation in the rehab. Develop individual skills Levels of Prevention Primary prevention Health promotion continued well-being Disease prevention no potential threat Secondary prevention Screening, referral, crisis intervention Tertiary prevention Rehabilitation social skill training, self-help groups, Components of a Community Support System Availability adequate resources Accessibility outreach, 24 hours services Integration collaboration & sharing Continuity inpt -> rehab. Community involvement community resources, grass root work, empowerment, advocacy, Elements of Case Management Psychiatric rehabilitation Resource linkage, Consultation/ liaison Advocacy Crisis intervention Home care Therapies Range of Community-based Care Home care - homebound clients Outreach services - for homeless clients Residential services Group homes - temp./permanent housing Halfway house - chemical dependency Apartment living programs Foster care and boarding homes Self-help groups Program models Psychosocial rehabilitation model 1948; (clubhouse model) -> better community function Fairweather lodge model 1960; -> increased community employment activities Training in community living model 1970; -> the client maintain stability in the comm. Satisfaction with life increased Program models (Cont'd) Consumer-run alternative models (Self-help program) 1980; consumers involvement Community worker model ordinary citizen provides support services Community support programs 1977; system change; support from all levels of government; hope for everyone ie consumers & helpers. public policy issues Numbers r/t Community Mentally ill
In the U.S. 20% of adults = MI 12% of children = mental or emotional pro. 1/3 of homeless have serious MI; >1/2 have a substance abuse problem 7% of inmates have a serious MI; 12.4% require psy attention 25% of those who have MI receive Tx. Many HIV infection or AIDS cases need psy Tx. Issues r/t community care Concepts about MI ie rehabilitation Stalled resources ie funding and planning Poverty ie. SSI Reinstitutionalization hosp & jail Special education for disabled children Stigma employment, housing, self-esteem Reforms Application of Nursing Process Assessment Aggregates and problems bureau of census, vital statistics, survey, local news Individuals -Severity of individual's illness; Amount of supervision required by the individual Diagnosis community oriented Nursing Process (cont'd) Planning Multidisciplinary team includes key people and agencies Short- and long-term goals Implementation Primary, secondary, & tertiary preventions Evaluation On going process Home care Def- Part of a comprehensive health and mental healthcare system that aims to provide an array of health-related services to clients and families in their places of residence. Residence private home, residential care facilities, group homes, Characteristics of home care natural setting; not an alternative to institutional care reduce or prevent hospitalization cost-effective rapidly growing and changing fields in health care, even though it is one of the oldest forms of ambulatory healthcare crisis intervention & emergency response Goals of home care Teaching problem-solving, stress-reduction, and coping skills to the clients/family members/ caregivers Providing respite and community resources Educating about MI/MH, medications, relapse prevention, and IPR & communication skills Coordinating medical, social, spiritual, ... community based services Care for the homeless with MI 5% of the people with MI are homeless Co-morbidity ie DM, Respiratory infections, asthma, malnutrition, dental caries, STD, thyroid problems, ... Roles of nurse in caring for the homeless Knowledge no standard protocols Perform an assessment physical, mental status, violence, hopelessness, spiritual, substance abuse, ... IPR & communication Immediate needs of the client Community resources The Negative Impact of Severe Mental Illness Impairment hallucination, depression Dysfunction lack of work adjustment skills, social skills, or ADL skills Disability unemployment, homelessness Disadvantage discrimination, poverty Challenges Use traditional knowledge/skill in new setting; Overlapping of professional and personal boundaries; Short, crisis oriented inpatient stay; Intensive outpatient services; Wider range of treatment modalities; Multidisciplinary collaboration Spiritual and Cultural competent care Spirituality & religion Spirituality A person's experience of, or a belief in, a power apart from his/her own existence; an individual search for meaning The concept of one's relationship with a transcendent reality Religion Outward practice of a spiritual system of beliefs, values, codes of conduct, and rituals Significance of spirituality & religion Social support -> lower distress Better coping with physical illness Healthier lifestyle lower incidence of substance abuse with purpose in life Decreased level of depression, anxiety with higher life satisfaction Roles of the nurse Clarifying values - What people believe and what is important to them Involving interdisciplinary team Ethical concerns Do not abuse the professional status Do not misrepresent the state of the research Do not impose one's own values on clients Culture A set of standard for behavior which a group of people attribute to those around them and which they used to orient their own behavior A design for living, influences every aspect of human interaction Essential Features of Culture Culture is learned Culture refers to systems of meanings Culture acts as a shaping template Culture is taught and reproduced Culture exists in a constant state of change Culture includes patterns of both subjective and objective components of human behavior Other Cultural Domains Folk beliefs/religion - can be confused with "religiosity" Stereotyping labels - avoid generalizations Ethnopharmacology - genetic influence, effect, metabolism Herbal therapies - interactions with meds Folk healers & tx approaches, e.g.., hysteria, psychosis Problems with Health Disparities - with cultural factors
Flaskerud, J. et al (2002) a review of 79 articles in the past 5 decades: Ignorance of certain groups (indigenous peoples) Inappropriate lump together ie. Hispanic members of disparate groups with their own cultural identity eg., Prerto Ricans, Mexicans, Cubans, Dominicans Aday's 2010 Priorities Showcase Needs within vulnerable population High-risk mothers & infants-of-concern Chronically ill & disabled Persons living with HIV/AIDS Mentally ill & disabled Alcohol & other substance abuses Suicide- or homicide-prone behavior Abusive families Homeless persons, Immigrants/refugees Impact of Cultural Competency More successful patient education Increases in pt's health care seeking behavior More appropriate testing and screening Fewer diagnostic errors. Avoidance of drug complications Greater adherence to medical advice Expanded choices and access to high-quality clinicians. Implications for Mental Health Care... It fosters clinician's sensitivity towards patients/clients judgment of normality vs. abnormality It enriches psychiatric knowledge. It enhances diagnosis and treatment. Culture Bound Syndromes
Anorexia Nervosa Bulimia Explanation
Preoccupied body wt. & image Binge eating followed by vomiting Insufficient blood or weakness of blood African American Low blood High blood Thin blood Blood that is too rich
Susceptibility to illness Culture Bound Syndromes Cont.
Food clings stomach & intestines: pain Stranger's attention causes illness in children Anxiety, phobias Mal ojo "evil eye" Susto Ethics Character, manners, moral, doing good Knowledge & value; reasoning Theories Altruism love others over oneself Egoism individual first Hedonism pleasure over all other values Rational paternalisms Relativism & subjectivism each culture &/or individual decides what is right or wrong Basic Theories Utilitarianism goal-based
the greatest happiness for the greatest number Deontology duty based, love-based Autonomy human right; self-determination Beneficence do good Justice - fairness Non-maleficence do no harm Veracity telling the truth Fidelity - keeping promise Comparison of 2 major theories
Utilitarian Deontology Consequences Who is the majority What is happiness Action & motives Value knowledge Ethical theory & scientific theory Justify human action Acceptance of theory Action Explain phenomenon True or false Predict, control Related to Culture Language communication Value decision maker Knowledge bill of rights Culturally competent care Cultural awareness Cultural knowledge Cultural skills Cultural encounter Cultural desire Roles of the nurse Nurse Practice Act defines the scope and limit of nursing practice Nurse's fundamental responsibility- value, concern, goals Ethics of caring (everyday ethics) respect, empathy, nurturing, commitment, being an advocate Participation of the family in decision making social assessment Alternative & complementary therapy Definition : healthcare practice not considered conventional by Western medicine. Background Evolution Significance < disclose their use of alternative therapies Side effect of alternative therapies Cultural competent nursing Introduction Alternative Therapies Long history Varieties Complementary Therapies Strength Body-mind-spiritual needs; holistic principles Weakness Physiological functioning Interaction with prescribed medication Counter interaction of alt. th Use of SSRIs with ST. John's wort -> serotonin syndrome Licorice with hypertension drugs Echinacea with Lupus Kava kava with liver failure Literature Review Who is using alternative therapies Trends of using alternative therapies Reasons for using alternative therapies Selections for alternative therapies Hidden problems in using alternative therapies Challenges for care providers Classification of Alt. Th Alternative systems of medical practice Traditional Chinese medicine; acupuncture, ayurveda, naturopathy, homeopahty Mind-body intervention Meditation, imagery, music therapy, spiritual healing & prayer Biologically based therapies Herbal therapies, aromatherapy Manipulative & body-based methods T'ai Chi, yoga, massage, chiropractice Energy therapies Reoolo, healing tough and therapeutic touch Roles of the nurse Respect the clients' decision based on their health belief Review various modalities, and ask the client which he/she thinks will help. Collaboration among interdisciplinary team members Have a nice weekend ...
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