Critical Evaluation of Integrated Care - Essay Example

Integrated Care: Critical Evaluation of a Case Scenario Case scenario 40 year old Y not mentioned for confidentiality reasons) was admitted to the mental health department with auditory hallucinations, false beliefs, emotional flatness and social withdrawal. Y was brought to the hospital by his wife X (name not mentioned for confidentiality reasons) who said that Y suffered from schizophrenia and was on treatment for the same. But since his behavior was uncontrollable, she contacted the psychiatrist who advised her to get him admitted. X was married to Y 15 years ago. According to X, Y appeared healthy at the time of marriage although he used to consume alcohol almost everyday. After a few months X noticed changes in Ys behavior. Y would talk aloud as if there was some one else in the room, even when there was no one around. He constantly kept telling X that the other person was plotting to kill him and hence he gave him a severe warning. Y also had many false beliefs. Over a period of time, X noticed that though these symptoms were not there for some days and then they reappeared in a severe form. X also complained that Y stopped attending social functions and preferred to either stay alone or only mingle with his friends who give him company while consuming alcohol. Gradually, the symptoms worsened and on one day, she noticed that Y laughed when X got hurt badly. 5 years after marriage, X managed to convince Y to meet a psychiatrist. Though he was started on some medication, Y did not take the tablets properly and did not return for proper follow ups. X also mentioned that Y kept complaining of abdominal pain for about a month prior to admission. He had lost weight and actually looked ill and tired. X and Y do not have children. At the time of admission, Y complained of headache and inability to sleep properly. He also complained of nausea. He had consumed alcohol about 18 hours prior to admission. Physical examination of Y revealed pallor, but no icterus. His blood pressures and pulses were within normal limits. He appeared restless and disinterested in the surroundings. Examination of the abdomen revealed tenderness in the epigastric and right hypochondriac region. Respiratory and cardiovascular examinations were unremarkable. He had mild tremors. Rest of the neurology evaluation was normal. A diagnosis of schizophrenia with alcohol abuse was made. Integrated care in the hospital Since Y suffered from multiple problems, an integrated care approach was used to treat him. The integrated care was delivered by a multidisciplinary team which included psychiatrist, physician, mental health nurse, psychotherapist, social worker, vocational counselor, dietician and family and friends. Role of psychiatrist The patient was first seen by a psychiatrist who took an elaborate history and evaluated the previous medications. He then asked the physician to see the patient. The psychiatrist started the patient on fluphenazine hydrochloride (prolixin) after discussing with the patient and his wife about the benefits and the side effects of the drug. The patient was asked to take the tablets 5 mg twice a day. The patient was started on single drug therapy as per NICE guidelines (2002). Rapid tranquilization was considered inappropriate for this patient. The psychiatrist monitored the therapeutic progress of the patient and also evaluated the tolerability of the drug at every stage of follow up. Patient education is very important in psychotic diseases. The psychiatrist spent some time with patient and his wife educating about the disease and the importance of medication compliance. He also stressed on the need for abstinence from alcohol. Role of physician After review of the patient by the psychiatrist, a physician was asked to see Mr. Y. On the first day of admission, the physician examined the patient in detail and asked for a few tests. The tests included complete blood picture, serum electrolytes, liver function tests, serum creatinine, blood urea nitrogen and abdominal ultrasound. Complete blood picture revealed iron deficiency anemia. Ultrasound abdomen was suggestive of fatty liver. Other tests were within normal limits. The physician made a diagnosis of acute gastritis with iron deficiency anemia and fatty hepatitis. He started the patient on acid suppression drugs and iron and multivitamin supplements. The physician explained to him that his alcohol consumption had affected the liver already. He opined that the effects could be reversed if the patient stopped alcohol consumption immediately. He recommended alcohol rehabilitation programme. Role of social worker A social worker was involved in the management of Mr. Y. Schizophrenia affects not only the patient but also the whole family. Other family members and close friends need to be informed about the condition of the patient and how to behave with the patient. Close family members will be upset with the condition of the patient and they need psychological support (NICE guidelines, 2002). In this case, the wife of the patient suffered the brunt of the psychological condition of her husband. The social worker offered her some psychological support and explained to her how to handle the situation. The social worker also enquired about the employment status and finances of the patient. In case of Mr. Y. his wife was employed and took care of day-to-day expenses. She however mentioned that it was difficult for her to pay up for the cost of the treatment. The social worker then contacted a social organization who partly paid for the treatment of Mr.Y. Role of Vocational counselor Since Mr.Y was graduated and showed interest in returning to employment, the social worker put him on a vocational rehabilitation program. The program was meant to increase global functioning and also improve quality of life. Many patient suffering from schizophrenia do not live with their families demanding them to have skills for independent living. For such patients housing is also a problem (Frances, 2007). Mr.Y is indeed lucky to have a supporting wife. Role of Dietician Although there is no special diet to be taken by a schizophrenic, a dietician was asked to see the patient to advise on health eating. This is important for over-all well being of the patient. Also, since Y suffered from iron deficiency anemia, the dietician advised diet appropriate for Mr. Y. Another important aspect to be noted at this point is, many antipsychotic medications are associated with weight gain and also changes in lipid and glucose metabolism (Frances, 2007). In such situations, nutrition counseling helps. Excess alcohol consumption also results in poor diet and nutrition which needs to be corrected. Role of psychotherapist Psychotherapy has no role in schizophrenia. However, Mr. X was referred to a psychotherapist as a part of alcohol deaddiction programme. During psychotherapy, the therapist confronted denial gradually in the patient. This is because, early and aggressive confrontation in alcoholics increases rather than decreasing the denial of having the problem (PsychCentral, 2006). Hence the initial role of the therapist is to get the patient to agree for detoxification. Mr. Y however did not need detoxification. The psychotherapist concentrated on drinking itself. He emphasized firmly on the present, past and future consequences of alcohol intake. When Mr.Y asserted that he had some emotional problems which need to be solved before giving up alcohol, the therapist firmly told him that other emotional problems can be addressed only after stopping alcohol. Role of mental health nurse in integrated care Nurses play a major role in the assessment and treatment of mental health patients. Nurses, by virtue of their proximity to the patients develop a sense of empathy and caring feeling which comes naturally to them and thus are able to promote the emotional well being of the patient. Mental health nurses work with people suffering from various types of mental illnesses. Their role includes caring for these patients, assessing the problems of the patients, providing reassurance, building relationship to encourage trust, listening to patients and interpreting their needs, monitoring the route and dosage of drug intake, determining the response to treatment, preparing and maintaining records, assessing risk responding to a distressed patient appropriately in an unthreatening manner, participating in group and one-to-one therapy sessions, encouraging patients to take part in recreative and rehabilitative measures, organizing social events aimed at developing patients social skills and coordination with other organizations like legal services and police (Mental Health Nurse, Prospects). Besides the knowledge of the mental diseases and treatments, to pursue their functions efficiently, it is important for the mental health nurses to understand the various factors which influence mental health of people. I think as a mental health nurse, I have done a good job of coordinating care from various health sectors for this particular case. I have also played an important role in encouraging the patient to undergo proper treatment. I have provided good support to his wife and have elicited proper history because of which proper care followed. Role of family and friends Family and friends are good allies to treatment. These people also know about relapses which can be concealed by the patient. Research has shown that those patient who are coerced and encouraged by family and friends into treatment are likely to continue the treatment and infact have a better outcome than those who are not pressurized (PsychCentral, 2006). Alcohol rehabilitation programme was started on the 3rd day. The patient was discharged on the 5th day. He continued to attend the rehabilitation program for about a month. He also regularly visited the psychiatrist and the physician and his wife made sure he took the medications on time. Before initiating the deaddiction program and medications, patients consent was taken in writing. It is now 6 months since he got admitted to our establishment. Y is doing well and is still on medications. He does not consume alcohol. However, we have recommended him to meet the alcohol rehabilitation manager once in every 6 months to prevent relapse of addiction. Discussion 40 year old Y had classical symptoms of schizophrenia. Schizophrenia is also known as insanity or madness. It is a chronic psychotic disorder which affects perception, thinking and behavior. It is the most severe end of a spectrum of schizophrenia-related disorders. The process of this disease is actually not well understood. The disease can be mild or severe and, stable or gradually deteriorating. The hallmark symptom is auditory hallucination, wherein the patients hear voices which others dont hear. Mr. Y has this symptom. The symptoms of schizophrenia can be divided into 3 categories namely, positive symptoms, negative symptoms and cognitive symptoms (Duckworth, 2007). Positive symptoms are those which have lost touch with reality. They are actually pathological excesses of emotion, thought and behavior (Comer, 2007). They include hallucinations, delusions, heightened perceptions and disorganized thinking and speech. Hallucinations are perceptions in the absence of a stimulus. When the person hears or sees things that are not present, they are known as hallucinations. Hallucinations can be visual, auditory, olfactory, tactile, proprioceptive and thermoceptive. Delusions are pathological fixed false beliefs. When the person believes that other people (who actually exist) are reading his thoughts and plotting against him, the person is said to suffer from delusions. Heightened perception is said to be present when the person feels that his senses are flooded with all the sights and sounds that surround him. Disorganized thinking and speech is said to be present when the person can not think logically and speaks peculiarly. Loose associations, perseveration and neologisms are all manifestations of disorganized thinking and speech (Comer, 2007). Negative symptoms are actually pathological deficits of emotion, thought and behavior. They include poverty of speech or alogia, emotional flatness or lack of expression, loss of volition, anhedonia and social withdrawal. A person is said to have alogia when his speech is brief and devoid of content. In other words, the person talks little and means little or he talks more and still means little. Symptom manifestations of blunt effect include showing less anger, sadness, joy and other feelings than most people. When the person shows no emotions at all, it is known as flat affect. Anhedonia means general lack of pleasure or enjoyment. Avolition means marked apathy or inability to start or complete a course of action (Comer, 2007). Cognitive symptoms include disorganized thoughts, difficulty concentrating and/or following instructions, difficulty completing tasks, memory problems (Comer, 2007). To arrive at a diagnosis of schizophrenia according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), the symptoms must last atleast for 6 months, with atleast one month of active symptoms and there must be significant impairment of social and occupational functioning (Frankenburg, 2007). Mr. Y had symptoms intermittently for more than 10 years. These symptoms had affected his social and family life. The first line of treatment for schizophrenia is antipsychotic drugs like include clozapine, risperidone, haloperidol and fluphenazine decanoate. These drugs diminish positive symptoms and prevent relapses. However, they are associated with many side effects like include akathisia, dystonia, hyperprolactinemia, parkinsonism, tardive dyskinesia and neuroleptic malignant syndrome. Clozapine is associated with agranulocytosis. Anticholinergic agents are frequently used with antipsychotics to prevent dystonic or extrapyramidal symptoms. Other drugs which may be useful are antidepressants, mood stabilizers and anxiolytics (Frankenburg, 2007). Mr. Y was initially started on risperidone but he did the take the medication regularly. After admission the hospital, the psychiatrist changed the medication to fluphenazine. Associated problems Mr. Y also was addicted to alcohol. He developed fatty liver due to this. Excessive alcohol (ethanol) consumption induces pathological changes in the liver which include alcoholic fatty liver, alcoholic hepatitis, and alcohol-related cirrhosis (Ismail, 2006). Fatty liver is characterized by marked increase in the fat cells in the liver. In alcoholic hepatitis, there is inflammation of the liver. In alcoholic cirrhosis, there is replacement of normal liver tissue with scar tissue. Fatty liver and alcoholic hepatitis are reversible conditions while cirrhosis of the liver is not reversible. At the time of admission to the mental health hospital, Y had some withdrawal symptoms and signs. Persons who are physically dependent on alcohol develop certain withdrawal symptoms when they stop or decrease consumption. These symptoms usually commence 6 to 24 hours after the last drink. They may last for about 5 days. The symptoms include head ache, nausea and vomiting, tremors, anxiety and depression, sweating and difficulty in sleeping. Sleeping disorder may last for several weeks When a person has both mental illness and substance abuse, it is known as dual diagnosis. Dual diagnosis is common and it is important to treat both the conditions to get the best results. Dual diagnosis services for clients with severe mental illness are emerging as an evidence-based practice (Drake, 2001). Offering dual diagnosis services is a relatively new concept (Drake, 2001). Until now, the services provided for substance abuse and mental illness were located in different places because of which the patient would be bounced back and forth between services or would be refused treatment by each of them (Hatfield, 1993) resulting in fragmented and ineffective care. The need for dual diagnosis services arises because of the high prevalence and the negative outcomes associated with the problem. In a study by Swofford and others (1996), they reported that schizophrenics with substance abuse were much younger, had significantly higher severity of illness scores, and had nearly twice as many hospitalizations and 4 times as many relapses when compared to those with only schizophrenia. Drake and others (2001) have mentioned in their study that there is increased incidence of negative outcomes, incarceration, violence, homelessness and serious infections such as HIV and hepatitis in those with dual diagnosis and that clinicians, administrators, researchers, family organizations, and clients themselves have been calling for the integration of mental health and substance abuse services for at least 15 years. These patients also have increased psychotic symptoms, poorer treatment compliance, housing instability and homelessness, poor money management, and greater use of crisis-oriented services that result in higher costs of care (Dixon, 1999). Substance abuse is also associated with low levels of satisfaction with family relationships among persons with severe mental illness (Dixon, 1995). Many studies have reported the benefits of dual diagnosis integrated services. Drake and colleagues (2006), studied 10 year recovery outcomes for clients with dual diagnosis and opined that there was hopeful long term perspective for these clients once they received dual diagnosis services. They reported that 62.7% were controlling symptoms of schizophrenia; 62.5% were actively attaining remissions from substance abuse; 56.8% were in independent living situations; 41.4% were competitively employed; 48.9% had regular social contacts with non–substance abusers; and 58.3% expressed overall life satisfaction. Treatment for those with dual diagnosis are generally added to community support programs within the mental health system because in most states, the publicly financed mental health system bears responsibility for providing treatment and support services for individuals with severe mental illness (Drake, 2001). Treatment involves integration of mental health services and substance abuse interventions. It means that the same clinicians provide appropriate mental health and substance abuse interventions in a coordinated fashion while working in one setting (Drake, 2001). The goal of treatment of dual diagnosis is recovery from two serious illnesses, the substance abuse and mental illness. In a study by Minkoff (1989), dual diagnosis patients were viewed as having two primary, chronic, biologic mental illnesses, each requiring specific treatment to stabilize acute symptoms and engage the patient in a recovery process. From the past studies, it is evident that these services need to incorporate outreach and motivational interventions with long-term rehabilitation (Drake, 2001). There have been various intervention models to provide services for those with dual diagnosis. These include staged interventions, behavioral skills training, intensive care management (Jerrel, 1995), individual-based cognitive–behavioural therapy (CBT) combined with a family intervention programme (Haddock, 2003), motivational intervention (Drake, 2001), social support intervention (Drake, 1998) and comprehensive management or psychosocial approach (Drake 2000). Which is the best model to deal with these clients is still under research. An ideal model would be that which produces positive outcomes, including substantial rates of stable remission of substance abuse (Drake, 1993), low cost (Clark, 2003) and helps the client lead a satisfying and fruitful life. Staged interventions involve delivering treatment in a staged manner (Jerrel, 1995). The client is first taken in to trust, is then motivated and then persuaded to gain recovery. Jerrel and colleagues (1995) developed a 12 stage intervention. In the process, the client is helped to acquire skills and supports for controlling illnesses and pursuing goals. Also, relapse prevention is aimed at. Through intensive care management (Jerrel, 1995), assertive outreach is aimed at. This may also involve meeting the client at home, providing him with daily needs and building a trustful relationship. This way, access to services is gained. Motivation helps those especially who are demoralized, symptomatic and confused (Drake, 2001). This method helps an individual identify his goals. Comprehensive approach is necessary to make the individual lead a symptom free and fruitful life. To achieve this, friends, activities and stress management must be included. Sometimes, it may be necessary to manage the finances and day-to-day needs of the client including housing and vocational rehabilitation. Another fundamental component of dual diagnosis services is counseling. This helps develop positive coping patterns, as well as promotes cognitive and behavioral skills (Drake, 2001). Counseling can be in the form of individual, group, or family therapy or a combination of these. The integrated services must also consider elements of cultural sensitivity (Drake, 2001). Cultural considerations will benefit certain sensitive groups like African-Americans and Hispanics. Also, adequate competence will benefit those who are homeless and women with children. In these cases, services must be tailored to their particular racial and cultural needs (Drake, 2001). In a study by Jerrell and Ridgely (1995), they reported that clients in the behavioral skills group demonstrated the most positive and significant differences in psychosocial functioning and symptomatology, compared with the Twelve Step recovery approach. Even the case management intervention resulted in several positive and important differences compared with the Twelve Step recovery approach. Haddock and colleagues (2003) studied the benefits of individual-based cognitive–behavioral therapy (CBT) combined with a family intervention programme. They reported that though the change in substance use was not that remarkable, patients who underwent this form of therapy had general improvement in their PANSS and GAF scores. There was definite reduction in harm even though they continued to use alcohol or other drugs. However, Clark and Mueser (2003) analyzed that this form of therapy was not cost effective when compared to other forms of treatment. Legal and ethical considerations and consent When political correctness demands that we embrace change with enthusiasm there is a strongly held view that nursing, along with many other professions, struggles with a theory gap practice (Rolfe et al, 2001). The nurse has a duty to promote what is best for the patient, ensure that the patients needs are met and protect the patients rights (Nettina, 2006). Each country or state has its own rules and regulations as far as legal considerations in the provision of care for the elderly is concerned. The nurse must be aware of these and implement them in their daily practice. The resident has the right to be from any physical restraint imposed or psychoactive drug administered. Other legal issues which need to be kept in mind and followed are accountability, confidentiality, and informed consent (Nettina, 2006). The nurse has to take responsibilities for actions taken and omissions. The nurse must exhibit professionalism without any deficiencies. The nurse must maintain familiarity of hospital policies, procedures and regulations. She should work with a local nursing organisation to make certain that local standards of practice are met. She should welcome and deliver honest constructive criticism. The Hippocratic Oath stresses on the privacy of the patient and the nurse must take all measures to protect this. She should have respect for her patients privacy and divulgence of information from medical records must be done as per hospital protocols like medical authorization and consent form. Whenever possible, confidentiality aspects must be discussed with the patient or his legal representative. The relationship between health professionals and patients is governed by the doctrine of informed consent. It relates to the right to accept or reject treatment by a health professional. Informed consent is a must in surgical or medical procedures. The informed consent should be obtained in the presence of a witness. In case of Mr. Y, informed consent was taken before administration of anti-psychotic drug and starting of alcohol deaddiction program. Confidentiality was maintained through out the course of treatment. Conclusion The case that was discussed in this assignment is a good example of Integrated Care. Many mental health patients suffer from other problems and treating all the problems under one roof benefits the patient and helps in faster recovery at lesser cost. The care provided to Mr. Y was appropriate and time-effective. Care was provided by physician, psychiatrist, deaddiction program manager, mental health nurse, diagnostic services and also friends and relatives. The success of care is evident from the health perspectives of the patient at the 6 month-follow up review. References Clark, R.E, & Mueser, K.T. (2003). Progress in research on dual disorders. The British Journal of Psychiatry, 183. Retrieved April 13th 2009 from http://bjp.rcpsych.org/cgi/content/full/183/5/377 Comer, R.J. (2007). Abnormal Psychology. (6th ed.). New York: Worth Publishers. Dixon, L. (1999). Dual diagnosis of substance abuse in schizophrenia: prevalence and impact on outcomes. Schizophrenia Research, 35 (1) S93-S100. Dixon, L., Mc Nary, S. & Lehman, A. (1995). 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Substance use: a powerful predictor of relapse in schizophrenia. Schizophrenia Research, 20, 145-151. Read More