Community-based Day Treatment Centers - Dissertation Example

? BUSINESS PLAN FOR A WELLNESS AND RECOVERY CENTER FOR DE ALIZED INDIVIDUALS CHAPTER TWO REVIEW OF LITERATURE BY AUDRY GREEN GORMAN DOCTOR OF NURSING PRACTICE CLINICAL PROJECT CHAPTER 2 Review of Literature As long-time residents of a mental institution, being deinstitutionalized to go back to community living may be unnerving especially for the adults with serious mental illness. Their context needs to be understood in order to plan an appropriate support program for them when they join the rest of mankind upon their deinstitutionalization. Community-based Day Treatment Centers When deinstitutionalized mental patients are discharged from mental health instituions, they would need to maintain the treatments and services that they have been receiving previously. Adult Day Treatment Programs in community health care centers may offer such interventions. McQueeney (1996) investigated the effects of hospitalization as opposed to day treatment programs and found that staying in mental health hospitals for a prolonged period of time promoted dependent behaviors and decreased functionality of the patients. On the contrary, day treatment programs not only exposed patients to community life but also enabled patients such as those with schizophrenia and active psychosis to productively participate in the interventions, become more independent and achieve community living skills. The medical model of adult day health care offers skilled therapeutic services from nurses, therapists, social workers, psychologists, psychiatrists, geriatric physicians and others (National Care Planning Council, 2012). For nurse-led community-based health centers, psychiatric evaluations, medication management, monitoring for side effects, medication education, and symptom management training are provided by the nurse practitioner and done on each patient in conjunction with the consulting psychiatrist and with assistance by the nursing staff. Adult day care providers with this kind of model are assisted by the Medicaid system by receiving payments for services under special Medicaid programs or under Medicaid waiver programs for home care. Such services intend to rehabilitate patients towards recovery while ensuring their health and wellness. Adult day care keeps patients active and engaged while they learn skills for reintegration into the community setting (National Care Planning Council, 2012). Studies have shown that community-based health centers catering to the mentally ill have been effective in reducing re-hospitalization rates and success in employment especially when the patients participate in multifamily group treatments (McFarlane et al., 1996). Similar findings came out of a study by Kuipers (1996) indicating that day treatment interventions were effective in helping schizophrenics manage and reduce their overall symptoms most especially when treatments are combined with family therapy. Nursing Care Nursing care at the community level has shown much positive outcomes for patients with mental illness, providing them with a better quality of life. Community nurses are adept in identifying changes in the behavior or symptoms of patients and in implementing strategies involving “screening, assistance with medications, monitoring for changes over time, referral and, perhaps, psychotherapies like counselling” (Thomson et al., 2008, p. 1420). Most of the time, only qualified mental health professionals like psychologists, psychiatrists, or even mental health nurses can conduct mental health assessment. However, community nurses may screen for the possibility of mental illness to be referred to qualified assessors. Flaskerud (2010) reports that the Josiah Macy, Jr. Foundation, a physicians group, encourages expanded roles for Nurse Practitioners. One evidence of this is their recommendation to remove legal and reimbursement barriers that prevent nurse practitioners from delivering primary care service and to include them in multidisciplinary teams of primary care providers (Josiah Macy Foundation, 2010). Indeed, the growing scope of nurses’ duties and responsibilities is corresponding to the breadth and depth of knowledge and skills that they are gaining over the years. With regards to training related to mental health, 62% of the administrators of community mental health centers in the study of Dakin & Quijano (2011) reported that their facilities provide resident mental health-related training for their staff. Topics for the trainings include general information on mental health/ mental illness, dealing with difficult behaviors of the mentally ill, depression, bipolar disorder, personality disorders and anxiety, Alzheimer’s disease, dementia. Direct care staff members reported they received mental health training through their employment in nursing homes or assisted living facilities, mental health education in a college or university or other professional development venues such as Certified Nursing Assistant (CNA) training (Dakin & Quijano, 2011). No matter what credentials direct care staff hold, it has been established in Dakin & Quijano’s (2011) study that training in dealing with patients with mental illness is crucial especially in the areas of managing difficult behaviors, understanding various mental illnesses, conflict resolution with residents with mental health issues and redirecting them to other more productive activities. Quality of life of residents should be prioritized whether or not he suffers from mental illness and this should be ensured by direct care staff. Health Care Provision Wade (2009) advocates holistic health care and proposed a system to guide community health care clinics in the management of their cases. It is to set goals for the patients that are customized to their needs. Proper evaluation will determine the appropriate services to be provided and the necessary support from other agencies. Wade (2009) concludes that taking on a holistic approach in patient care would likely lead to clinical decisions that are more appropriate for the patient taking into account all factors relevant to his case. Treatments become more patient-centered, considering the individual’s own perspective. Also, should referrals to other supports and services be necessary, the thorough evaluation of the case would provide enough information and justification for the support. Wade (2009) also contends that being ill, whether in body or mind, is a social phenomenon, so the patient’s personal and social context greatly influences his behavior. This implies that health care practitioners need to know each patient’s context. Community clinics and other health care services need to work closely with other organizations that are responsible for more general social policies like employment or housing. Adult Day Treatment Program for Individuals with Persistent and Severe Mental Illness. Day Treatment Programs provide mental health services through a multidisciplinary approach for individuals in need of psychiatric care. These patients need less than inpatient services to maintain or enhance current levels but more services than provided in traditional outpatient settings. Patients benefit from the structure of a daily program, symptom management, self-esteem and skill development. Day Treatment programs offer various services. One example was studied by Husted and Wentler (2000) who described the following program to be effective for their patients: Patients come to the Day Treatment Center thrice a week for three hours. Mental health practitioners or licensed psychologists conduct group therapy, and the curriculum emphasizes development and maintenance of their skills, attitudes and behaviors in order to be able to live independently. Basic skills include hygiene, management of their medication, readiness for work, advanced social skills, decision-making, management of stress and budgeting (Husted and Wentler, 2000). These treatment sessions raised the patients’ self-esteem considering they have been institutionalized for a certain period and may have affected their own self-confidence to rejoin the community as functioning individuals. The empowerment approach helps individuals make healthy choices by increasing their control over their physical, social and internal environments. According to Homans and Aggleton (1988), participatory learning techniques help people examine their own values and beliefs and explore the extent to which factors such as past socialization as well as social location affect the choices they make. Participatory learning techniques include group work, problem-solving techniques, patient-centered counseling, assertiveness training and social skills training as well as educational drama. The self-empowerment paradigm, with its emphasis upon self-awareness and skills, echoes what Stroebe and Stroebe (1995) refer to as the ‘therapy model’ of health promotion which uses a wide range of psychological techniques such as cognitive restructuring, skill training and self-conditioning in order to help individuals act upon their intentions to adopt health behaviours. In the provision of interventions in day treatment clinics, it is essential that the practitioners apply into practice theories that would help them reintegrate into the community. Social Cognitive Theory (SCT) proposes that people’s actions are informed by their perceptions of social reality and that behavioural intentions will change with changes in social cognitions, which include beliefs, attitudes, self-efficacy and perceptions of social norms (Willig, 1999). Hence, with mentally ill patients, their perceptions of social reality may be distorted and these may be corrected with various therapeutic techniques. 1. Group Therapy Establishing a support group for a certain issue of concern would be highly beneficial to the treatment of the patients. Patients attend a variety of psycho-educational, psychodynamic, activity, and skill building groups to build coping skills, daily living skills, and develop readiness for rehabilitation activities, or to resume their previous level of functioning Group therapy fulfills certain needs that can only be met by therapeutic factors such as universality, identification, catharsis, altruism, imparting information, corrective recapitulation of the primary family group, interpersonal learning and development of socializing techniques (Yalom and Leszcz, 2005). It also offers opportunities to break social isolation, develop assertiveness skills and vicarious learning from others. However, if the group has more than ten participants, it could be intimidating for the patients to speak up. Facilitators of the group therapy may tend to just skim through the topics and issues to avoid the uncomfortable silence brought about by the hesitancy of the participants to speak up. Larivie`re et al. (2010) reported that with group therapy, it is recommended that common problems and situations be combined rather than to focus on each person individually. In doing so, there is greater reflection on a greater and wider variety of issues. It was also suggested that the facilitator observe just one group activity per week and then to offer their input for each participant in their individual sessions. Group therapy may also include therapeutic activities which had themes that are well-connected to the needs of the patients. Some of these activities are projected activities, role-playing, psycho-education, reading, homework, relaxation, weekly goal, physical activities, outings, games and cooking (Larivie`re et al., 2010). Patients in Larivie`re et al’s.(2010) study found that projective activities were very revealing, surprising and enjoyable and provided an avenue to externalize their feelings and problems. They also found the psycho-education, reading and role-playing strategies were useful in gaining insight into themselves and possible causes of their issues. The patients were made to work towards their goals for each week to give them a sense of direction and motivation. They also had group relaxation techniques that soothed their emotional and mental stress. The participants in the study appreciated the variety of themes and modalities brought into the group therapy and they expressed that such variety allowed them to work on different aspects of themselves as well as kept the therapy stimulating for them to give their full attention to (Larivie`re et al, 2010). Solution-Focused Brief Therapy (SFBT) is one practical therapeutic psychological strategy which will likely work with a group of patients with mental disorders. SFBT does not emphasize the need to understand the original cause of the problem in order to solve it. More time is spent in focusing on the present and future circumstances rather than the past, and on the patients’ strengths and resources rather than the problem. Such discussions provide the advantage of helping the therapist form better rapport with the patient which otherwise may be difficult to establish considering the problematic situation. (Smith, 2005). Giving the patients control as to the brevity of the treatment is likewise effective, as most aim to get better sooner than later so they are motivated to be cooperative with the therapists’ strategies. 2. Individual Treatment Individual sessions are available according to the patient's needs. Treatment and discharge planning is developed by the patient and their therapist. The advantage of individual sessions is that it allows for a longer and more personalized time to go in-depth with the patient’s concerns and illness, leading to self-disclosure. This is especially crucial with individuals with personal issues that affect their mental health so that they can deal with the root cause of their illness. Some patients prefer to discuss more personal topics in private and not brought up during group therapy sessions (Larivie`re, 2010). Some individual therapeutic interventions include psychotherapy and holistic treatment. A. Psychological therapies In line with the Health Belief Model, which proposes that health behaviour is determined by one’s personal beliefs or perceptions, it is important to help mentally ill patients to correct whatever erratic perceptions they have that may hinder them from full recovery and reintegration into the community. One kind of psychotherapy which directly addresses this is Cognitive Behavior Therapy. The basic premise of Cognitive Behavior Therapy is the patient’s erratic or exaggerated beliefs that it is their fault why they came to such a dreadful state. The goal of therapy is to help the patient realize that reorganizing the way they view situations will call for a corresponding reorganization in behavior (Corey, 2005) – sort of marrying the concepts of “mind over matter” and “self-fulfilling prophecy”. The therapist uses a variety of therapeutic strategies depending on what he decides will work on his particular patient. He also delegates responsibility to his patient by expecting him to do homework outside the therapy sessions. Homework is aimed at positive behavior that brings about emotional and attitudinal change. Donald Meichenbaum’s Cognitive Behavior Modification. It features patient’s self-verbalizations that involve a heightened sensitivity to his thoughts, feelings, actions, physiological reactions and ways of reacting to others (Corey, 2005). The patient is also taught more effective coping skills practiced in real-life situations. He may be considered his own coach because his self-talk reminds him of how he should restructure his thinking and behavior. Meichenbaum also puts emphasis on stress management which can be very helpful to patients when faced with stressful situations not unlike those that caused their flawed thinking (Corey, 2005). Another kind of psychotherapy is the Psychoanalytic or Psychodynamic approach. The goals of Psychodynamic therapy are settling unresolved conflicts in a person’s past that deeply affect his current patterns of behavior and personality. It may involve bringing repressed painful memories to resurface to be dealt with consciously through the techniques of free association, dream analysis, hypnosis, transference, and analysis of resistance handled by a skilled psychoanalyst (Corey, 2005). This tedious process intends for the patient to reach a level of self-understanding for him to be able to move on with his life without the heavy emotional baggage he has been carrying all his life. This understanding is necessary for an eventual change in views, personality and character. Person-centered therapy stems from the theories of Carl Rogers, a noted psychologist who espoused humanistic views in therapy. This approach has great respect for a patient’s subjective views and potential for self-actualization. It offers a fresh and hopeful perspective on its views on human nature. Being congruent means being real and authentic – no discrepancy between one’s perceptions and one’s being. A therapist needs to be congruent himself before he can decipher incongruence in his patients. His wisdom enables him to spot patients whose ideal self-concept is far from the truth, (i.e. the mistaken perception of one’s greatness in a skill when in reality, he is very poor at it). His goals include helping his patients have an openness to experience, a trust in themselves, an internal source of evaluation and a willingness to continue growing (Corey, 2005). B. Holistic Interventions Being mainstreamed into the community after a period of institutionalization, patients in a community day treatment center should be supported not only of their mental health but their over-all health and recovery. A good health promotion program to implement in such environment is Ewles & Simnett’s (2005) Holistic health care approach. It takes into account all dimensions of a person’s development. This program addresses the physical or how the body functions; mental or how the person thinks and makes judgments; social or how one maintains relationships; emotional or how a person manages his emotions and how he expresses it appropriately; spiritual or a person’s religious and personal beliefs, principles and ways of being at peace with oneself; sexual or the acceptance of and ability to achieve a satisfactory expression of one’s sexuality; societal or how a person relates to his society in terms of shelter, peace, food, income and his own contribution to society and finally, environmental or his physical environment which includes his housing, transport, sanitation, availability of clean water, pollution control. (Ewles & Simnett, 2004) In order to address all these needs, collaborative care among other agencies should be done to ensure that the patient gets everything necessary for him to live independently in the community hopefully without the stigmatization most mentally ill patients get. 3. Family/Couples Therapy Mentally ill patients who have been discharged from mental health facilities and avail of services of community-based clinics need to reconnect with their loved ones. Gehart (2012) contends that what is central to their recovery are the human connections and social inclusion. These may involve partners, family, peers, friends, pets, social service workers, professionals and/or support groups (Repper & Perkins, 2006). Part of the recovery is rebuilding or strengthening relationships that may have been affected by the mental illness or institutionalization of the individual, increasing the intimacy shared and the social support given. These are goals of family therapy. McFarlane’s (2004) evidence-based multifamily psychoeducational groups for families with a member with severe mental illness, a Cognitive-behavioral family therapy approach. This has significantly reduced relapses while the patient recovers across a wide range of functioning without psychiatric symptoms, employment, social skills, medical health and over-all well-being. This multifamily psychoeducation approach was found to be more effective than educating individual families (McFarlane, Dixon, Lukens, & Lucksted, 2003). 4. Supportive Employment Still following the Holistic health philosophy, some community based treatment and recovery centers provide clerical skills enhancement training and job placement assistance for individuals with psychiatric, physical, developmental, or substance abuse disabilities, and disabled veterans. Holmes (2000) described three employment possibilities for individuals with mental disabilities namely: competitive, supported, and secured sheltered: Sheltered employment offers the adult with mental illness a degree of job security However, it has one major drawback: he may stay in the sheltered workshop indefinitely, and may never be prepared for more independent work. Secure employment offers structured work and a guaranteed job, but it also trains the adult with mental illness so he may eventually be able to work in a more independent and competitive workplace. Supported employment is ideal for adults with mental illness who has acceptable behavior and has learned the skills necessary to work in the competitive work force, yet still needs supervision to complete the job requirements. In this type of employment, adults with mental illness work alongside nondisabled adults at a real job site, doing work such as stocking store shelves, pricing merchandise, assembling products, and cleaning offices. The adults with mental illness are supported by a job coach. To look for employment, individuals with mental illness, their family members or the representatives from the community adult day treatment center must begin by contacting agencies that may be of help, such as state employment offices, mental health departments, and disability-specific organizations. They must explore special projects in the area and find out whether they are eligible to participate in these programs. It is also important to find employers who are willing to work with people with mental illness (Autism Society of America, 2003). 5. Guidance and direction are provided to patients who may need assistance with obtaining housing, medical insurance coverage, and social agency referrals In line with the holistic health approach, one should also address patient’s social circumstances and opportunities. Like getting up again on their feet, they need help in accessing social services and resources to ensure that their basic needs are met such as food, housing, medical care and even legal assistance (Gehart, 2012). All these needs are put together for case management. The Americans with Disabilities Act (ADA) protects and empowers individuals with disabilities including the mentally ill to be included in society without discrimination. It states that “No qualified individual with a disability shall, by reason of such disability, be excluded from participation in or be denied the benefits of the services, programs, or activities of a public entity, or be subjected to discrimination by any such entity.” (ADA, 1990) Funding for the independent housing of mentally ill individuals would depend on the statutory regulations of each state. Some organizations, though, extend their assistance with people with disabilities and with regards to their housing. An example of a successful housing project for individuals with mental illness was the Robert Wood Johnson Foundation Program on Chronic Mental Illness (RWJF-PCMI). This organization centralized and financed mental health and related services in local mental health authorities. Their services included significant housing intervention along the organizational and financing intervention. They established a non-profit housing development corporation that was committed to the development, ownership, management of independent housing for persons with chronic mental illness (Cohen and Sommers, 1990; Newman and Ridgely, 1994). 6. Family Support A major tenet with families of adults with mental illness is that families and children can benefit from stable, comprehensive, family-centered support. Supportive relationships among the policy makers, professionals, and families can be constructive for a large number of instrumental, social, and emotional reasons, all of which can contribute to a strong, cohesive family environment, and a desirable context for behavioral growth of the adult with mental illness. Dunlap, et al (1999) also pointed out that the most effective support is provided through relationships that are based on trust, commitment, and mutual respect, all of which are qualities that require time to develop and in a supportive environment. 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