Community Health Framework and Intervention Plan - Research Proposal Example

Introduction The reach of mental health extends credibly into general social being and care. This explains the proposal of this paper, that mental health should be pursued collaboratively with primary medical health. Both of these areas are inseparable from the social health of a community and hence in important ways can shape public and influence public or social planning as a genuine intervention tool. This proposal will deal with a public policy model for intervening with older adults with mental illnesses. It will initially discuss how the federal government is dealing with this population and explain why because of the focus on costs, it is having some difficulty in promoting the concept of collaborative care. This report will review several other models and policy initiatives that promote both mental and primary care for the elderly who have mental illnesses and, accordingly, suggest a prevention model. The Federal Government OConner et al (2009) point out that federal policy will have to change to realistically begin to face the growing needs of older adults with mental illnesses. The elderly population will be growing at increasing rates over the upcoming decades. The DHHS estimates that 20% of the elderly population have mental illnesses of which 2% are seen as serious. It is a population which requires ongoing mental health services. Elderly with mental illness in general face shorter life expectancy compounded by comorbid medical illnesses and unhealthy and limiting lifestyles that are sometimes characterized by alcohol and drug abuse, poor nutrition, obesity, and cigarette smoking. These characteristics often lead to medical problems of cardiovascular disease and diabetes among others. Mental illnesses may also lie hidden underneath the combination of physical illnesses, leading to misdiagnosis and insufficient treatment regimens. The main concern of federal and state governments toward the mentally ill has been in regard to controlling costs. O’Conner et al outline the various federal programs for treating the elderly mentally ill and explain how these programs have had shortfalls usually in the more difficult area of providing consistent government funding. The authors discuss how federal and state policy struggle to provide long-term care for this population. Initially Medicaid policy did not cover institutions for mental diseases (IMDs) or nursing homes as coded by the Pre-Admission Screening and Resident Review (PASRR) stricture. Also, the Medicaid Home and Community Based Services (HCBS) further confounded housing support for the population. However, the new Patient Protection and Affordable Care Act of 2010 (ACA), recently created to reform American health, is now enabling states flexibility to create special benefit packages for specific populations. The ACA clarifies the Medicaid 1915(i) provision, the Home and Community Based Service (HCBS) state plan amendment option and importantly provides ways for the state to receive funding help in providing long term services to the elderly with mental illness. Integrated Services Models United States Marion et al discuss a model of integrating primary and mental health care to enable specific targeting of patients with severe and persistent mental illnesses (SPMI). Their project is an example of public policy planning that could represent coordination of services between a private agency that is federally qualified and an academic nursing school. People with SPMI are at a disadvantage of receiving only episodic and fragmented treatment. SPMI are sometimes typified as succumbing to comorbid conditions where physical illnesses are complicated by psychotropic medications. Substance abuse complicate and raise the risks of such individuals who many times live in impoverish conditions that may involve violent incidents, unprotected sex and poor nutrition. Medical care is not consistent but mainly provided by emergency care centers. One intervention scheme that may involve a measure of hope is social planning coordination between a school of nursing and a federally funded private center as exemplified by the community psychiatric rehabilitation center Thresholds, in partnership with the College of Nursing at the University of Illinois at Chicago (UNIC) (Braun et al, p. 71). Addressed as the Center for Integrated Health Care (IHC), this partnership successfully services over 1,000 SPMI patients, part of the Threshold clientele with a full pallet of in-house and outreach services that include home visits, health education classes and fairs and group home services. Threshold operates many facilities throughout the Chicago area of which IHC coordinates the IHC North and IHC South clinic and a clinic devoted to mother and child services. Staffing is provided primarily by the College of Nursing faculty and students from mental health disciplines. Social planning intervention is represented by the strategic coordination offered through the College of Nursing of shared resources and balanced power reflecting the heart of the IHC partnership. All resources are shared by Thresholds and the College of Nursing, including equipment, monies, grant writing, publicity, etc. to reflect joint cooperation. The quality assurance infrastructure of the cooperative business model is guided by the Nursing Institute of the College of Nursing. The main objective of the social intervention model is that generalized health care is combined and coordinated with consistent treatments for SPMI. Services for primary health are offered along with services for mental health. For the IHC, generalized primary care would include annual physical examination, HIV/AIDS and STD screening, substance abuse treatments, health education for nutrition and medication understanding. The IHC social planning intervention model is a practical one which services a clientele who display severe risks comorbid diseases along with SPMI. This practicality is oftentimes overlooked by the medical system because it is compounded with severe lifestyles conditions of poverty. In some aspects IHC has importantly changed this view. The IHC has formalized its intervention center using several methods. These include tracking for wellness, primary care, and mental health billing codes, tracking for diabetes and hypertension, mapping Center utilization. A new integrated medical records information had to be adapted. Teaching models have been enhance with integrated systems of digital learning shared on the Internet among faculty, students, and staff on and offsite. Practicum are arranged virtually at any point for undergraduates. Graduate students and undergraduates are challenged with a rich offering of the complexity of clinical delivery systems and develop appreciation of program models of psychotherapy and disease management. Planned in the IHC intervention model are strategies that support ongoing research efforts. In Institutional Review Board governs and approves the ethics of research cooperatively pursued by both partners. One such project involved the effects of moderate-intensity physical activity on Threshold clients at risk for diabetes (p. 73). Funding has come from the federal government U.S. Health Resources and Services Administration, Bureau of Health Professions, Division of Nursing, Medicaid, some from Medicare, and from grants and donors. IHC costs have averaged $200,000 per site per 4 day week. The costs exceed income and the effort is to strategically align with a "naming" donor gift and/or a major foundation grant. IHC progress is evaluated quarterly by representative leaders from the College of Nursing and Threshold. Progress is evaluated over the mission which is to "provide best quality advanced practice nursing care to address both the primary and mental health needs of the members of Thresholds..." (p. 73). Canada L. Southern et al address the problem of providing competent mental health assessment and psychosocial intervention "in the right place, at the right time and by the right person" (2007, p.29). Their urgent care center, located the South Calgary Health Center (SCHC) , is part of the Canadian Calgary Health Region. This community health center addresses the needs of clients who have non-life threatening, but urgent medical needs. Southern and her colleagues form the six-member mental health urgent care (MHUC) team that works with the SCHC housing. Their purpose is to integrate diagnostic assessment and interventions in those situations where clients present with mental health problems such as depression, psychosis, and psychosis. Their consultations accompany presentations of original medical issues such as deriving from domestic violence and miscarriage among others. The nurses are importantly committed to concepts of collaborative health care and family nursing. This more widened area of medical service identifies this papers model of social planning intervention which combines programs of general medical delivery and assessable mental health delivery virtually under one arm of service. In several vignettes Southern et al demonstrate how the urgent care triage nurse employs the Canadian emergency Department Triage and Acuity Scale (CTAS) to refer patients directly to the MHUC team or to an urgent care physician. The physician may also refer patients directly to the team. After initial physical health assessment the MHUC member conducts psychiatric assessment and/or a psychosocial intervention, both incorporating a DSM-IV diagnosis. The patient is then referred by the MHUC nurse to resolving treatment that may take the form of in-patient admission, or discharge referral to outpatient program or community resources. The advantage of the MHUC united in the community health center is that wait time under the Canadian system is significantly cut down in comparison to receiving treatment in an emergency room. And, just as important, seamless care is provided to patients who presented secondary mental health issues. Such social planning intervention involves individuals of particular professional skills. They must not only display ability to do psychiatric assessment, but they must also demonstrate strong clinical skills to aid mental health clients and medical clients with biological and spiritual care outlining the complexity of psychosocial models. Such nurses would display confidence and autonomy at high levels characteristic of the skillful interviewer and experienced diagnostician. The MHUC nurses further experience ongoing reinforcement training and education schedules. Family nursing to some widens the complexity of nursing, but it is a requirement of collaborative health care involved in social planning intervention. Another mental health program in Calgary, but specifically for elders, is the Comprehensive Community Care Program at the Carewest Sarcee Long-Term Care Centre. The program has a clientele of elderly people who are over 65 who present depression and anxiety symptoms but who want to stay home. The program has proved successful in helping clients avoid acute-care hospitalization. Clients have available a medical clinic and rehabilitation therapy services. There are six short-term treatment beds. RN Terry Robertson is a specialist in psychiatric/mental health nursing and attends those clients requiring mental illness services. Skilled in cognitive behavioural therapy, Robinson also consults with the programs psychiatrist who may offer more treatment and medications. Most of the clients are on antidepressants. Australia Callaly and Fletcher (2005) identify the need of mental health services to be better integrated with other primary health services in the Australian service delivery model. The authors argue for better coordination of services that may cover as wide as range of social services such as housing and employment to mental health services for the acute, chronic, and less severe sufferers as well. The Australian government has pursued such integrated policies with the publication and pursuit of its Third National Mental Health Plan (2003-2008) (p. 352). The plan was committed to promoting partnerships between primary care and public and private mental care resources. The government later promoted a series of (three) Mental Health Integration Projects (MHIP) to promote before the public collaborative partnerships between primary care resources, including GPs, and mental health services that were public sector and private (psychiatrists). One important finding was that cultural and systems change were required from both the professional psychiatrist interests and public concepts of the working models. In her review of non-medical primary health and social care services in Victoria Australia, Mitchell provides a good functional definition of primary health care derived from the World Health Organization. She explains "primary health care should be multi-sectoral, or linked to sectors other than health that influence the behavioural, social environment and economic determinants of health" (p. 73). Among these sectors that provide non-medical primary health and social care services, Mitchell found that promotion of mental health was not given high or regard and that such providers did not favor targeting such individuals (p. 80). There was a lack of public policy pressure, she suggested, to encourage and promote such involvement. The Better Outcomes in Mental Health Care (BOiMHC) program was initiated in Australia in July 2001. The Access to Allied Psychological Services component of this program evolved as a collaborative effort that combined the work of GPs (general practitioners) with that of psychologists social workers, mental health nurses and occupational therapists in the service of primary mental health care delivery. Clients assessed by Gps as having prevalent mental disorders such as depression and anxiety were referred for six sessions of mental health care, evidence-based, with psychologists. Success with the formalization of the program was demonstrated in the number of GPs and allied health professionals participating and the number of clients that were served (Fletcher et al, 2009). Funding for the services was provided by several funding schemes from the Australian government. England Hatfield et al explain how community mental health teams (CMHTs) have functioned under Englands new policy directives of the country is national service framework (NSF) for mental health. The CMHTs comprise multi-disciplinary teams of specialists and were designed to be cost-effective while meeting personal social problems of clients with effective interventions for mental and primary care. The authors yet point to a significant group of clients who may fall outside the net which the CMHTs have been refocused to meet. This group may have social problems exacerbated by the complexity and severity of their mental illness and requiring more excess to secondary services. Graduate mental health workers would function as Gateway workers to integrate mental health needs with primary care. The Hatfield et al reports outlined several risks factors of their clients draw from a study of Knowsley, a small town facing some degree of social deprivation and poverty (p. 25). These risks included self-harm, violence to others, and being a victim of abuse or exploitation. The study summarized the treatment outcomes of new cases, closed cases, and active cases. The active or continuing cases displayed impairment risks of self-neglect and were supported with longer-term interventions beyond mere management of mental illness. These cases had high rates of schizophrenia and bipolar disorder. The new cases group appeared to be comprised primarily women with young families and with high risks of self-harm and depression (p.25). Interventions with broader ranges have refocused the CMHTs under the new policy directives. Capacity of the CMHTs to re-adjust has been increased in providing primary care along with mental illness services. Conclusion The intervention model this study suggests is based on combining primary health with mental for the care of the elderly population with mental illness. Initially the client should be given comprehensive medical screening at the proposed community health center with the goal of combining all results in an accessible medical record. Such screening should include but not limited to abdominal aortic aneurysm; breast cancer; bone density; cardiovascular for elevated lipid levels; cervical and vaginal cancer by Pap and pelvic examination; colorectal cancer; diabetes mellitus; glaucoma, and prostate screening. HIV/AIDS and STD screening should also be considered depending on client background. During initial screening if the patient shows signs of depression, the nurse can access them with the Geriatric Depression Scale. If depression or other mental illness symptoms present, the patient can be referred to the advance practice nursing team (APNT) which is modeled on mental health urgent care (MHUC) team of the South Calgary Health Center. The APNT is able to administer further assessment tests, such as MMPI-2 or the Beck Depression Inventory. The APNT is able to conduct ongoing consultation and if necessary set up cognitive behavior therapy sessions, or refer the patient to a consulting psychiatrist for medication. The main point of the intervention model is that it combines primary care and mental illness services under the auspices of one clinic, easily accessible by the elderly. The clinic allows early view of any rising symptoms of mental illness. Such an intervention model, in order to be successful, would have to have public policy support from government bodies and preferably have collaborative staff and resource support from education bodies, as illustrated by the Center for Integrated Health Care (IHC). References Callaly, T., and Fletcher, A. (2005). Providing integrated mental health services: a policy and management perspective. Australian Psychiatry, 13(4), 351-356. Elstead, T.A., Eide, A.H. (2009). User participation in community mental health services: Exploring the experiences of users and professionals. Scandinavian Journal of Caring Sciences, 23, 674-681. Fletcher, J.R., Pirkis, J.E., Bassilios, B., Kohn, F., Blashki, G.A., and Burgess, P.M. (2009). Australian primary mental health care: improving access and outcomes. Australian Journal of Primary Health, 15, 244-253 Hatfield, B., Sharma, I., and Ryan, T. (2007). Changing the focus of community mental health teams: A study in one English locality. Journal of Integrated Care, 15(3), 17-30. Marion,L.N.,Braun, S., Anderson, D., McDevitt, J., Noyes, M., & Snyder, M. (2004). Center for integrated health care: Primary and mental health care for people with severe and persistent mental illnesses. Academic Practice Exemplars, 43(2), 71-74. Mitchell, P. (2008). Mental healthcare roles of non-medical primary health and social care services. Health and Social Care in the Community, 17(1). 71-82 OConnor, D., Little, F., McManus, R. (2009). Elders with serious mental illness: Lost opportunities and new policy options. Journal of Aging & Social Policy, 21, 144-158. Robertson, T., and Hollings, J. (2010). Mental health services within a comprehensive community care program help the frail elderly. Albert RN, 66(4), 20-22. Southern, L., Leahey, M., Harper-Jaques, S., McGonigal, K., & Syverson, A. (2007). Integrating mental health into urgent care in a community health center. Canadian Nurse, 103(1), 29-34. Read More