Chapter 4 Treatment Setting
Objectives
 Analyze the continuum of psychiatric care and the variety of care options available.
 Describe the role of the primary care provider and the psychiatric specialist in treating
psychiatric disorders.
 Explain the purpose of patient-centered medical homes and implications for holistically
treating individuals with psychiatric disorders.
 Evaluate the role of community mental health centers in the provision of communitybased care.
 Identify key components and benefits of community-based care such as psychiatric home
care.
 Discuss other community-based care providers including assertive community treatment
(ACT) teams, partial hospitalization programs, and alternate delivery of care methods
such as telepsychiatry.
Background
 1860s: Asylums have roots in Civil War era
 1950s: First antipsychotic medication
 1960s: Medicare and Medicaid with no funding for psychiatric care
 1999: Olmstead Decision: Deinstitutionalization
 2016: Drop in state psychiatric hospitals from 322 in 1950 to 195 in 2016
 Current system: Outpatient and inpatient settings
Outpatient Psychiatric Mental Health Care
 Primary care providers
 Specialty psychiatric care providers
 Patient-centered health/medical homes
 Community clinics (Group setting/support)
 Psychiatric home care
 ACT
 Intensive outpatient programs and partial hospitalization
 Other outpatient venues for psychiatric care
o Telephone crisis counseling
o Telephone outreach
o Internet
o Telepsychiatry
Emergency Care
 Comprehensive Emergency Service Model
 Hospital-Based Consultant Model
 Mobile Crisis Team Model
Chapter 4 Treatment Setting
Case Study: Edgar
Edgar is a soldier recently returned from a war zone. He and his wife Annie first came to his
primary care physician about what he describes as depression. Edgar has mostly come at Annie’s
insistence. She is very anxious about his emotional state.
Both you and Edgar’s physician work at a patient-centered medical home. Edgar’s physician
calls on you to come to a team meeting when he begins to feel that Edgar needs more than he
feels qualified to provide on his own.
Audience Response Questions
Which most accurately describes a patient-centered medical home?
A. All levels of mental and physical care are addressed by a team that coordinates with the
broader health system.
B. Emergency services, community and/or home-based services, and outpatient services
across the life span are provided.
C. The patient received psychiatric services in the home.
D. A multidisciplinary team works intensively with patients in their homes, or in agencies,
hospitals, or clinics—whatever settings patients find themselves in.
Prevention Strategies
 Primary prevention
 Secondary prevention
 Tertiary prevention
Case Study: Edgar
Edgar is diagnosed with major depression and posttraumatic stress disorder (PTSD). At the team
meeting, Edgar describes some of the struggles he’s had with this disorder since returning home
from the war. He agrees with his wife Annie and his team that while they will work on treating
his current symptoms, they will also collaborate on preventing its progression to a more severe
level so that it doesn’t become disabling or lead to suicidal ideation.
Which type of prevention is Edgar’s team most focused on?
A. Primary prevention
B. Secondary prevention
C. Tertiary prevention
D. It’s too late for prevention; Edgar already has a depressive disorder.
Objectives
 Describe the role of the nurse as it pertains to outpatient settings.
 Identify the main types of inpatient care and the functions of each.
Role of the Nurse in Outpatient Settings
 Strong problem-solving and clinical skills
 Cultural competence
Chapter 4 Treatment Setting
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Flexibility
Knowledge of community resources
Autonomy
Promoting recovery and continuation of treatment
Discussion: Needs of Outpatients
You are working with a patient who will be discharged from inpatient services into outpatient
community services soon. What are some problems that may affect the success of treatment?
 Meds? Housing? Support? Finance?
 Housing adequacy and stability: If a patient faces daily fears of homelessness, it is not
possible to focus on other treatment issues.
 Income and source of income: A patient must have a basic income—whether from an
entitlement, a relative, or other sources—to obtain necessary medication and meet daily
needs for food and clothing.
 Family and support system: The presence of a family member, friend, or neighbor
supports the patient's recovery and gives the nurse a contact person, with the patient's
consent.
 Substance abuse history and current use: Often hidden or minimized during
hospitalization, substance abuse can be a destructive force, undermining medication
effectiveness and interfering with community acceptance and procurement of housing.
 Physical well-being: Factors that increase health risks and decrease life span for
individuals with mental illnesses include decreased physical activity, smoking,
medication side effects, and lack of routine health exams.
Settings for Inpatient Care
 Crisis Stabilization/Observational Units
 General Hospital and Private Hospital
 State Hospital
Entry to Acute Inpatient Care
 Direct admission on referral
 Emergency department or crisis service
 Voluntary or involuntary
Objectives
 Discuss the purpose of identifying the rights of hospitalized psychiatric patients.
 Define the therapeutic milieu.
Patients’ Rights
 Hospitalized patients retain their rights as citizens
 Patient’s need for safety must be balanced against patient’s rights as a citizen
Chapter 4 Treatment Setting
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Mental health facilities have written statements of patient’s rights and applicable state
laws
Teamwork and Collaboration
 Members of each discipline are responsible for gathering data and participating in the
planning of care
 Treatment plan or clinical pathway provides a guideline for patient’s care during hospital
stay
 Nurse’s role is often to lead planning meetings
 For standardization in treatment and improve outcomes, inpatient units use clinical
pathways.
Therapeutic Milieu
 Surroundings and physical environment
o Managing behavioral crises
o Safety
o Unit design
Inpatient Psychiatric Nursing Care
 Completing comprehensive data collection that includes the patient, family, and other
health care workers
 Developing, implementing, and evaluating plans of care
 Assisting or supervising mental health care workers
 Maintaining a safe and therapeutic environment
 Facilitating health promotion through teaching
 Monitoring behavior, affect, and mood
 Maintaining oversight of restraint and seclusion
 Coordinating care by the treatment team
After a suicide attempt, Edgar tells the nurse, “I need my belt to keep my pants up. They keep
falling down.” Which response should the nurse provide?
A. “Your belt is locked in the business office for safekeeping, along with all your other
valuables.”
B. “For safety reasons, hospitalized clients are not allowed to keep certain personal
possessions.”
C. “I cannot provide your belt, but I will help you get some pants with an elastic waistband.”
D. “I will ask the psychiatric technician to get your belt for you.”
Specialty Treatment Settings
 Pediatric psychiatric care
 Geriatric psychiatric care
 Veterans administration centers
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Forensic psychiatric care
Alcohol and drug abuse treatment
Self-help options
Chapter 4 Treatment Setting
Key Points to Remember
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Entry into the mental health system can be bewildering process due to the people's
reluctance to share their own experience. Cognitive change just from the disorders
themselves and confusion over physical versus mental symptoms
Treatment options can be based on the least restrictive environment, that is, the setting
that provides the necessary care while allowing the greatest personal freedom.
Psychiatric care settings evolved during the 20th century from mass institutionalization to
a variety of outpatient and inpatient settings.
It continuum of care model helps differentiate between levels of acuity within treatment
setting.
Primary care providers have an increasingly important role in identifying and treating
mental disorders. This treatment choice may feel familiar and reduce stigma. Time
limitation may impact a complete mental assessment and training limitations may make
some providers uncomfortable
Specialty care providers possess educational and experiential background in psychiatric
and mental health.
Patient-center, medical homes with multiple services and array of providers are becoming
increasingly popular as a way to integrate mental and other physical care.
Community mental health centers provide a wide range of mental health services for
individuals who lack funding for care
Registered nurses and social workers provide psychiatric home care for individuals who
are homebound.
Assertive Community Treatment (ACT) is an intensive case management for people who
are unable or unwilling to participate in traditional treatment. ACT teams are composed
of a variety of professional who provide 24 hour, seven day a week support
Intensive outpatient and partial hospitalization programs are available as a step down
from inpatient care. Or as a step up from other, less restrictive treatment settings
Emergency psychiatric care and crisis stabilization is available in emergency rooms and
from emergency teams
Primary, secondary, and tertiary preventions are aimed at reducing the effect of mental
illness by preventing its occurrence, preventing its progression, or by restoring functional
ability.
Inpatient setting, including crisis stabilization units, general hospitals and private hospital
acute care and a state funded acute care system
Inpatient psychiatric mental health nursing requires a strong skill in management,
communication, and collaboration
Basic level inpatient nursing intervention includes admission, providing a safe
environment, psychiatric and physical assessment, milieu management, documentation,
medical medication, administration and preparing for discharge to a community.
Chapter 4 Treatment Setting
Chapter Review
1. A patient needs supportive care for a maintenance treatment of bipolar disorder. The new
nurse demonstrates an understanding of the services provided by the various members of
the patient's mental health care team. When he makes which statement:
A. “Your social worker will help you learn to budget your money effectively.”
B. “Your counselor asked me to remind you of your group session on critical
thinking at 2:00 o'clock today.”
C. “The mental health technician on staff today will administer the medication that
you require.”
D. “Remember to ask the occupational therapist about your sources of financial help
that you are qualified for.”
2. A patient has been voluntarily admitted to a mental health facility after an unsuccessful
attempt to harm himself. Which statement demonstrates a need to better educate the
patient on his patients’ rights?
A. “I understand why I was restrained when I was out of control.”
B. “You can’t tell my boss about the suicide attempt without my permission.”
C. “I have a right to know what all of you are planning to do to me.”
D. “I can hurt myself if I want to. It’s none of your business.”
3. Which intervention demonstrates an attempt by nursing staff to meet the goal identified
by The Joint Commission as National Patient Safety Goals? Select all that apply.
A. Identifying patients using both name and date of birth before drawing blood.
B. Sitting with the patient diagnosed with an eating disorder during meals
C. Administering the Beck scale on each patient at the time of admission
D. Performing a medication history assessment on each new patient.
4. The mental health team is determining treatment options for a male patient who is
experiencing psychotic symptoms. Which question(s) should the team answer to
determine whether a community outpatient or inpatient setting is most appropriate?
SATA
A. “Is the patient expressing suicidal thoughts?”
B. “Does the patient have intact judgement and insight into his situation?”
C. “Does the patient have experiences with either community inpatient mental
healthcare facilities?”
D. “Does the patient require a therapeutic environment to support the management of
psychotic symptoms?”
E. “Does the patient require the regular involvement of their family/significant other
in planning and executing the plan of care?”
Chapter 4 Treatment Setting
5. The nurse frequently includes daily sessions involving relaxation techniques. Which
assessment data would most indicate a need for this intervention to be included in a
patient’s initial plan of care?
A. Family history of anxiety and symptoms of anxiety
B. Significant other has a chronic health issue
C. Hopes to retire in 6 months
D. Recently adopted infant twins
6. A newly divorced 36-year-old mother of three has difficulty sleeping. When she shares
this information to her gynecologist, she suggests which of the following services as
appropriate for her patients’ needs?
A. Assertive community treatment
B. Patient-centered medical home
C. Psychiatric home care
D. Primary care provider
7. An Afghanistan Conflict veteran has been homeless since being discharged from military
service. He is now diagnosed with schizophrenia. The nurse practitioner recognizes that
assertive community treatment (ACT) is a good option for this patient since ACT
provides:
A. Psychiatric home care
B. Care for hard-to-engage, seriously ill patients
C. Outpatient community mental health center care
D. A comprehensive emergency service model
8. An adolescent female is readmitted for inpatient care after a suicide attempt. What is the
most important nursing intervention to accomplish upon admission?
A. Allowing the patient to return to her previous room so that she will feel safe
B. Orienting the patient to the unit and introducing her to the patients and staff
C. Building trust through therapeutic communication
D. Checking the patient’s belongings for dangerous items
9. Emma is a 50-year-old married female who has found it increasingly difficult to leave
home due to agoraphobia. Emma’s family is appropriately concerned and suggests that
she seeks psychiatric care. After investigating her options, Emma decides to try:
A. Telepsychiatry
B. Assertive community treatment
C. Psychiatric home care
D. Outpatient psychiatric care
10. Pablo is a homeless adult who has no family connection. Pablo passed out on the street
and emergency medical services who took him to the hospital, where he expresses a wish
to die. The physicians recognize evidence of substance use problems and mental health
Chapter 4 Treatment Setting
issues and recommends inpatient treatment for Pablo. What is the rationale for this
treatment choice? SATA
A.
B.
C.
D.
E.
Intermittent supervision is available in inpatient settings.
Je requires stabilization of multiple symptoms
He has nutritional and self-care needs
Medication adherence will be mandated
He is in imminent danger of harming himself