Chapter 4

Treatment Settings

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 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.

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 Objectives (Cont.)
 Evaluate the role of community mental health centers in
the provision of community-based 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.

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 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
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 Outpatient Psychiatric
Mental Health Care
 Primary care providers
 Specialty psychiatric care providers
 Patient-centered health/medical homes
 Community clinics
 Psychiatric home care
 ACT

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 Outpatient Psychiatric
Mental Health Care (Cont.)
 Intensive outpatient programs and partial
hospitalization
 Other outpatient venues for psychiatric care
 Telephone crisis counseling
 Telephone outreach
 Internet
 Telepsychiatry

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 Emergency Care

 Comprehensive Emergency Service Model

 Hospital-Based Consultant Model
 Mobile Crisis Team Model

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 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.

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 Case Study: Edgar (Cont.)
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.

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 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.

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 Prevention Strategies

 Primary prevention
 Secondary prevention
 Tertiary prevention

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 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.

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 Audience Response Questions
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.

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 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.

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 Role of the Nurse in Outpatient
Settings
 Strong problem-solving and clinical skills
 Cultural competence
 Flexibility
 Knowledge of community resources
 Autonomy
 Promoting recovery and continuation of
treatment

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 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?

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 Settings for Inpatient Care

 Crisis Stabilization/Observational Units

 General Hospital and Private Hospital
 State Hospital

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 Entry to Acute Inpatient Care

 Direct admission on referral

 Emergency department or crisis service
 Voluntary or involuntary

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 Objectives

 Discuss the purpose of identifying the rights of

hospitalized psychiatric patients.
 Define the therapeutic milieu.

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 Patients’ Rights

 Hospitalized patients retain their rights as

citizens
 Patient’s need for safety must be balanced
against patient’s rights as a citizen
 Mental health facilities have written statements
of patient’s rights and applicable state laws

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 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.

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 Therapeutic Milieu

 Surroundings and physical environment

 Managing behavioral crises
 Safety
 Unit design

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 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

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 Audience Response Questions
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.”
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 Specialty Treatment Settings

 Pediatric psychiatric care

 Geriatric psychiatric care
 Veterans administration centers
 Forensic psychiatric care
 Alcohol and drug abuse treatment
 Self-help options

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 Case Study: Edgar
After release from the hospital, Edgar returns to his outpatient team. He
expresses a desire to “start again,” while acknowledging that major
depression is a chronic disorder. He and his wife Annie have decided to
join a support group for veterans and their families that focuses on dealing
with PTSD and major depression.
Annie shares that he has also
given her a birthday surprise: he
has enrolled them both in a yoga
class together—“something,” she
says, “that I have always wanted
us to do together!” They remain
guardedly optimistic about the
future.

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