Tips help staff deal with psych patients

Expert offers practical advice

Nurses who work with psychiatric patients often enter unfamiliar territory. Severely mentally ill patients often have very poor coping skills. They might have low medication compliance without supervision, which means they become "frequent fliers" at the local hospital, and they may become dangerous to themselves or others.

"Any time you go into a home environment, your concern has to be your safety as well as your patient’s safety," says Andrea K. Schroder, LCSW, team leader for Intensive Psychiatric Com munity Care (IPCC) at the VA Medical Center in Denver. The VA Medical Center has an intensive psychia tric in-home program, one of 43 similar programs employed by more than 40 Department of Veter ans Affairs hospitals.

The program provides intensive intervention and community and at-home counseling services to veterans with severe mental illness. It is based on the Program of Assertive Community Treatment, which was developed at the Mendota Mental Health Institute, a state psychiatric hospital in Madison, WI.

"The idea is to help people until they’re integrated into the community," says Mike Neale, PhD, clinical psychologist and IPCC project director at the Northeast Program Evaluation Center of the VA Connecticut Healthcare Service in West Haven, CT. "For most patients, we have an ongoing type of treatment. But we also have a one-year track where we’re trying to see what we can do in that period of time."

Schroder’s IPCC work is different from traditional medical home care because she and other clinicians may visit patients regularly for years. Although such supervision is costly, studies have shown it is less expensive than if these patients were left to bounce back to inpatient treatment. One study showed that severely mentally ill patients who were assigned to a VA IPCC program had greater long-term clinical improvement and cost less than the same type of patients who received inpatient services.

Success starts with the nurse’s assessment

Despite the differences between the IPCC program and the services a home care agency might provide for mentally ill patients, Schroder says home care nurses might learn something from her experiences. Here are some of her suggestions about how to handle psychiatric patients:

Make medication compliance a top priority. Psychiatric patients may be unreliable in taking their medications. An elderly patient might experience mental confusion in addition to his mental illness. A patient with manic-depression might begin to feel good and believe medication is no longer necessary, which means home care professionals must emphasize medication compliance and perhaps monitor it closely when the patient first is admitted to home care.

"Sometimes the staff go every day to patients’ homes to make sure they’re taking their medication," Schroder says. In one case, an IPCC nurse would visit an elderly patient once a week and fill his medication box so he could easily take his morning and afternoon pills each day.

"We have some patients we see as often as three times a week because they are psychiatrically unstable and have mood swings or are depressed and unable to get out of bed," she says. "We were worried they would not eat and not take their medications."

Learn how to stabilize these patients. The first step is to make sure the nurse does a good assessment and develops a treatment plan that includes the patient’s and family’s input, she advises. That includes finding out what the pa tient’s history has been with regard to medical care and social problems.

When possible, the nurse also should assess the patient’s financial situation and his or her medical compliance before home care admission. "You need to have a clear understanding of what has gone wrong up to this point," Schroder adds.

Next, the nurse should make sure the patient voluntarily agrees to allow home care visits from a nurse or therapist to help work on problems. Also, home care professionals always should be aware that their own safety and the patient’s safety are top priorities. "We don’t go into any homes where there’s a history of assault or a history of owning firearms or weapons," she says.

Watch for "transference." The psychiatric concept of transference means that the feelings patients have for their home care caregivers are based on their experiences with the important people in their lives."All patients bring some components with significant others into their relationships," Schroder explains. "If you had good experiences with women in your life, then you will have a better perception of a female nurse who comes to your door than would someone whose mother was abusive and whose wife just left him." One patient of Schroder’s referred to her as "the devil," and she felt unsafe returning to that patient’s home. The staff agreed to treat the patient in the clinic instead.

Assess the home environment for safety issues. Schroder suggests home care nurses follow a typical evaluation for unsafe environmental features and to determine whether there is adequate food and finances. "At the first home visit, you do an assessment of the environment and develop some kind of plan of what you need."

Nurses should ask what will help patients stay in the community and improve their lives. This might be extensive help with household management. In one case, Schroder helped a patient obtain an apartment by taking him to the bank where he withdrew enough money to pay rent. Then she drove him to a secondhand store and helped him select basic kitchen items. She even took him to the grocery store to buy coffee, bread, meat, and other goods. "Then we put the groceries away, and I met with the manager of the apartment building and let her know who I was. We went over the rental agreement, and I told the patient I’d come back in two days."

She continued to see the patient twice a week for several weeks, and then one morning she found him outside the apartment building, yelling and asking for a beer. He wanted her to walk up to the apartment, but she refused. Instead, she talked to the apartment building manager, who called the police. Schroder convinced the police officers to take the patient to a detoxification facility.

The point to remember is that she did nothing to endanger herself or the patient once she saw his condition and alcohol abuse were out of control. However, she also did her best to keep him safe by waiting for and talking with the police. "It’s been our experience that it takes six months to a year of more intensive work to get somebody stabilized," she says. "We need time to develop a trusting relationship with the patient and to help patients stabilize their lives medically and socially."

Help patients find financial help, when appropriate. "Some of our patients have bad financial circumstances," she says. "Another reason people often enter the hospital is that they don’t have money to find a place to live."

Some mentally ill patients will spend their money as soon as they receive it, or they might have drug and alcohol problems. The IPCC program provides basic information on money management, helps them find a guardian, and shows them how to shop for groceries and clothing.

Home care staff must be aware that these patients are prone to being abused financially and alert the agency and state authorities when there’s evidence of abuse.

Suggested reading

Rosenheck R, Neale M. Cost-effectiveness of intensive psychiatric community care for high users of inpatient services. Arch Gen Psych May 1998; 55:459-466.

Rosenheck R, Neale M, et al. Intensive Psychiatric Community Care (IPCC): A New Approach to Care for Veterans with Serious Mental Illness in the Department of Veterans Affairs. West Haven, CT: Department of Veterans Affairs, Northeast Program Evaluation Center; Nov. 1997, p. 30.

sources

Mike Neale, PhD, Clinical Psychologist, Project Director, Intensive Psychiatric Community Care, Northeast Program Evaluation Center, VA Connecticut Healthcare Service, NEPC-182, 950 Campbell Ave., West Haven, CT 06516. Phone: (203) 932-5711, ext. 3696.

Andrea K. Schroder, LCSW, Team Leader, Intensive Psychiatric Community Care Program, VA Medical Center, 1055 Clermont, Denver, CO 80220. Phone: (303) 399-8020, ext. 2534. Fax: (303) 393-5151.