Management of Clients in the Community (1).pptx

Brainstorming session MANAGEMENT OF CLIENTS IN THE COMMUNITY BY MRS. MULLINGS-THOMPSON/ MRS. J. LAWAL (NURSE EDUCATOR) INTRODUCTION The recognition that large psychiatric institutions could lead to patients becoming institutionalized, the advent of pharmaceutical treatment and contemporary reha...

Brainstorming session MANAGEMENT OF CLIENTS IN THE COMMUNITY BY MRS. MULLINGS-THOMPSON/ MRS. J. LAWAL (NURSE EDUCATOR) INTRODUCTION The recognition that large psychiatric institutions could lead to patients becoming institutionalized, the advent of pharmaceutical treatment and contemporary rehabilitative methods were some of the driving forces behind the development of a community based mental health service across several countries globally. INTRODUCTION CONT’D The Pan American Health Organisation (PAHO) “was instrumental in developing a countrywide community care in Jamaica”. Recommendations from PAHO consultants in 1962 helped to “redraft Jamaica's mental health legislation and develop a community mental health service (CMHS), an intensive training program for mental health providers and rehabilitation and a systematic deinstitutionalization programme for the BVH” (McKenzie, nd)  INTRODUCTION CONT’D According to McKenzie (nd) the “multifaceted nature of the work of Mental Health Officers has been the glue that has held together the country’s mental health system” Abel et al (2012) outlined that the key components of good community mental health services (CMHS) include inpatient care, outpatient services, mobile outreach teams, long term residential and occupational rehabilitation services.  OBJECTIVES At the end of the teaching, students will be able to: State the World Health Organization (WHO) view on Community Mental Health Care; Outline the Components of Community Mental Health Service; Identify members of the CMHS team; List the various Facilities involved in CMHS; Describe the Management of Clients in the Community. WHO ON COMMUNITY MENTAL HEALTH CARE In the context of national efforts to strengthen mental health, it is vital to not only protect and promote the mental well-being of all, but also to address the needs of people with mental health conditions. This should be done through community-based mental health care, which is more accessible and acceptable than institutional care, helps prevent human rights violations and delivers better  WHO CONT’D recovery outcomes for people with mental health conditions. Community-based mental health care should be provided through a network of interrelated services that comprise: Mental health services that are integrated in general health care, typically in general hospitals and through task- sharing with non-specialist care providers in primary health care;  WHO CONT’D Community mental health services that may involve community mental health centers and teams, psychosocial rehabilitation, peer support services and supported living services; and Services that deliver mental health care in social services and non-health settings, such as child protection, school health services, and prisons.  COMPONENTS OF THE CMHS As outlined in the Community Mental Health Policy and Procedure Manual, components of the community mental health services includes: Mental health promotion and education programmes Inpatient services Outpatient services Crisis and Psychiatric Emergencies  COMPONENTS OF THE CMHS Home visiting Assertive outreach programmes for the homeless mentally ill Psychological, social and occupational intervention services Forensic Psychiatric Services Services provided by Non-governmental organizations Collaboration and Liaison THE MULTIDISCIPLINARY TEAM Psychiatrists Mental Health/Psychiatric Nurse Practitioners Mental Health Officers Psychologists Social Workers Occupational therapists TEAM CONT’D Activity therapists Psychiatric Nursing Aides Drivers Secretaries/Data Entry clerk  FACILITIES Primary Care facilities Provided mainly in Types III – V Health Centres. Also in some Types II depending on the geographical location or pooling of clients Services include: Mental and physical examinations  FACILITIES CONT’D Diagnostic and laboratory investigations Psychosocial interventions Referrals Secondary Care Facilities Provided in general hospitals and the specialist hospitals and units; UHWI and Cornwall Regional Hospital  FACILITIES CONT’D Non Governmental Facilities include: Residential facilities including infirmaries and nursing homes Day Care/drop in centres Night shelters Residential facilities based in communities MANAGEMENT OF THE CLIENT IN THE COMMUNITY - CLINICAL MANAGEMENT Initial assessment – Usually done by the psychiatrist Involves a comprehensive history Physical examination Mental status examination MANAGEMENT: CLINICAL MANAGEMENT CONT’D Laboratory and diagnostics testing Diagnosis Treatment plan The comprehensive history should include the following information: Identifying or demographic data MANAGEMENT: CLINICAL MANAGEMENT CONT’D Chief compliant History of present illness Past medical/surgical/psychiatric history Developmental history Family history Psychosexual history and Social history  MANAGEMENT CONT’D The physical examination is on: Neurological examination Vitals signs including height and weight Urine tests It may be necessary to carry out a full head to toe examination  MANAGEMENT CONT’D Mental status examination: Appearance Behaviour Mood and affect Speech Cognitive features – orientation, memory, concentration, judgement, intelligence  MANAGEMENT CONT’D Perceptual disturbances Thought process Thought content – including suicidal/homicidal ideations Insight It may be necessary to carry out a suicidal risk assessment or violence risk assessment if necessary MANAGEMENT CONT’D Laboratory and diagnostics tests may be ordered based on findings from history, mental status and physical examination Main tests include; Haematology Chemistry Brain imagining – CT Scan, MRI etc  MANAGEMENT CONT’D Diagnosis of the client is made using the: Diagnostics and Statistical Manual of Mental Disorder Text Revision (DSM IV TR and DSM V) International classification of diseases (ICD 10)  MANAGEMENT CONT’D Treatment plan outline: Psychotherapeutic interventions and counselling Individual, group and family psychotherapy, support psychotherapy, cognitive behaviour therapy, Psychopharmacological therapy Psychoeducation and general health education MANAGEMENT CONT’D Social interventions Occupational therapy Follow –up visits Referrals MANAGEMENT CONT’D Follow-up visits Usually done to monitor clients as necessary whether weekly, bi monthly or monthly Follow-up assessments and reviews are usually done by the mental health nurses The Psychiatrist are required to review each client at least once annually  MANAGEMENT CONT’D Referral to the CMHS Sources of referrals may be either Direct – Primary and Secondary Care Health facilities- General Hospitals, Mental Hospital, Health Centres; Medical Officers in Private Practice and members of the health team. Indirect – Schools, Children Services, Police/Correctional Services, other institutions and agencies, NGOs, relatives and concerned citizens.  MANAGEMENT CONT’D Referrals from the CMHS As with any other service, this is usually done based on the needs assessment of the client In order to ensure a holistic treatment approach Most often involves referrals for more in-depth consultation, additional medical assessment and treatment and social support MANAGEMENT CONT’D Crisis interventions are done for client or individuals who need professional attention promptly. Without this intervention, the situation could result in homicide, suicide, child abuse, domestic violence or other serious problems Offered by a Psychiatric Emergency Maintenance Team (PEMT) MANAGEMENT CONT’D In crisis interventions, the team often has to utilize involuntary detention This can only be utilized in a case where the individual is at risk of injuring himself/herself or others MANAGEMENT CONT’D - HOME VISITING Home visits are usually done: To obtain information about the patient from relatives and caregivers. To obtain information on clients whose social situation needs clarification before discharge from hospital can be considered. To observe how discharged patients are readjusting to their homes and communities  MANAGEMENT: HOME VISITING CONT’D To ensure that the environment is conducive to the maintenance of the health of clients. To ensure that clients are taking their medications and to educate relatives about the: importance of clients taking their medications possible side effects of medications that may occur steps to take if side effects occur. MANAGEMENT: HOME VISITING CONT’D To follow up clients who have not been attending clinic over a period of 1-2 months. To assess and make decisions on clients who have relapsed or those suspected of being mentally ill but lack the insight to seek medical attention. To administer long acting/monthly injections to difficult clients or those unable to attend clinic. (CMH Policy & Procedure Manual, 2012)  MANAGEMENT: ASSERTIVE OUTREACH This service is provided for mentally ill persons who may be on the streets This may be as a result of symptoms of illness or displacement from usual place of residence  MANAGEMENT: FORENSIC REVIEW Forensic review are usually indicated for: Assessment for fitness to plead for offender with minor offences Assessment for fitness to plead for offenders with major offences (Capitol or Non-Capitol) For a comprehensive forensic psychiatric report for offenders with major offences (Capitol or Non Capitol)” (CMH Policy & Procedure Manual, 2012)  MANAGEMENT: INPATIENT CARE Admission to hospital is usually done if a client is acutely ill and must be stabilized to prevent his/her condition from worsening Admissions can be done: Voluntarily – the patient is willing to check into a facility. Client must be given appropriate consent form which must be signed. Additionally, client’s relative also will take client in for admission  MANAGEMENT: INPATIENT CARE Involuntarily – detaining and admitting a person who is suffering from a mental disorder without his/her consent (if he/she is at risk of being injured or injuring others) NOTE: Only MHOs and Police officers have the authority by law to detain a person involuntarily  MANAGEMENT: DOCUMENTATION As with any service, documentation of client’s information and any care offered to the client is essential It is the process of supplying documents and supporting references or records. It is used to communicate health information, demonstrate accountability and meet legislative requirements” (CMH policy and Procedure Manual, 2012)  MANAGEMENT: DOCUMENTATION Documents used in the CMHS include: Assessment/intake form Progress/continuation form Consent forms CMH reporting form; Registers Restraint monitoring form Crisis/emergency intervention form MANAGEMENT: COLLABORATION AND LIAISON Effective management of the client in community requires collaboration and liaison with various individuals, departments and agencies in the community that are not a part of the health care delivery system. Included are: The Jamaica Constabulary Force – Police Ministry of Local Government – Poor relief, infirmaries Ministry of labour and Social Security MANAGEMENT: COLLABORATION AND LIAISON Ministry of Education – Teachers and Guidance Councillors Churches and other faith based agencies Child development agency Ministry of Justice – Family court Voluntary organisations including service clubs and friendly societies MANAGEMENT: SUPPORT SERVICES Provided mainly by Non-governmental organisations or groups. E.g. Mensana (mental health support group) Westmoreland Association for Street People (WASP) Ebenezer home for the Mentally Challenged Open Arms Drop in centre MANAGEMENT: SUPPORT SERVICES All NGOs providing residential care are required to be designated as a psychiatric facility Nursing Homes providing care should also meet the requirements of the Nursing Home Registration Act (1934)  MANAGEMENT: ETHICAL AND LEGAL ISSUES In managing the client, the Mental Health Team must acknowledge ethical and legal issues related to the client and provision of care. These include: Ethical issues – autonomy, beneficence non-maleficence, justice, confidentiality, veracity, utilitarianism Patients’ rights Human rights principles Mental Health legislation – Mental Health Act 1997  Any question ?  REFERENCE McKenzie, K. (N.d). Jamaica: Community Mental Health Services. London: Author Mental Health Policy and Service System Development in the English-speaking Caribbean. (2012). West Indian Medical Journal: 61 (5): 454 Ministry of Health. (2012) Community Mental Health Services: Policy and Procedure Manual. Kingston, Jamaica: author https://www.who.int/news-room/fact-sheets/detail/ment al-health-strengthening-our-response