Keltner: Psychiatric Nursing, 5th Edition

Chapter 3: Continuum of Care

Chapter Focus
The continuum of care provides consumers with a wide range of treatment modalities to
assist the individual in achieving his or her optimal level of functioning. Entry into the
system is effected by suggestion of medical personnel, by laypersons who have contact
with the patient, or by self-referral, and can occur at any point on the continuum of
services. The initial role of the nurse and other professionals is to assess the individuals
current level of functioning to direct the person to the appropriate resources that will
enhance quality of life and decrease fragmentation of care. Coordination of services for
the individual necessitates multidisciplinary collaboration. Additional referrals can be
made as the needs of the individual evolve. During treatment, the individual and care
providers develop specific problem-oriented outcomes based on objective data and
subjective self-reports. These outcomes are monitored continually and their achievement
becomes the basis for third-party reimbursement.
Psychiatric treatment must be cost-effective, occur in the least restrictive setting, and be
individualized and outcome-based. Managed care has influenced the care continuum in a
number of ways. Less money for mental health and addiction services has resulted in
closing inpatient beds and insufficient community treatment. Fewer inpatient beds and
short inpatient stays have created a need for intensive community treatment. Decreased
reimbursements for care and lack of parity for mental health and addiction services has
resulted in lack of access to care and lack of needed treatment and services.
Hospital-based care is reserved for patients who require 24-hour intensive supervision in
a secure environment as a result of being a danger to self or others, who are gravely
disabled and at risk for accidental harm, or who require medical evaluation or treatment
for toxic reactions or withdrawal from chemical substances. Length of stay is typically 3
to 5 days. Types of psychiatric units vary. A small hospital might have only one closed
(i.e., locked) inpatient unit that accepts all patients with all diagnoses. A larger hospital
might offer more options for specialized care, such as for children, adolescents, adults,
and older adults, or individuals who are or are not psychotic, or who are dealing with
addictions. The psychiatric intensive care unit has evolved as a setting for providing care
for clients who demonstrate at-risk behaviors such as suicide, assault, self-mutilation,
sexual acting out, arson, or escape. For all hospitalized patients, discharge planning
begins at admission and is conducted by the multidisciplinary mental health team.

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Instructor's Manual

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Nurses are the only members of the multidisciplinary team who provide 24-hour care
during the hospital stay. No matter how sick the individual or what behaviors he or she is
exhibiting, the individual needs to know that the nurse is caring, empathetic, supportive,
and helpful. The nursing assessment must be direct, specific, and comprehensive. With
regard to psychopharmacology, the nurse is instrumental in obtaining the medication
history, monitoring for medication effectiveness and the presence of side effects, and
educating the patient and family about medications. The nurse emphasizes the importance
of medication compliance in symptom management and control with the individual and
family. The emphasis of milieu management is helping the individual cope with
immediate needs and with stressors and problems in his or her home or living
environment. Milieu groups are problem-focused, goal-oriented, and relevant to the
individuals needs. The nurse assists the individual to apply information obtained in
group to his or her own situation and teaches problem-solving skills.
Psychiatric nurses offer valuable contributions to community-based care because of their
ability to adapt the nursing process and psychotherapeutic management model of care to
any setting. Nursing knowledge of reimbursement systems and budget restrictions is also
helpful, because nurses advocate and negotiate for services.
Community-based nursing practice includes the following:
Traditional outpatient services
Partial programs and day treatment
Psychiatric home care
Community outreach programs
Residential services such as nursing homes, group homes, apartment living, foster
care, and boarding homes
Self-help groups
Intensive outpatient programs such as clubhouses and recovery-oriented programs
Programs providing case management, assertive community treatment, primary care,
and integrated community treatment
Developing a nurse-patient relationship in the community is challenging because of the
decreased contact and time spent with the individual. In community-based settings, it is
highly essential for the nurse to teach the individual and caregiver or family about
medications, the importance of taking them as prescribed, and monitoring for side effects
and signs of noncompliance. In community-based care, the principles of milieu
management are adapted in assessing agencies, programs, and private homes. The nurse
adapts care based on limitations of the environment and availability of resources.
The nurse applies the nursing process in the community as the foundation for case
management in areas of psychiatric rehabilitation, crisis intervention, home care, therapy,
consultation and liaison, resource linkage, and advocacy. Assessment is comprehensive
and serves as the basis for establishing nursing diagnoses, outcome identification, and
planning. Implementation is holistic in scope and evaluation is ongoing.
Copyright 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.

Instructor's Manual

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Key Terms
case management
continuum of care
managed care

Learning Objectives
After reading this chapter, you should be able to:
1. Identify the various levels of care within the continuum of care.
2. Understand the types of care that might be available in hospitals and in the
community.
3. Identify the role of the nurse in implementing the psychotherapeutic management
model in hospital and community-based care.
4. Apply the nursing process to patients who are receiving care in the community.
Chapter Outline

Hospital-Based Care

Teaching Strategies
Continuum of care provides a wide range of treatment
modalities to assist individual in achieving his or her
optimal level of functioning
Referral to system: medical personnel, community
members, individual patient
Role of nurses and other professionals:
Assess current level of functioning and direct to
appropriate resources.
Coordinate services to decrease fragmentation of care;
this requires multidisciplinary collaboration.
Develop specific problem-oriented outcomes with
individual and monitor via objective data and self-report.
Purpose and effects of managed care:
Fewer inpatient beds, insufficient community treatment
Decreased reimbursements
Shorter hospital stays
Less expensive types of treatment
Might determine which medications are prescribed
Result: psychiatric treatment must be flexible,
individualized, cost-effective, problem-oriented, outcomebased, and occur in the least restrictive setting.
Typical stay now 3 to 5 days, reduced from 4 to 6 weeks
This has resulted in:
Changed purpose and goals of hospitalization

Copyright 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.

Instructor's Manual

3-4

Greater need for risk assessment before admission

Implementation of varied types of care
Changing staffing patterns
Increased patient acuity
Increased importance of discharge planning
Purposes of Psychiatric
Highest priority: safety for self and others, necessitating 24Hospital-Based Care
hour supervision in a secure setting
Needed by the actively suicidal, those who are selfmutilating, and those threatening others with harm
Other purposes:
Protect the gravely disabled, who are at risk for
accidental harm.
Protect the acutely psychotic, who are unable to meet
basic needs.
Provide thorough medical and psychiatric evaluation.
Treat toxic reactions to medications.
Treat withdrawal from substances.
Goals: assist individuals to attain initial stabilization and a
safe level of functioning; assess for appropriate referrals for
aftercare.
Types of Hospital-Based Care Units accepting all diagnoses
Specialized units:
Psychiatric intensive care unit (PICU), typically 8 to 10
beds, for patients demonstrating high-risk behaviors
(e.g., suicide, assault, self-mutilation, sexual acting out,
arson, escape)
Purpose: symptom and behavioral control so individuals
can be transferred to treatment-oriented units; seclusion
and restraint used more often on these units
Discharge Planning
Accomplished by interdisciplinary mental health team
Putting It All Together
Psychotherapeutic
Management
Nurse-Patient Relationship
Nursing is the only discipline providing 24-hour care during
hospitalization.
Patients are more acutely ill and exhibit more
psychopathology than in the past.
During shortened LOS, nurses must:
Convey respect and maintain the dignity of the
individual.
Establish therapeutic relationship.
Identify immediate needs.
Provide intervention for behaviors dangerous to self or
others.

Copyright 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.

Instructor's Manual

Psychopharmacology

Milieu Management

Community-Based Care
Traditional Outpatient
Services

3-5
Assess full range of client needs using multiple sources.
Provide holistic quality care.
Provide discharge planning.
Nursing responsibilities:
Obtain medication history, including history of allergies.
Seek individuals perspective on medication
effectiveness, problems with side effects, present and
past compliance.
Monitor medication effectiveness and presence of side
effects.
Educate patient and family regarding effects and side
effects.
Assess need for prn medication.
Emphasize need for medication compliance in symptom
management and control.
Milieu activities: emphasize helping the individual cope
with immediate needs and with stressors in living
environment
Structured milieu includes groups that are problem-focused,
goal-oriented, relevant to patient needs
Nurse: assists individual to apply information obtained in
groups to own situation; teaches problem solving
Clinics and private offices: frequency of visits varies with
patient need; typically weekly to monthly

Partial Programs and Day

Treatment

Appropriate for patients who require some supervision,

structured activities, ongoing treatment, and nursing care
Schedule: might be 4 to 8 hours for 1 to 5 days/week
Day, evening, or night programs exist.
Psychiatric Home Care
Needed for individuals who are homebound because of
their illness or disability; serves individuals with severe
mental illness or those with a combination of psychiatric
and medical illness; home visits made by nurses from
public and private home care agencies
Community Outreach
Include mobile crisis teams to reach homeless or transient
Programs
groups, neighborhood clinics to serve individuals who shun
other community-based services
Residential Services
For individuals who need temporary or long-term housing;
include group homes, halfway houses, apartment living,
foster care and boarding homes, nursing homes
Self-Help Groups
Support groups run by members rather than mental health
professionals; usually meet weekly
Intensive Outpatient ProgramsMore intensive than traditional outpatient services
Clubhouse model: provides daytime work-organized

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Instructor's Manual

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activities focused on care and maintenance of the
clubhouse; evening, weekend, and holiday leisure activities,
support for employment, housing
Recovery model: provides consumer with control and
responsibility for own life; emphasizes consumer strengths
and choices as well as collaboration and involvement with
friends, family supports, and professionals
Case management model: coordinates services and
resources needed by individual to live independently in the
community

Assertive Community
Treatment

Other Types of Intensive

Service
Primary Care

Integrated Community
Treatment
Putting It All Together
Psychotherapeutic
Management
Nurse-Patient Relationship

Psychopharmacology

Goal: prevent rehospitalization by providing comprehensive

and cost-effective services
A team of professionals assumes direct responsibility for
providing services needed by the consumer 24/7 in settings
where the consumers problems arise, including but not
limited to homeless shelters, the streets, and jails. Case
managers are often nurses.
Care sought by some in primary care offices and clinics
because of lack of knowledge about who can provide help
and reduced access to care.
Psychopharmacologic medications might be prescribed;
advanced practice nurses can assist the patient by
implementing interventions related to coping, problem
solving, behavioral management, and substance-related
problems.
Model providing treatment for physical and mental health
care in one location or clinic; focuses on health promotion,
illness prevention, and illness care

Limited time spent with the individual and family in the

community makes developing the nurse-patient relationship
challenging. However, developing collaborative
relationships with patients, families, and other professionals
is crucial for maintaining the continuum of care.
Nurse and caregivers must know about medications
prescribed and their importance; noncompliance is major
cause of relapse and rehospitalization.
Nursing responsibilities: teach about medication effects,
side effects, management of side effects, relationship

Copyright 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.

Instructor's Manual

Milieu Management

3-7
between medication and symptom management; monitor
for symptoms of side effects and early symptoms of
noncompliance and intervene quickly.
Nurse adapts principles of milieu management in assessing
agencies, programs, and private homes, and
determines which services in the continuum will meet
patient needs in the least restrictive setting.

Use of the Nursing Process in

the Community
Assessment
Comprehensive assessment performed by the nurse
typically includes medication compliance and management;
symptom management; social supports; family
involvement; medical needs and limitations; cognitive,
vocational, social, and problem-solving skills; spiritual and
religious needs and concerns; coping abilities.
Outcome Identification and Planning and setting priorities are accomplished after
Planning
comprehensive assessment and establishment of nursing
diagnoses.
Implementation
Calls for nurse to take a holistic approach, recognizing and
addressing the interconnectedness of factors in the patients
lifephysical, mental, emotional, spiritual, environmental,
financial
Evaluation
Each intervention and overall patient status must be
continually evaluated.

Copyright 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.