Chapter 4 - User Behavior Analysis

H.I.V.E.
Homecare Sanctuary
San Isidro Cararayan, Naga City
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CHAPTER IV
User Behavior Analysis
The entire analysis will focus on the two major users, the market and the
management. The market analysis which were categorized as to psychiatric
patients and substance abuse patients would be the main user and would include
recent demography.
Projected market will only compose the first half of the entire users. The
other half would be the management determined by the size of the clients.
Provisions mandated by the Department of Health will also be considered in
determining the management type and organizational structure of the nursing
home.
I.
Market Type Analysis

Categorization of mental disorders as well as substance abuse cases is vital
in identifying the types of patients suitable for the facility. Various mental conditions
will be discussed together with their corresponding therapeutic recommendations
to aid the markets continuous and long term care. Collated and evaluated annual
demographic counts of the projected market determines the size and facilities to
be provided for the users.
A. Projected Market
1. Post Psychiatric Patients
Once a patient is diagnosed with mental disturbance in a mental

hospital, appropriate treatments are delivered. Such facility provide
treatments to help patients acquire mental stability for a span of time or even
fully recover from the illness. Treatment may last from two weeks to three
months. When patients reached the maximum treatment duration, they are
discharged as per policy of the facility.
Post psychiatric patients may be discharged from the facility but that
does not mean that the patient have recovered from their disorder. After
patients leave their continuous treatment, monitoring of medication may not
133 | U S E R B E H A V I O R A N A L Y S I S
H.I.V.E. Homecare Sanctuary

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be as strict as that of the previous institution they are in. According to Don
Susano J. Rodriguez Memorial Mental Hospitals resident psychiatrist Dr.
Lalyn Marzan, chances of recurrence especially for those who are suffering
from chronic type of illness is inevitable. This cases often happens due to
various factors and are recorded in numerous case study reports.
The following are the psychiatric disorders with their corresponding

follow up treatments that the facility can continuously manage and support.
a. Psychotic Disorders
i.
Schizophrenia
Definition
Thought disorder that impairs judgment, behavior & ability to

interpret reality.
Symptoms must be present at least 6 months to be able to

make a diagnosis.
Risk Factors/Etiology
Men have an earlier onset, usually at 15 to 25 years of age.
Dopamine & abnormalities in Serotonin.
Many believe the family may be the cause of the patient's

schizophrenia. If the mother gives mixed messages, it is
called the double-bind theory.
There are families that are critical, intrusive, and hostile to the
patient. When this occurs, it has been linked to high rates of
relapse.
Schizophrenia may be viral in origin.
Schizophrenia is more prevalent in the low socioeconomic

status groups, either as a result of downward drift or social
causation.
Physical & Psychiatric Presenting Symptoms
Hallucinations (mostly auditory)
Delusions (mostly bizarre)
Disorganized speech or behavior
Catatonic behavior
Negative symptoms

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Usually experience social &/or occupational dysfunction
Physical exam usually unremarkable, but may find saccadic

eye movements, hyper vigilance, etc.1
Treatment
Hospitalization is recommended for either stabilization or

safety of the patient.
Antipsychotics (Atypical): To help control both positive and

negative symptoms.
If no response, consider using Clozapine
The
suggested
psychotherapy
will
be
supportive
psychotherapy
Types of Shizophrenia
Schizophrenia Paranoid Type
MC Type of Schizophrenia
Older patients (Onset is in their late twenties or thirties)

Best prognosis
Presenting Symptoms: Preoccupation with delusions

and/or hallucinations, usually involving grandeur or
persecution
Schizophrenia Disorganized Type
Presenting
Symptoms:
Disorganized
speech
and
behavior. Flat or inappropriate affect. Marked regression

to primitive disinhibited behavior (Bizarre Behavior).
Severe thought disorder. Poor contact with reality
Risk Factors: These patients tend to be younger than 25 "

Worst prognosis
Schizophrenia Catatonic Type
Presenting
Symptoms:
Psychomotor
Disturbances,
ranging from severe retardation to excitation. Extreme

negativism. Peculiarities of voluntary movements. Mutism
is very common
Nabeel Kouka, MD, DO, MBA, August 2009 New Jersey, USA, Psychiatry for Medical Students and Residents

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Complications: Medical care may be necessary because

of exhaustion, malnutrition, self- inflicted injury, or
hyperpyrexia2
Schizophrenia Residual Type
Symptoms: Absence of positive symptoms (delusions,

hallucinations, disorganized speech/behavior & catatonic
behavior)
Patients tend to have negative symptoms (Social

Withdraw, Flat Affect, and Occupational Dysfunction)
Schizophrenia Undifferentiated Type
Presenting Symptoms: Meet criteria for schizophrenia. Do

not meet criteria for other schizophrenia types
Other Psychotic Disorders

Schizophreniform Disorder (> 1 month but < 6 months)
Presenting Symptoms: Same as in Schizophrenia

(Hallucinations, Delusions, Disorganized speech, grossly
disorganized or catatonic behavior, Negative symptoms,
Social &/or Occupational dysfunction)
Difference from Schizophrenia: Symptoms are present > 1

month but < 6 months & most of the patients return to their
baseline level of functioning
Risk Factors: Many of these patients have affective

symptoms as compared with schizophrenics. Suicide is a
risk factor given that the patient is likely to have a
depressive episode after the psychotic symptoms resolve
Treatment
o Must
assess
whether
the
patient
needs
hospitalization, to assure safety of patient &/or

others
o Antipsychotic medication is indicated for a 3-6
month course
o Individual psychotherapy3
2
3
Ibid.
Ibid

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Schizoaffective Disorder
Presenting Symptoms: Mood Disorders (major depressive

episode, manic episode, or mixed episode) + Psychosis
(schizophrenia). Delusions or hallucinations for at least 2
weeks in the absence of mood symptoms
Prognosis:
Better
prognosis
than
patients
with
schizophrenia. Worse prognosis than patients with

affective (mood) disorders
Treatment: Must first determine whether hospitalization is

necessary.
Use
antidepressant
medications
&/or
anticonvulsants to control the mood symptoms. If these

are not effective, consider the use of antipsychotic
medications to help control the ongoing symptoms. Start
with treatment of the worst syndrome
Delusional Disorder
Presenting Symptoms: Non-bizarre delusions for at least

one month. No impairment in level of functioning.
Types include erotomanic, jealous, grandiose, somatic,

mixed, unspecified.
Risk Factors: Mean age of onset is about 40 years (better

prognosis). Seen more in women & most of these patients
are married and employed.
Associated with low socioeconomic status as well as

recent immigration.
Associated with conditions in either the limbic system or

basal ganglia
Treatment:
Antipsychotic
medications
&
Individual
psychotherapy
Brief Psychotic Disorder (> 1 day but < 1 month)
Presenting Symptoms: Same as in Schizophrenia
Difference from Schizophrenia: Symptoms are present > 1

day but < 1 month
Patient appears to be responding to internal stimuli

(Hearing Voices)
Risk
Factors:
Seen
most
frequently
in
the
low
socioeconomic status as well as in those who have


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preexisting personality disorders or the presence of

stressors.4
Treatment
o Hospitalization is warranted if the patient is acutely
psychotic
o Antipsychotics & short-term Benzodiazepines (for
Rx of agitation)
b. Mood Disorders
i.
Major Depressive Disorder (Major Depression)
Mood disorder that presents with at least a 2-week course

of symptoms that is a change from the patients previous
level of functioning
Must have depressed mood or anhedonia (absence of

Pleasure)
Risk Factors/Epidemiology
Women > Men (2:1) due to several factors, such as

hormonal differences
Onset is 40 years
Incidence is higher in those who have no close

interpersonal relationships
Neurotransmitters
abnormalities:
Serotonin,
Norepinephrine & Dopamine

o Serotonin metabolites (5 HOIAA) in suicide &
aggression
Other risk factors include family history, exposure to

stressors & behavioral reasons, such as learned
helplessness.
Presenting Symptoms
Depressed mood & Anhedonia (absence of Pleasure)

during most of the day
Typical Features (Vegetative Changes of Depression)

o (low) Appetite, Weight & Sleep (Insomnia)
Ibid

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o Psychomotor retardation or agitation

o Fatigue or loss of energy nearly every day
o Feelings of worthlessness or guilt
o Diminished ability to concentrate
o Recurrent thoughts about death. (Ask about
Suicide)
Atypical Features
o (high) Appetite, Weight & Sleep (Hypersomnia)
May Also Include Psychotic features: Worse prognosis
Physical Examination
Usually within normal limits
May find psychomotor retardation, such as slowing of

movements & speech
May also find evidence of cognitive impairment, such as

decreased concentration
Lab tests are not diagnostic but may find abnormal

Dexamethasone
Suppression
test
or
Thyrotropin-
Releasing Hormone test

Treatment
Must first (Ask about Suicide) & Secure the safety of the
patient
Antidepressants: Selective Serotonin Reuptake Inhibitors

(SSRI), Tricyclic Antidepressants (TCA) & Monoamine
Oxidase Inhibitors (MOI)
Electro-Convulsive Therapy (ECT) may be indicated if

patient is suicidal or worried about side effects from
medications
Individual Psychotherapy: To help the patient deal with

conflicts & sense of loss
Cognitive Therapy: To change the patients distorted

thoughts about self & world.
ii.
Bipolar Disorder
A mood disturbance in patient that experiences manic

symptoms for > 1 week & cause significant impairment in
his/her functioning level

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Men = Women
Onset in young adults & average age of about 30 years
More prevalent among High Socioeconomic status & who

didnt finish college
Considered to be the illness with the greatest genetic

linkage. (50-70%)
Coexisting disorders: Anxiety, Alcohol Dependence &

Substance Abuse
Presenting Symptoms
Abnormal or persistently elevated mood lasting > 1 week
High Self-esteem or grandiosity
Excessive involvement in activities & Distractibility
Psychomotor agitation & more talkative than usual
Flight of ideas
High Sexual activity
High in goal-directed activity
Usually within normal limits
May find evidence of psychomotor agitation & pressured

speech
Treatment
Must assess patient safety to determine the need for

hospitalization.
Pharmacotherapy: Antimanic Mood Stabilizers (Lithium,

Carbamazepine & Valproic Acid), Benzodiazepines &
Antipsychotics in ER
Individual psychotherapy
Differential Diagnosis
Mental disorders: Schizophrenia & Personality Disorders
Medical disorders: CNS diseases, Hyperthyroidism &

Medications (Stimulants)5
Ibid.

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iii.
Dysthymic Disorder
A chronic mood disorder (mild Depression) characterized by

a depressed mood that lasts most of the time for > 2 years.
(Major depression - usually up to 1 year)
> In women who are < 64 years of age as well as in those

that are unmarried & young individuals from low-income
families
Coexisting disorders: Anxiety, Substance Abuse &/or

Borderline Personality
Treatment
o Hospitalization is usually not indicated in these
patients
o Long-term individual insight-oriented Psychotherapy
o SSRI, TCA or MOI6
Differential diagnosis is essentially the same as for major

depression
Must consider minor depressive disorder & recurrent brief

depressive disorder7
iv.
Cyclothymic Disorder
A chronic mood disorder (mild Bipolar II Disorder)

characterized by many periods of Depressed Mood & many
periods of Hypomanic Mood for > 2 years
6
7
Seen more frequently in women.
Family histories of bipolar disorder
It frequently coexists with borderline personality disorder
Alcohol & substance abuse are common
Ibid.
Ibid.

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Many of the patients have interpersonal and marital

difficulties
Treatment
Pharmacotherapy: Antimanic Mood Stabilizers (Lithium,

Carbamazepine & Valproic Acid)
Psychotherapy will focus on helping the patients gain insight

into their illness & how to cope with it
Medical: Seizures, substances & medications
Mental: Other mood disorders, personality disorders,

medications again
v.
Seasonal Affective Disorder
A mood disorder characterized by depressive symptoms

found during winter months & absent during summer months
Believed to be caused by abnormal melatonin metabolism

("MSH)
Treatment
Phototherapy or sleep deprivation8
c. Anxiety Disorders
Definition: Anxiety is a syndrome with Psychologic &

Physiologic components
Psychologic components
o Worry that is difficult to control
o Hypervigilance
o Restlessness
o Difficulty Concentrating
o Sleep Disturbance
Physiologic components
o Autonomic Hyperactivity
o Motor Tension
Ibid.

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Psychodynamic Theory
Anxiety occurs when instinctual drives are thwarted.
Behavioral Theory
Anxiety is a conditioned response to environmental stimuli

originally paired with a feared situation
Biologic Theory implicate
Various neurotransmitters (GABA, Norepinephrine &

Serotonin)
Various CNS structures (Reticular Formation & Limbic

System)
Presenting Symptoms
Excessive Nervousness
Fears
Sense of impending Doom
Irrational Avoidance of objects or situations
Anxiety Attacks
Physical & Psychiatric Examination
Mental Status: Hyper-arousal, ! Startle Reflexes, Timidity &

Worries
Physical Examination: Evidence of Autonomic Arousal &

Motor Restlessness
Diagnostic Tests
Evidence of medical conditions (Thyroid Problems) or

substances that cause anxiety disorders
Adjustment disorders with Anxious mood
Anxiety disorders (Generalized Anxiety disorder, panic

disorder, phobias & Post-Traumatic Stress Disorder)
Anxiety disorder due to general medical conditions (Thyroid

Problems)
Substance-induced Anxiety disorder9
Ibid.

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Treatment
i.
Psychotherapies (Behavioral Modification)
Pharmacotherapy: Antidepressants & Benzodiazepines
Panic Disorders
Definition
Recurrent unexpected Attacks of Intense Anxiety that

include marked physical symptoms, such as Tachycardia,
Hyperventilation, Dizziness, and Sweating
Have a Genetic Component
Associated w/ separations during childhood & interpersonal

loss in adulthood
Occur in response to Panicogens (i.e. Lactate, CO2,

Caffeine & Yohimbine)
Presenting Symptoms
Prevalence: 2% of the population
Occurs at a 1 to 2 male-to-female ratio
Onset: Often during the third decade
Course: Severity of symptoms may Wax & Wane and may

be associated with inter-current stressors
Duration: Attacks usually last a few minutes
Associated problems
Agoraphobia, Depression, Generalized Anxiety &

Substance Abuse
Treatment
Pharmacotherapy
Short term Treatment: Benzodiazepines (Alprazolam)
Long term Treatment: SSRI (Fluoxetine) &/or TCAs

(Imipramine)
Others: Clonazepam & MOI (Phenelzine)
Psychotherapy
Relaxation Training for panic attacks


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ii.
Systematic Desensitization for Agoraphobia10
Phobic Disorder
Definition
Irrational fear & avoidance of objects & situations
Presenting Symptoms
Agoraphobia
Fear or avoidance of open spaces from which escape

would be difficult in the event of panic attack (Public
Places, Transportation, Crowds)
More common in women
Often leads to severe restrictions on individuals travel

& daily routine.
Social Phobia
Fear of humiliation or embarrassment in either general

or specific social situations (e.g., Public Speaking,
Stage Fright)
Specific Phobia
Fear or avoidance of Objects or Situations other than

Agoraphobia or Social Phobia.
Involves
Animals
(Carnivores,
Spiders),
Natural
Environments (Storms), Injury (Injections) & Situations

(Heights, Darkness)
Treatment
Cognitive-Behavioral Therapies for phobias
Systematic Desensitization, Flooding & Assertiveness

Training
Pharmacotherapy
10
11
SSRI, Buspirone & B-Blockers (for Stage Fright)11
Ibid.
Ibid.

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iii.
Obsessive-Compulsive Disorder (OCD)
Definition
Characterized by recurrent Obsessions or Compulsions that

are recognized by the individual as unreasonable
Obsessions:
commonly
Anxiety-Provoking
concerning
&
Intrusive
Contamination,
Thoughts
Doubt,
Guilt,
Aggression & Sex
Compulsions: Peculiar Behaviors that reduce Anxiety via

Hand-Washing, Organizing, Checking, Counting & Praying
Associated with abnormalities of Serotonin metabolism
Presenting Symptoms
Symptoms usually Wax & Wane
Prevalence: 2% of population.
Occurs at a 1 to 1 male-to-female ratio ***
Onset: Insidious & occurs during childhood, adolescence or

early adulthood
Depression, other Anxieties & Substance Abuse are

common
Chapped hands when hand-washing compulsion is present
Treatment
Pharmacotherapy: SSRI (Fluoxetine or Fluvoxamine) &

Clomipramine
Behavioral Psychotherapies: Relaxation Training, Guided

Imagery, Exposure,
Response Prevention, Thought Stopping Techniques &

Modeling12
iv.
Acute Stress Disorder & Post Traumatic Stress Disorder
Definition
12
Ibid.

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These disorders are characterized by Severe Anxiety

symptoms & follow a threatening event that caused feelings
of Fear, Helplessness or Horror
Acute Stress Disorder: Anxiety lasts < 1 month (but > 2

days)
Post-Traumatic Stress Disorder (PTSD): Anxiety lasts > 1

month
Traumatic events precipitate Acute Stress & Post Traumatic

Stress Disorders
Pre-morbid factors, such as personality traits &/or play an

uncertain role
Onset: May occur at any age 50% of cases resolve within 3

months
o Symptoms begin immediately after trauma, but may occur

after months / years
Three key symptom groups
Re-experiencing of the Traumatic Event
Dreams, Flashbacks or Intrusive Recollections
Avoidance of Stimuli associated with the trauma or numbing

of general responsiveness
Increased
Arousal:
Anxiety,
Sleep
disturbances
&
Hypervigilance
Anxiety, Depression, Impulsivity & Emotional Lability are

common
Survivor guilt - A feeling of irrational guilt about an event

sometimes occurs
Treatment
Counseling after a stressful situation to prevent PTSD from

developing
Group Psychotherapy with other survivors is helpful
Pharmacotherapy:
Antidepressants
(SSRI,
TCAs)
or
Benzodiazepines13
13
Ibid.

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v.
Generalized Anxiety Disorder
Definition
Excessive
&
poorly
controlled
Anxiety
about
life
circumstances (> 6 months)
Both Psychologic & Physiologic symptoms of Anxiety are

present
Genetic Predisposition for an anxiety trait
Presenting Symptoms
Prevalence: 5% of the population
Occurs > in Women at a 2 to 3 male-to-female ratio
Onset: Often during childhood, but can occur later
Course: Usually chronic, but symptoms worsen with stress
Associated problems: Depression, Somatic Symptoms &

Substance Abuse
Treatment
Behavioral
Psychotherapy:
Relaxation
Training
&
Biofeedback
Pharmacotherapy:
Venlafaxine,
Antidepressants,
Buspirone & Benzodiazepine14
d. Adjustment Disorders
Definition
Maladaptive Reactions to a psychosocial STRESSOR ***
Cause: environmental stressors having an effect on

functioning
14
Ibid.

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Risk that a stressor will cause an adjustment disorder

depends on an individuals emotional strength & coping
skills
Prevalence: Extremely common; all age groups
*** Onset: Within 3 months of the initial presence of the

stressor
*** Course: Lasts 6 months or less once the stressor is

resolved
Can become chronic if stressor continues & no ways of

coping with stressor
Associated Problems
Social
&
occupational
performance
deterioration
or
withdrawn behavior
Normal reaction to stress
Disorders that occur following stress
Post-Traumatic Stress Disorder (PTSD) - Severe Symptoms
Grief - Same symptoms as Adjustment Disorder, but

due to death
Major Depressive Disorder - Severe Symptoms
General Anxiety Disorder
Treatment
Supportive Psychotherapy
Pharmacotherapy: Anxiolytics or Antidepressants15
Patterns of care of a large sample of patients discharged after

short inpatient treatment are discussed in the light of the changes
introduced by the 1978 Mental Health Act in the Italian psychiatric care
delivery system. Three closely related issues are considered: 16
Use of psychiatric hospitalization.
15
Ibid.
Barbato A, Terzian E, Saraceno B, Montero Barquero F, Tognoni G. (1992 Jan 27) Soc Psychiatry Psychiatr Epidemiol.
From: http://www.ncbi.nlm.nih.gov/pubmed/1313602
16

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Relationships between inpatient and community treatment

before and after an admission episode.
Continuity of care.
The main findings are:
Great variability between services suggests that local factors

play an important role in determining the contents of care in
Italian post-reform psychiatry.
The relationship between inpatient and community services is

complex, partial integration being the most common picture.
Psychiatric hospitalization is the entry point into the care

system for a sizeable group of patients.
Continuity of care is achieved for half the patients, mostly with

diagnoses of severe mental disorders.
Subjects with a recent history of revolving door behavior or a

past history of mental hospital admission show the highest
likelihood
of
remaining
in
community
care
following
discharge.17
2. After Substance Abuse
"...the more treatment an addict receives, the better his or her

chances are of remaining sober."18
People would like to think that completing a drug rehab will "fix"
the addiction. However, the disease of addiction is incurable, but
manageable. It is imperative to have an after-care plan before
graduating from treatment. Relapse is a reality no matter how much one
thinks they have a handle on their disease and most likely occurs within
days of walking out of the facility to years. Most addicts and alcoholics
who relapse do so within the first 18 months. Some tools to consider
17Ibid.
18
http://www.projectknow.com/research/aftercare/#learn

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when building aftercare plan is transitional- living, extended treatment,

and 12-step programs. Speaking with counselors, therapists, family
members and peers with a substantial amount of sobriety can help in
learning how to maintain recovery. It is best to build the after-care plan
before leaving the facility so the recovering addict can be prepared for
certain situations and know how to keep themselves safe.19
Substance use disorder (DSM II) is a generic term referring to
psychiatric disorder associated with regular use of substances that
affect the central nervous system. The behavioral changes resulting
from such disorders are generally viewed as socially desirable.
Pathologic use of centrally acting substances is divided into
categories of abuse and dependence (DSM III).
Misuse of substances must be present long enough for

pathologic pattern to be established for it be considered
substance abuse; sporadic excessive drug abuse is not
technically abuse. Formal diagnosis requires that the
following criteria exist for at least 1 month.20
The term dependence denotes here physiologic dependence,

which characterized by the presence of tolerance and
withdrawal. Dependence usually develop in individuals with a
pathologic pattern of use and its social consequences, but it
may occasionally occur in individuals who have not exhibited
a pathologic pattern, as in the case of a patient who becomes
dependent on a narcotic during a treatment of a medical
treatment.
Tolerance has developed when the same dose of

substance produces a decreases effect or when
increasing doses are necessary to produce the same
effect.
Withdrawal refers to the development of an abstinence

syndrome, which is specific to the substance in use
when it is withdrawn or dosage is decreased.
Addiction is a term used by many researchers to refer to

overwhelming involvement with seeking and using drugs or
alcohol and a high tendency to relapse after withdrawal. It is
19
20
Dr. Howard Samuels n.d. After Care Plan, http://www.thehillscenter.com/drug-rehab/what-to-do-after

Steven L. Dubovsky 1985 by Harwal Publishing Company, Media, Pennsylvania, Psychiatry

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therefore a quantitative description of the degree to which

drug use pervades an individuals life rather than a condition
that can be clearly defined. Insofar as total preoccupation with
a drug is a severe pattern of pathologic use, addiction may be
said to be a form of substance abuse as defined in section 1B.
While some practitioners feel that all addicted individuals are
physically dependent, many authorities state that it is possible
to be drug dependent and not be addicted in that ones life is
not organized around finding and using the drug. Conversely,
it may be possible to be addicted in the sense that drugseeking behavior is paramount in an individuals life without
that individual being physically dependent.21
i.
Transition
Sober/Transitional Living
A transitional living or sober living house can vary in
services, structure, dynamics, and capacity. Generally run by

a live-in manager, a structured house usually integrates drug
testing, curfews, meetings, and probation periods. Ask a lot of
questions when viewing or selecting the sober living; View it
as an extension of treatment, as safety should be number one.
Outpatient Care
This is a great tool for extending the benefits of
treatment.
Counseling,
group
and
individual
therapy,
medication management, and drug testing are usually offered.

Recovering addicts that don't have the benefit of living in a
sober/transitional living are highly recommended to utilize
outpatient care to extend their treatment.
Sober Coach/Companion
An excellent tool for chronic relapses, vulnerable
situations or unstable addicts in early recovery. Companions

assist individuals in achieving objectives through exploration
of problems and their ramifications, examination of attitudes
and feelings, consideration of alternative solutions, and aiding
in decision-making. Coaching basically help clients utilize
21
Ibid

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their resources to resolve problems and/or modify behaviors,

attitudes and values.
12-Step Programs
12-step
programs
are
available
for
addictive,
compulsive, or behavioral problems based on the 12-steps of

Alcoholics
Anonymous.
For
drug
addicts,
Narcotics
Anonymous meetings are available, as well as specific drug

12-step groups. These programs have proven successful for
addicts in recovery. With these programs an addict can find
anonymous support and tools from others walking the same
path.22
ii.
After Drug Rehab

Boredom can be an instant trigger for relapse. Since
addiction is a disease of the mind, "staying out of one's head"
and keeping active are suggested. The old way of living didn't
work. Knowing what to do after drug rehab, and how to have
fun in sobriety is very important. Sober friends, hobbies, and
choices can be fun and ensure a happy healthy way of life.23
iii.
Family Involvement
For family and friends of drug- or alcohol-addicted
individuals, addressing the addiction is one of the most
difficult aspects of helping the addicted person seek
treatment. Often, over time, daily family involvement has only
managed to enable the addict. Family members frequently do
not know how to bring up the issue of addiction therapy, and
opt to ignore the problem for fear of pushing their loved one
away during a confrontation or intervention.
These are legitimate concerns, and while families
should understand that approaching their loved one should be
a gentle and supportive process, they also need to
understand that most patients seek substance abuse
treatment because of positive family involvement and
intervention.24
22
Ibid
23
Ibid.
24 Ibid.

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After a Substance Abuse Treatment Program

There truly is no clear-cut end to the addiction therapy
process. Families struggling with the effects of their loved

ones drug and alcohol addiction should continually attend Al
Anon or Nar Anon meetings (perhaps both) on a regular basis
to continue a constructive program of support and ongoing
education.
Alcohol and drug addiction are both considered family
diseases, and family involvement with people combating
drug and alcohol addiction requires continual attendance at
these meetings during and after the formal inpatient or
outpatient addiction therapy session. Additionally, while these
meetings help individuals to understand the disease and how
to support someone they care about, they also assist friends
and family with their own emotional support during what is
most often an incredibly trying and stressful time. By
continuing to attend Al Anon and Nar Anon meetings, friends
and family of an addicted individual can continue to stay out
of the destructive cycle of enabling and codependency and
fully realize the benefits of addiction therapy.25
B. Market Demography
The following data are taken from Don Susano J. Rodriguez Memorial
Mental Hospitals record. The 2013 report was classified as to Inpatient,
Outpatient, and Patient Discharge. The succeeding demography were also
categorized as to type of disorder as well as the location where patients often
come from.
The collated reports also include first quarter of 2014s statistics of
psychiatric patients arranged according to sex and age. Analysis of the
following statistics will determine the size of the facility. Market size will be
based on the annual growth report of mental disorder and substance abuse
cases in the entire region.
25
Steven Gifford n.d., LICDC, LPChttp://psychcentral.com


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1.
Regional Psychiatric Demography
Don Susano J. Rodriguez Memorial Mental Hospital 2013

(Inpatient and Outpatient Records)
Date
Outpatient Department
Admission
Discharge
2013
Male
Female
Total
Male
Female
January
292
277
118
53
66
February
159
149
98
39
55
March
343
310
110
53
68
April
396
327
135
53
70
May
373
321
100
43
59
June
369
318
96
36
50
July
215
210
82
50
47
August
196
192
96
41
42
September
252
260
103
43
60
October
267
259
79
38
50
November
257
246
84
45
57
December
248
217
80
35
47
Total
3367
3086
1181
529
671
Table 1.0 Source: Don Susano J. Rodriguez Memorial Mental Hospital records officer
The figures presented in table 1.0 showed the outpatients, admitted, and
discharged mental patients for the entire 2013 in the whole Bicol region. The
census from Don Susano J. Rodriguez Memorial Mental Hospital had revealed that
male outpatients outnumbered female in general. Female though have a higher
discharge rate than admitted male patients.

(Classification According to Disorder)

z
Mental Disorders
January
February
March
April
IPD
OPD
IPD
OPD
IPD
OPD
IPD
OPD
Schizophrenia, Undifferentiated
Type
21
68
19
65
23
67
70
Schizophrenia, Paranoid Type
24
72
24
59
25
73
36
18
67
15
60
17
65
20
Schizophrenia
82
20
87
13
94
11
Bipolar Disorder MRE Manic with

Psychotic Feature
51
73
80
39
Substance Induced with Psychotic

Feature
70
Major Depression Disorder
25
Psychosis NOS
23
22
28
11
Adjustment Disorder
Mental Disorders
May
June
July
August
IPD
OPD
IPD
OPD
IPD
OPD
IPD
OPD
Type
34
63
25
75
10
87
47
41
18
87
16
74
15
12
14
94
13
88
Schizophrenia
13
45
16
100
19
94

Psychotic Feature
35
13
16
12

Feature
10
27
35
Psychosis NOS
14
Adjustment Disorder
11

z

Mental Disorders
September
October
November
December
IPD
OPD
IPD
OPD
IPD
OPD
IPD
OPD
Type
23
95
18
90
12
78
19
75
18
87
21
97
20
83
12
79
15
68
16
87
15
80
10
81
Schizophrenia
12
126
19
122
26
85
28
101

Psychotic Feature
10
31
32
14
76
17
53

Feature
15
11
16
Psychosis NOS
22
10
13
Adjustment Disorder
The tables above are sorted data of inpatients and outpatients according to
mental disorder in Don Susano J. Rodriguez Memorial Mental Hospital for the year
2013.

(Sorted According to District)
Province/District
January
February
March
April
IPD
OPD
IPD
OPD
IPD
OPD
IPD
OPD
District I
11
64
26
12
20
13
68
District II
10
74
30
95
83
District III
11
49
33
47
11
72
District IV
112
10
95
105
74
Iriga CIty
24
25
28
11
74
22
79
Naga City
17
70
21
12
94
15
92
Camarines Norte
12
62
16
29
11
65
11
74
Albay
10
57
23
23
56
15
65

z
Sorsogon
11
40
12
14
16
64
12
62
Masbate
11
19
28
Catanduanes
26
Quezon
(According to District)
Province/District
May
June
July
August
IPD
OPD
IPD
OPD
IPD
OPD
IPD
OPD
District I
73
68
50
48
District II
76
70
53
50
District III
74
73
12
58
55
District IV
76
13
71
10
60
52
Iriga CIty
18
87
13
79
14
70
12
60
Naga City
13
80
83
60
62
Camarines Norte
11
65
16
76
48
53
Albay
15
59
63
45
50
Sorsogon
10
61
53
42
30
Masbate
33
28
Catanduanes
10
15
(According to District)
Province/District
September
October
November
December
IPD
OPD
IPD
OPD
IPD
OPD
IPD
OPD
District I
45
59
50
10
49
District II
10
42
52
13
49
12
46
District III
11
52
56
53
10
45
District IV
54
13
64
57
57
Iriga CIty
59
15
77
15
68
11
65
Naga City
47
11
66
63
13
53
Camarines Norte
52
57
63
55

z
Albay
53
12
45
54
58
Sorsogon
28
47
31
30
Masbate
Catanduanes
The tables above are sorted 2013 data of inpatients and outpatient based
on district and province from the whole region.
Do n Su san o J. Rod r igu ez M em or ial M en tal Hosp ital 2013

(In p atien t an d Ou tp atien t Recor d s)
400
350
300
250
200
150
100
50
0
Male Outpatient
Female Outpatient
Total Inpatient
Male Discharge
Female Discharge
The graph above shows the sorting of outpatient according to male and
female, the total admitted patients, and male and female discharge rate. The
month of April have shown the peak of outpatients for both male and female.
Outpatients include recurring cases and psychiatric consultation.
In the same month, as observed in the graph, shows the highest admission
rate for both male and female patients. Together with the increase of patient
admission in the month of April is the peak of discharge rate for both male and
female patients as well.

(First Quarter Report)
OUTPATIEN
T
10-14
15-19
20-44
45-64
65+
Total
Gran
d
Total

z
Month
January
22
19
114
109
121
117
31
25
292
277
569
February
11
81
64
61
67
159
149
307
March
33
39
152
135
132
119
18
12
343
310
700
April
11
30
36
121
112
108
96
21
23
291
275
566
May
20
25
112
104
84
49
27
25
249
237
486
June
22
17
137
122
90
62
27
28
279
220
528
5.5
4.
5
22.6
7
24.
5
119.
5
107.6
7
99.3
3
85
21.8
3
19.
5
268.8
3
244.6
7
Month
January
15
12
22
18
25
41
66
53
119
February
18
18
15
25
16
55
39
94
March
17
13
21
17
30
23
68
53
121
April
17
10
13
19
15
16
46
47
93
May
15
12
18
15
13
19
48
46
94
June
11
14
24
18
17
14
52
47
99
1.3
3
0.
5
15.5
11.
5
19.3
3
17
20.8
3
21.
5
0.0
0.0
55.83
47.5
AVERAGE
INPATIENT
AVERAGE
The table above is the 2014 first quarter data of inpatients and outpatient
according to gender. Statistics are also grouped with accordance to their
corresponding age bracket.
Do n Su san o J. Rod r igu ez M em or ial M en tal Hosp ital 2014
(Ou tp atien t Recor d )
May
March
January
0
65 and aboveyrs old
50
100
45 to 64yrs old
150
200
20 to 44yrs old
250
15 to19 yrs old
300
10 to 14 yrs old
The graph above shows the outpatient department market rate categorized
in their corresponding age brackets. The market have shown level increase from

z
ages 15 to 19 until 44 to 64. With a total average of 227.17 cases, the peak of
outpatients came from ages 20 to 44 years old for both genders.
Do n Su san o J. R o d r igu e z M e m o r ial M e n tal Ho sp ital 2014

(In p atien t Recor d )
June
May
April
March
February
January
0
65 and above
10
20
45 to 64yrs old
30
40
20 to 44yrs old
50
60
15 to19yrs old
70
10 to 14yrs old
The graph above shows the inpatient department market rate categorized
in their corresponding age brackets. Same with the outpatient department, the
market have shown level increase from ages 15 to 19 until 44 to 64. And with a
total average of 42.33 cases, the peak of inpatients came from ages 45 to 64 years
old for both genders.
2.
Substance Abuse Demography

City Health Office (Naga City) Substance Abuse Records
2013
2012
2011
January
February
March
April
May
June
July
August
10
September
October

z
November
December
Source: City Health Officer
City Health Office (Naga City) Substance Abuse Records

Age Range
Reported Case (2013)
13-16
17-20
20-25
15
26-30
18
41-50
Source: City Health Officer
The records provided by the city health office were limited due to
confidentiality. For the complete annual report, the August 2013 record shows that
the highest count of rehabilitation inpatient in DOH-Camarines Sur Treatment and
Rehabilitation Center. Based on the tables shown above, the 20-25 and 26-30 age
brackets have shown an increase in number of the total patients in the same
facility.
C. Related Case Study Reports

Psychiatric Case Study
A group of researcher in the psychiatric department of University
of Michigan conducted a study on what awaits discharged patients after
psychiatric treatment. The investigation showed that timely outpatient
follow-up after hospitalization may not reduce readmission or
substantially improve longer-term depression treatment, suggesting a
need for additional or more effective care processes.
The study have revealed that transitions between inpatient and
outpatient health care settings are associated with elevated risks of
adverse events and, therefore, are a focus of quality improvement
initiatives. After 30 days of discharge from a psychiatric hospitalization,
approximately 10%15% of patients are readmitted due to recurrence,

z
and suicide rates are more than 100 times higher than in the general
population.
Homecare treatment after psychiatric hospitalization have vivid
effects in the reduction of incidence of hospital readmission. Continuous
aftercare had aided the risk of psychiatric adverse outcomes. The
National Committee for Quality Assurance, therefore, includes
outpatient mental health follow-up within seven days of discharge from
a psychiatric hospitalization as a quality measure in the Healthcare
Effectiveness Data and Information Set (HEDIS). To understand the
clinical utility of applying health system resources toward improving this
measure, it is important to assess whether timely outpatient mental
health follow-up corresponds with greater receipt of evidence-based
treatments or fewer adverse outcomes.
In 2008, the Veterans Health Administration (VHA) implemented
a policy mirroring this HEDIS quality measure. All patients discharged
from an inpatient mental health setting were required to have a followup outpatient contact within seven days. In 2009, VHA adopted this
measure as a quality indicator to evaluate its medical centers and
regional networks. These policy changes provide an opportunity to
evaluate whether improved performance in providing seven-day followup visits is associated with improvements in other care processes and
outcomes.
Prior research have demonstrated a spillover effect (also referred
to as a halo effect) of performance monitoring, suggesting that focused
improvement in one aspect of treatment may benefit other aspects of
care for the same disorder.26
In the period following discharge from hospital, psychiatric
patients are at high risk of readmission. Within the first 6 months,
readmission occurs for between 20 and 40% of patients (Caton et al,
1985; Boydell et al, 1991). In selected groups of patients the figure is
higher; over 50% of patients were readmitted within 6 months of a
course of electroconvulsive therapy (Robertson & Eagles, 1997). The
peak period of risk for readmission is within the first month (Naji et al,
1999). For long-stay psychiatric patients a similar pattern obtains, with
26
Paul N. Pfeiffer, M.D.; Dara Ganoczy, M.P.H.; Kara Zivin, Ph.D.; John F. McCarthy, Ph.D.; Marcia
Valenstein, M.D.; Frederic C. Blow, Ph.D. (2012) Psychiatric Services retrieved: http://ps.psychiatryonline.org/

z
likelihood of readmission exhibiting a decaying curve over time, albeit

with a lower initial rate of returning to in-patient care (Rothbard et al,
1999).
Suicide data tend to mirror those for readmission. Rates of
suicide are high in the year after discharge, notably within the first 28
days (Goldacre et al, 1993; Geddes & Juszczak, 1995; Geddes et al,
1997; Sohlman & Lehtinen, 1999). Noting an increase in rates of postdischarge suicide among women from 1968 to 1992, Geddes and
Juszczak (1995) made a link with decreasing numbers of in-patient
beds. The National Confidential Inquiry into Suicide and Homicide
(Scottish Executive, 2001) found a peak of post-discharge suicides
within the first 2 weeks, when 8% of all suicides by community
psychiatric patients occurred. Eighty percent of this group died before
their first follow-up contact. These findings gave rise to the authors'
recommendations that all patients should be followed up within 1 week
of discharge (within 48 hours for patients who have been at high risk),
and that discharge should be preceded routinely by a joint case review
between in-patient and community teams, with this review including an
assessment of risk.
As reflected in the second confidential inquiry recommendation
above, it is often held that poor communication, notably between
healthcare professionals, is responsible for problems that arise around
the time of discharge. Certainly, with respect to the communication that
hospital specialists have with general practitioners (GPs), this criticism
is probably well founded.27
If GPs are to implement continuity and changes in care following
admission then they require information, accurately and promptly,
following a patient's discharge. Orrel and Greenberg (1986) found that
only 26% of GPs had received a brief communication about an in-patient
stay within 2 weeks of discharge. While it is straightforward to tailor
information to suit GPs' preferences by altering the format of the handwritten discharge letter (Walker et al, 1998), this information still has to
reach the GP. Once fears about confidentiality have been allayed, it is
to be hoped that electronic transmission will usually be used. Meanwhile,
we rely on patient transmission by hand. Although this can be
27
Ibid.

z
augmented by posting a copy of the hand-written discharge summary

(Curran et al, 1992), patients are, perhaps surprisingly, usually quite
reliable in relaying this letter to their GP (Colledge et al, 1992; Naji et al,
1999). GPs are keener to be telephoned about their patients at the time
of discharge than hospital specialists might think (Sagar, 1990; Walker
& Eagles, 1994).
Poor information transfer at discharge does appear to increase
the likelihood of readmission (Olfson & Walkup, 1997) and one study
found that, after discharge, an alarming 90% of elderly patients were
receiving different medication regimes at home from those they had
been prescribed in hospital (Cochrane et al, 1992). Are efforts to
improve communication helpful in a patient's post-discharge care?
McInnes et al (1999) found that pre-discharge visits to the frail elderly
improved GP-hospital collaboration, were associated with increased
patient satisfaction and gave rise to greater use of community resources.
It is perhaps doubtful that this would transfer cost-effectively to
psychiatric settings. A randomized trial in Aberdeen (Naji et al, 1999) of
standard discharge procedure v. a package of enhanced communication
(GPs were telephoned; patients' appointments were arranged with GPs
before discharge; discharge letters were posted as well as handdelivered) indicated marginal benefit only. There was a trend towards
lower rates of readmission and patients had more consultations about
psychiatric issues with their GPs after discharge.28
Various clinical interventions have sought to ameliorate patients'
vulnerability in the post-discharge period. As with efforts to enhance
inter-professional communications, there is little evidence that these
have been successful.
The UK 700 trial recruited patients with psychosis, either at the
time of discharge from hospital, or when living in the community but
having been admitted during the preceding 2 years. The patients were
randomly assigned to standard or intensive case management, the latter
being similar in format to the Care Program Approach. Intensive case
management had no impact on suicidality (Walsh et al, 2001), nor on
either clinical status or social functioning (Burns et al, 1999). There was
no impact on likelihood of readmission (Burns et al, 1999). However, a
28
Ibid.

z
similar study in London (Tyrer et al, 1995) found that closely monitored
community-based patients spent significantly longer in hospital. Tyrer et
al (1995) did find that loss to follow-up was less common in the closely
monitored group.Few studies have focused more specifically on the
post-discharge period. Sullivan and Bonovitz (1981) found that
subsequent out-patient attendance was improved by offering the first
appointment within 3 days of discharge. A nurse discharge coordinator
had no positive effect on readmission rates, on post-discharge wellbeing or on patient satisfaction ratings (Walker et al, 2000). As in Roy's
(2001) recent review, there have been no intervention studies of
representative cohorts of discharged patients to determine whether
suicidality can be influenced. Psychological autopsy studies, with all
their inherent flaws, can perhaps yield pointers towards clinical practices
that may reduce suicidality. King et al (2001) found that discontinuity of
contact was associated with post-discharge suicides in Wessex.
However, rates of key personnel on leave or leaving were said to be
1% in the control group and 5% in the suiciding patients. Given that the
average consultant psychiatrist is on leave for some 15% of the time,
this strongly suggests incomplete and selective recording.29
Currently, researchers know that psychiatric patients are
vulnerable in the post-discharge period, but they have no good evidence
to direct their efforts to improve the situation. Attempts to enhance interprofessional communication have the advantage of being very cheap
(Naji et al, 1999), which probably makes them worth pursuing despite
the tenuous evidence of effectiveness. The same cannot be said for
clinical packages of care in the post-discharge period, such as the predischarge meetings and rapid follow-up espoused by the National
Confidential Inquiry (Scottish Executive, 2001). As others have pointed
out (Marshall, 1996; Geddes, 1999), it is probably premature to
introduce such policies without an adequate evidence base. It seems
much more logical to conduct good research studies to determine
whether patients' vulnerability in the post-discharge period can indeed
be ameliorated and to design appropriate policies thereafter.30
29
Ibid.
Shona A. Walker, Senior Registrar and John M. Eagles, Consultant Psychiatrist (2002), Psychiatric Bulletin retrieved
from: http://pb.rcpsych.org
30

z
II.
Management Type Analysis

As mentioned in the earlier part of this chapter, the facility will be comprised
of two type of users wherein the first half would be the client and the second part
is composed of the management staff. The analysis will discuss the following
management type as well as the roles and responsibilities of each staff member.
Management scale will also be scaled in proportion to the market size.
A. Management Type
1.
Administrative Order No. 147 S. 2004

Amending Administrative Order No. 70-A, Series 2002 re:
Revised Rules and Regulations Governing the Registration,
Licensure and Operation of Hospitals and Other Health Facilities
in the Philippines
a. Section 6. Definition: A hospital is a health facility for the
diagnosis, treatment and care of individuals suffering from
deformity, disease, illness or injury, or in need of surgical,
obstetrical, medical or nursing care. It is an institution where
there are installed bassinets or bed 24-hour use or longer by
patients in the management of deformities, disease, injuries,
abnormal physical, and mental conditions, and maternity
cases.
b. Section 7. Classification of Hospitals and other Health
Facilities: Hospitals and other facilities shall be classifies as
follows
Government or Private
Government Operated and maintained partially or
wholly by the national, provincial, city or municipal
government, or other political unit: or by any
department, division, board or agency thereof.31
Private Privately owned, established and
operated with funds through donation, by any
individual corporation, association or organization.
General or Special
General Provides services for all types of
deformity, disease, illness or injury.
Special Primarily engaged in the provision of
specific clinical care and management.
Service Capabilities
31
Department of Health, April 28, 2004 Philippines, Administrative Order No. 147 S. 2004

z
32
Primary Care
o Non-departmentalizes
hospital
that
provides clinical care and management
on the prevalent diseases in the facility.
o Clinical Services include general
medicine, pediatrics, obstetrics, and
gynecology, surveying and anesthesia.
o Provide appropriate administrative and
ancillary services (clinical laboratory,
radiology, pharmacy)
o Provides nursing care for patients who
require intermediate, moderate and
partial category of surprised care for 24
hours or longer.
Secondary Care
o Departmentalized hospital that provides
clinical care and management on the
prevalent diseases in the locality, as well
as particular forms of treatment, surgical
procedure and intensive care,32
o Clinical services provided in Primary
Care, as well as specialty clinic care.
o Provides appropriate administrative and
ancillary services (clinical, laboratory,
radiology, and pharmacy)
o Nursing care provided on primary care,
as well as total and intensive skill care.
Tertiary care
o Teaching and training hospital that
provides clinical care and management
and the prevalent diseases in the locality,
as well as specialized forms of treatment,
surgical procedure and intensive care.
o Clinical services provided by in
secondary care, as well as subspecialty
clinical care.
o Provides appropriate administrative and
ancillary services (clinical laboratory,
radiology, pharmacy)
o Nursing care provided secondary care,
as well as continuous and highly
specialized critical care.
Infirmary A health facility that
provides emergency treatment
and care to the sick and injured,
as well as clinical care and
management to mothers and
newborn baby.
Birthing Home A health facility
that provides maternity services
on pre-natal and post-natal care,
Ibid

z
normal spontaneous delivery, and

care of newborn baby.33
Acute Chronic Psychiatric Care
Facility A health facility that
provides
medical
services,
nursing care, pharmacological
treatment
and
psychosocial
intervention for mentally ill
patients
Custodial Psychiatric Care Facility
A health facility that provides
long-term care, including basic
human services such as food and
shelter, to chronic mentally ill
patients.34
With accordance to the Administrative Order no 147 s. 2004 of

Department of Health Philippines, the management would be privately
operated and would offer special treatment for specific clinical care and
management. The facility would fall under other health facilities and would
provide tertiary care service capabilities. Under the tertiary care, the
facility would comply with the staffing requirements of Acute-Chronic
Psychiatric Care Facility/Custodial Psychiatric Care Facility.
B. Organizational Mandate
Vision
The Filipino people with the highest level of mental health.
Mission
To promote mental health and prevent mental disorders through
advocacy, education, prevention, and best practice interventions for the
Filipino people.
Goals
To promote mental health and prevent mental disorders through
advocacy, education and information dissemination, and capability building;
33
34
Ibid
Ibid

z
To provide best practice interventions for assessment, treatment,

and
rehabilitation
that
are
multi-disciplinary,
family-focused,
and
community-based;
To promote the conduct of research in mental health that will serve
as basis for policy and program development;
To collaborate and build alliances with government and nongovernment organization, local and international, for the advancement of
mental health.35
C. Organizational Structure
Gracedale Nursing Home Operational Assessment Final Report Table taken from
www.phcr.org
Organizational Chart taken from www.maristowhouse.co.uk
35
Philippine Mental Health Association, Inc, http://www.pmha.org.ph

HIVE Organizational Chart

z
HIVE Organizational Chart
The organizational structure of the HIVE is based on existing nursing home

staffing chart. The organizational management of the facility was divided in

z
accordance to the Department of Health personnel administration. The subgroups

were mainly Medical Service Department where physicians medical plans are
provided, the Nursing Service Department, where personal care are given, the
Ancillary Service Department, for continuous therapeutic services, and the
General Administrative Service Department, for overall clerical, maintenance,
dietary and housekeeping services.
D. Management Roles and Responsibilities
The
following
are
enumerated
management
staff
with
their
corresponding roles and responsibilities. Job descriptions are also provided

for each member of the organization. Descriptions were patterned from
existing facility type and provision given by the Department of Health,
Philippines.
1.
Owner
Means the individual, partnership, corporation, association or other
person who owns a facility. In the event a facility is operated by a person

who leases the physical plant, which is owned by another person, "owner"
means the person who operates the facility, except that if the person who
owns the physical plant is an affiliate of the person who operates the facility
and has significant control over the day-to-day operations of the facility, the
person who owns the physical plant shall incur jointly and severally with the
owner all liabilities.36
2.
Administrator
The nursing home administrator is appointed by the governing body.
Federal regulations require that a nursing home be supervised by an

administrator licensed by the state. The administrator is charged with
management of the facility. He/she is expected to administer the facility in
a manner that allows each resident to maximize physical, mental and
psychosocial well-being.37
36
37
Health Facilities and Regulation (210 ILCS 45/) Nursing Home Care Act, http://www.ilga.gov
Mark W. Swanson, O.D, 1998 243 N. Lindbergh Blvd., St. Louis, Optometric Care of Nursing Home Residents

z
3.
Medical Director
The Certified Medical Director in Long Term Care recognizes the
dual clinical and managerial roles of the medical director. The CMD
credential reinforces the leadership role of the medical director in promoting
quality care and offers an indicator of professional competence to long term
care providers, government, quality assurance agencies, consumers, and
the general public.
Role 1Physician Leadership

The medical director serves as the physician
responsible for the overall care and clinical practice carried
out at the facility.
Role 2Patient Care-Clinical Leadership

The medical director applies clinical and administrative
skills to guide the facility in providing care.
Role 3Quality of Care

The medical director helps the facility develop and
manage both quality and safety initiatives, including risk
management.
Role 4Education, Information, and Communication

The medical director provides information that helps
others (including facility staff, practitioners, and those in the
community) understand and provide care.
Function 1Administrative
The medical director participates in administrative
decision making and recommends and approves relevant
policies and procedures.
Function 2Professional Services

The medical director organizes and coordinates
physician services and the services provided by other
professionals as they relate to patient care.

z
Function
3Quality
Assurance
and
Performance
Improvement
The medical director participates in the process to
ensure the quality of medical care and medically related care,
including whether it is effective, efficient, safe, timely, patientcentered, and equitable.38
Function 4Education
The medical director participates in developing and
disseminating key information and education.
Function 5Employee Health

The medical director participates in the surveillance
and promotion of employee health, safety, and welfare.
Function 6Community
The medical director helps articulate the long-term care
facilitys mission to the community.
Function 7Rights of Individuals

The medical director participates in establishing
policies and procedures for assuring that the rights of
individuals (patients, staff, practitioners, and community) are
respected.
Function 8Social, Regulatory, Political, and Economic

Factors
The medical director acquires and applies knowledge
of social, regulatory, political, and economic factors that relate
to patient care and related services.
Function 9Person-Directed Care

The medical director supports and promotes persondirected care.39
38
39
The Nursing Home Medical Director: Leader and Manager, March 2011, http://www.amda.com/
Ibid.

z
4.
Attending Physician
Means any doctor of medicine duly licensed to practice in the
Philippines, an active member in good standing of the Philippine Medical

Association and accredited by the Commission.40
Responsibility for Initial Patient Care. The attending

physician should:
o Assess a new admission in a timely fashion (based on
a joint physician-facility-developed protocol, and
depending on the individual's medical stability, recent
and previous medical history, presence of significant or
previously unidentified medical conditions, or problems
that cannot be handled readily by phone);
o Seek, provide, and analyze needed information
regarding a patient's current status, recent history, and
medications and treatments, to enable safe, effective
continuing
care
and
appropriate
regulatory
compliance;
o Provide appropriate information and documentation to
support the facility in determining the level of care for a
new admission;
o Authorize admission orders in a timely manner, based
on a joint physician-facility-developed protocol, to
enable the nursing facility to provide safe, appropriate,
and timely care; and
o For a patient who is to be transferred to the care of
another health care practitioner, continue to provide all
necessary medical care and services pending transfer
until another physician has accepted responsibility for
the patient.
Support Patient Discharges and Transfers. The attending

physician should:
o Follow-up with a physician or another health care
practitioner at a receiving hospital as needed after the
transfer of an acutely ill or unstable patient;
40
Book IV - Health, Safety and Social Welfare, http://www.dole.gov.ph


z
o Provide whatever documentation or other information

may be needed at the time of transfer to enable care
continuity at a receiving facility and to allow the nursing
facility to meet its legal, regulatory, and clinical
responsibilities for a discharged individual; and
o Provide pertinent medical discharge information within
30 days of discharge or transfer of the patient.
41
Make Periodic, Pertinent On-Site Visits to Patients. The

attending physician should:
o Visits patients in a timely fashion, based on a joint
physician-facility-developed protocol, consistent with
applicable state and federal regulations, depending on
the patient's medical stability, recent and previous
medical history, presence of significant or previously
unidentified medical conditions, or problems that
cannot be handled readily by phone;
o Maintain progress notes that cover pertinent aspects of
the patient's condition and current status and goals.
Periodically, the physician's documentation should
review and approve a patient's program of care.
o Determine progress of each patient's condition at the
time of a visit by evaluating the patient, talking with staff
as needed, talking with responsible parties/family as
indicated, and reviewing relevant information, as
needed;
o Respond to issues requiring a physician's expertise,
including the patient's current condition, the status of
any acute episodes of illness since the last visit, test
results, other actual or high risk potential medical
problems that are affecting the individual's functional,
physical, or cognitive status, and staff, patient, or family
questions
regarding
the
individual's
care
and
treatments; and
o At each visit, provide a legible progress note in a timely
manner for placement on the chart (timely to be defined
by a joint physician-facility protocol). Over time, these
progress notes should address relevant information
41
Role of the Attending Physician in the Nursing Home, March 2003, http://www.amda.com

z
about significant ongoing, active, or potential problems,

including reasons for changing or maintaining current
treatments or medications, and a plan to address
relevant medical issues. 42
Ensure Adequate Ongoing Coverage. The attending

physician should:
o Designate an alternate physician or appropriately
supervised midlevel practitioner who will respond in an
appropriate, timely manner in case the attending
physician is unavailable;
o Update the facility about his or her current office
address, phone, fax, and pager numbers to enable
appropriate, timely communications, as well as the
current office address, phone, fax and pager numbers
of designated alternate physicians or an appropriately
supervised midlevel practitioner;
o Help ensure that alternate covering practitioners
provide adequate, timely support while covering and
intervene with them when informed of problems
regarding such coverage;
o Adequately notify the facility of extended periods of
being unavailable and of coverage arranged during
such periods
o Adequately inform alternate covering practitioners
about patients with active acute conditions or potential
problems that may need medical follow-up during their
on-call time.
Provide Appropriate Care to Patients. The attending

physician should:
o Perform
accurate,
timely,
relevant
medical
assessments;
o Properly define and describe patient symptoms and
problems,
clarify
and
verify
diagnoses,
relate
diagnoses to patient problems, and help establish a

realistic prognosis and care goals;
o In consultation with the facility's staff, determine
appropriate services and programs for a patient,
42
Ibid.

z
consistent with diagnoses, condition, prognosis, and

patient wishes, focusing on helping patients attain their
highest practicable level of functioning in the least
restrictive environment; 43
o In
consultation
treatments,
with
including
facility
staff,
ensure
that
rehabilitative
efforts,
are
medically necessary and appropriate in accordance

with relevant medical principles and regulatory
requirements;
o Respond in an appropriate time frame (based on a joint
physician-facility-developed protocol) to emergency
and routine notification, to enable the facility to meet its
clinical and regulatory obligations;
o Respond to notification of laboratory and other
diagnostic test results in a timely manner, based on a
protocol developed jointly by the physicians and the
facility, considering the patient's condition and the
clinical significance of the results;
o Analyze the significance of abnormal test results that
may reflect important changes in the patient's status
and explain the medical rationale for subsequent
interventions or decisions not to intervene based on
those results when the basis for such decisions is not
otherwise readily apparent;
o Respond promptly to notification of, and assess and
manage
adequately,
reported
acute
and
other
significant clinical condition changes in patients;

o In consultation with the facility staff, manage and
document ethics issues consistent with relevant laws
and regulations and with patients' wishes, including
advising patients and families about formulating
advance directives or other care instructions and
helping identify individuals for whom aggressive
medical interventions may not be indicated; and
o Provide
orders
that
ensure
individuals
have
appropriate comfort and supportive care measures as
43
Ibid.

z
needed; for example, when experiencing significant

pain or in palliative or end-of-life situations; 44
o Periodically review all medications and monitor both for
continued need based on validated diagnosis or
problems and for possible adverse drug reactions. The
medication review should consider observations and
concerns offered by nurses, consultant pharmacists
and others regarding beneficial and possible adverse
impacts of medications on the patient.
Provide
Appropriate,
Timely
Medical
Orders
and
Documentation. The attending physician should:

o Provide timely medical orders based on an appropriate
patient assessment, review of relevant pre- and postadmission information, and age-related and other
pertinent risks of various medications and treatments;
o Provide sufficiently clear, legible written medication
orders
to
avoid
misinterpretation
and
potential
medication errors, such orders to include pertinent

information such as the medication strength and
formulation (if alternate forms available); route of
administration; frequency and, if applicable, timing of
administration;
and
the
reason
for
which
the
medication is being given;

o Verify the accuracy of verbal orders at the time they are
given and authenticate, sign and date them in a timely
fashion, no later than the next visit to the patient.
o Provide documentation required to explain medical
decisions, that promotes effective care, and allows a
nursing facility to comply with relevant legal and
regulatory requirements
o Complete death certificates in a timely fashion,
including all information required of a physician. 45
Follow Other Principles of Appropriate Conduct. The

attending physician should:
o Abide by pertinent facility and medical policies and
procedures
44
45
Ibid
Ibid.

z
o Maintain a courteous and professional level of

interaction with facility staff, patients, family/significant
others, facility employees, and management
o Work with the medical director to help the facility
provide high quality care
o Keep the well-being of patients/residents as the
principal consideration in all activities and interactions.
o Be alert to, and report to the medical director and
other appropriate individuals as named through facility
protocol-- any observed or suspected violations of
patient/resident rights, including abuse or neglect, in
accordance with facility policies and procedures. 46
5.
Nurse Practitioner
Nurse Practitioners are registered nurses who have acquired the
formal education, extended knowledge base and clinical skills beyond the
registered nurse level to practice in an advanced role as direct health care
providers.
Nurse Practitioners are authorized to practice by the Board in a
specialty area via their registered nurse licensure and advanced practice
certification in a specialty area.
Nurse Practitioners utilize critical judgment in the performance of
comprehensive
health
assessments,
differential
medical
diagnosis
including ordering, conducting, and interpreting diagnostic and laboratory

tests, and the prescribing of pharmacologic and non-pharmacologic
treatments in the direct management of acute and chronic illness and
disease.47
6.
Clinical Nurse Specialist

Using the core competencies of advanced practice nursing to design,
implement, and evaluate programs of care to enhance patient outcomes,

particularly for complex patients and across systems of care.
46
47
Ibid.
Arizona State Board of Nursing, January 2009, http://www.azbn.gov

z
CNS involvement in care delivery and planning depends on a

variety of factors, e.g. the assessed needs of patients and
learning needs of staff.
Leading
multidisciplinary
groups
in
designing
and
implementing innovative solutions that address system

problems and patient care issues.
Serving as a leader, consultant, mentor and change agent to

achieve quality cost-effective outcomes.48
Developing differential diagnoses and interventions to treat or

prevent illness.
Planning and implementing educational opportunities for

health professional staff, patients and communities.
7.
Pharmacist
The consultant pharmacist for a nursing home shall conduct a

drug regimen review for actual and potential drug therapy
problems in the nursing home and make remedial or
preventive clinical recommendations into the medical record
of every patient receiving medication. The consultant
pharmacist shall conduct the review at least monthly in
accordance with the nursing home's policies and procedures.
The consultant pharmacist shall report and document any

drug irregularities and clinical recommendations promptly to
the attending physician or nurse-in-charge and the nursing
home administrator.49
The consultant pharmacist shall report drug product defects

and adverse drug reactions.
The consultant pharmacist shall ensure that all known

allergies and adverse effects are documented in plain view in
the patient's medical record, including the medication
administration records, and communicated to the dispensing
pharmacy. The specific medications and the type of allergy or
adverse reaction shall be specified in the documentation.
The consultant pharmacist shall ensure that drugs that are not
specifically limited as, to duration of use or number of doses
shall be controlled by automatic stop orders. The consultant
48
49
AACN Statement of Support for Clinical Nurse Specialists, March, 2006, www.aacn.nche.edu
Nursing home pharmacy reports; duties of consultant pharmacist, 2003, http://www.ncga.state.nc.us

z
pharmacist shall further ensure that the prescribing provider

is notified of the automatic stop order prior to the dispensing
of the last dose so that the provider may decide whether to
continue to use the drug.
8.
Nursing Director
The Director of Nursing assumes authority, responsibility, and

accountability for the delivery of nursing services in the facility.
In
collaboration
with
facility
Administration,
allocates
department resources in an efficient and economic manner to

enable each resident to attain or maintain the highest practical
physical, mental, and psychosocial well-being. Collaborates
with other departments, medical professionals, consultants,
and organizations, including government agencies and
advocacy groups, to develop, support and coordinate resident
care, related administrative functions, and to represent the
interests of the facility.
Develops, maintains, and implements nursing policies and

procedures that conform to current standards of nursing
practice, facility philosophy, and operational policies while
maintaining compliance with state and federal laws and
regulations.
Communicates and interprets policies and procedures to

nursing
staff,
and
monitors
staff
practices
and
implementation.
Participates in all admission decisions, and may visit

prospective residents before admission.
Participates in daily or weekly management team meetings to

discuss resident status, census changes, personnel, or
resident complaints or concerns.
Evaluates the work performance of all nursing personnel,

assists in the determination of wage increases, and
implements discipline according to operational policies.
Ensures delivery of compassionate quality care and nursing

supervision as evidenced by adequate services and staff
coverage on unit, absence of odors, general cleanliness,
prevention of pressure wounds, and apparent maintenance of
optimal resident functions.

z
Demonstrates knowledge of and application of Key Clinical

Quality Indicators, and proactively monitors and implements
systems to achieve and/or surpass company thresholds.
Exercises overall supervision of resident assessments and

care plans.50
Reviews 24-hour report from every unit daily to monitor and

ensure timely, effective responses to significant changes in
condition,
transfers,
unexplained
injuries,
discharges,
falls,
use
behavioral
of
restraints,
episodes,
and
medication errors.
Collaborates
with
physicians,
consultants,
community
agencies, and institutions to improve the quality of services

and to resolve identified problems.
Coordinates nursing services with all other departments

including Therapy.
Oversees nursing schedules to assure they meet resident

needs and regulatory and budgetary standards.
Participates in the recruitment and selection of nursing

personnel and assures sufficient staff are hired.
Oversees and supervises development and delivery of inservice education to equip nursing staff with sufficient
knowledge and skills to provide compassionate, quality care
and respect for resident rights.
Proactively develops positive employee relations, incentives,

and recognition programs. Promotes teamwork, mutual
respect, and effective communication.
Participates
in
budget
development
for
the
nursing
department, and for medical, nursing, and central supplies.

Assures nursing staff properly charges out ancillaries used.
Helps the Administrator prepare staff for inspection surveys,

instructing staff on matters of conduct and disclosure, being
interviewed by inspectors, immediate corrections of problems
noted by surveyors, etc. Reviews and reinforces important
standards previously cited.
Participates in the preparation of the Plan of Correction

response to an inspection survey.
50
Job Description Director of Nursing, March 2004, http://www.ihca.org


z
Communicates directly with residents, families, medical staff,

nursing
staff,
interdisciplinary
team
members,
and
Department Heads to coordinate care and services, promote

participation in care plans, and maintain a high quality of care
and life for residents.51
Promotes customer service and hospitality and responds to

and adequately resolves complaints or concerns from
residents or families about nursing services.
Monitors facility incidents and complaints daily to identify

those defined as unusual occurrences by State policy and
promptly reports such occurrences to Administrator/Executive
Director for appropriate action.
Monitors complaint reports daily for allegations of potential

abuse or neglect, or the loss or misappropriation of resident
property, and participates in these investigations.
Promotes compliance with accident prevention procedures,

safety rules, and safe work practices to prevent employee
injury and illness and control workers compensation costs.
Assures staff is trained in fire and disaster and other

emergency procedures, and evaluates performance during
drills.
Interacts courteously with residents, family members,

employees, visitors, vendors, business associates, and
representatives of government agencies.
Acts in an administrative capacity in the absence of the

Administrator.52
9.
Charge Nurse
In Skilled nursing Facilities, the Director of Nursing Services shall
designate as charge nurse for each shift a registered nurse, a licensed

practical nurse, or a licensed psychiatric technician nurse. Responsibilities
of the charge nurse shall include supervision of the total nursing activities
in the facility during his/her assigned tour of duty.53
51
Ibid.
Ibid.
53 Charge Nurse, http://aipp.afmc.org
52

z
Responsibility for observation of work performance of aides in

delivery of direct care.
Administration of medication if there is no assigned

medication nurse.
Ordering medications from the pharmacy.
All direct observations of patients to observe and evaluate

physical and emotional status.
Delegate responsibility for the direct care of specific patients

to the nursing staff based on the need of the patients.
10.
Taking phone orders from physicians or dentists.
Giving shift report to the next shift.
Shift count of control drugs.
Dietary observations.54
Unit Supervisor
Manages and assumes 24-hour responsibility and accountability for
resident care on assigned unit. Manages the unit in accordance with policy
and procedure.
Assumes 24-hour responsibility and accountability for

resident care on assigned unit.
Ensures complete and prompt reporting of incidents with

follow-up as necessary to Administrator and Director of
Nursing.
Meets with all 3 shifts at least once per month.
Actively participates in committee/programs as directed by

Director of Nursing.
Participates in the development and implementation of new

policies and procedures based on identified needs.
Serves as MDS (Minimum Data Set) coordinator for assigned

unit and completes admissions MDS for each resident.55
Oversees resident care to promote the highest level of

physical, mental and psychosocial functioning possible for
assigned unit.
54
55
Ibid.
Champaign County Job Description, January, 2006, http://www.co.champaign.il.us

z
Actively participates in the Quality Assurance process,

including attendance at Quality Assurance meetings and
submission of required reports.
Ensures that significant changes in resident condition are

communicated to the physician, family or responsible party.
Makes daily rounds on unit to ensure resident care needs and

environmental standards are met, this includes monitoring of
dining room during meal times.
Works
collaboratively
with
other
members
of
the
interdisciplinary care team to provide holistic care. Reviews

clinical records for completeness and accuracy as necessary.
Monitors, tracks, evaluates and reports infections for the unit.

Acts as a resource for nursing staff.
Reviews applications for admission to the unit with Director of

Nursing and Admissions Director. Works collaboratively with
Director of Nursing to identify and provide orientation and
continuing education for unit staff members.
Attends and actively participates in nursing supervisory

meetings.56
11.
Licensed Practical Nurse

Licensed practical nurses provide nursing care usually under the
direction of medical practitioners, registered nurses or other health team

members. They are employed in hospitals, nursing homes, extended care
facilities, rehabilitation centers, doctors' offices, clinics, companies, private
homes and community health centers. Operating room technicians are
included in this unit group.57
Provide nursing services, within defined scope of practice, to

patients based on patient assessment and care planning
procedures
Perform nursing interventions such as taking vital signs,

applying aseptic techniques including sterile dressing,
ensuring infection control, monitoring nutritional intake and
conducting specimen collection
56
57
Ibid.
Licensed Practical Nurse jobs Canada, Visa Bureau 2003-2014, http://www.visabureau.com

z
Administer
medication
and
observe
and
document
therapeutic effects
Provide pre-operative and post-operative personal and

comfort care
Monitor established respiratory therapy and intravenous

therapy
Monitor patients' progress, evaluate effectiveness of nursing

interventions and consult with appropriate members of
healthcare team
Provide safety and health education to individuals and their

families.58
12.
Certified Nursing Assistant
Performs any combination of following duties in care of

patients in hospital, nursing home, or other medical facility,
under direction of nursing and medical staff: Answers signal
lights, bells, or intercom system to determine patients' needs.
Bathes, dresses, and undresses patients.
Serves and collects food trays and feeds patients requiring

help.
Transports patients, using wheelchair or wheeled cart, or

assists patients to walk.
Drapes patients for examinations and treatments, and

remains with patients, performing such duties as holding
instruments and adjusting lights.
Turns and repositions bedfast patients, alone or with

assistance, to prevent bedsores.
Changes bed linens, runs errands, directs visitors, and

answers telephone.
Takes and records temperature, blood pressure, pulse and

respiration rates, and food and fluid intake and output, as
directed.
Cleans, sterilizes, stores, prepares, and issues dressing

packs, treatment trays, and other supplies.59
58
59
Ibid.
Nurse Assistant Job Description, 1997-2013, careplanner.com

z
13.
Physical Therapist
PTs examine each individual and develop a plan using treatment
techniques to promote the ability to move, reduce pain, restore function, and
prevent disability. In addition, PTs work with individuals to prevent the loss
of mobility before it occurs by developing fitness- and wellness-oriented
programs for healthier and more active lifestyles.
Diagnose and manage movement dysfunction and enhance

physical and functional abilities.
Restore, maintain, and promote not only optimal physical

function but optimal wellness and fitness and optimal quality
of life as it relates to movement and health.
Prevent
the
onset,
symptoms,
and
progression
of
impairments, functional limitations, and disabilities that may

result from diseases, disorders, conditions, or injuries.60
14.
Occupational Therapist
OTs provide intervention in many areas of occupation such as:
activities of daily living (ADLs) including bathing, dressing, grooming;

instrumental activities of daily living (IADLs) including home and financial
management, rest and sleep, education, work, play, leisure, and social
participation (AOTA, 2008). They also develop and implement health and
wellness programs to prevent injuries, maintain function, and improve
safety of residents. For example, OTs and OTAs can take a leadership role
in developing and implementing programs to educate clients on
compensatory techniques for low vision, customized exercise programs, or
strategies to prevent falls. Occupational therapy practitioners may also
consult with other staff within the facility or in the community on a variety of
topics related to increasing safe engagement in activities.61
15.
Speech Therapist
In a nursing home environment, diagnoses and treats speech and
language
problems,
and
engages
in
scientific
study of
human
communication. Evaluates speech and language skills as related to
60
61
Guide to Physical Therapist Practice, 2nd Edition (2003), http://www.apta.org

American Occupational Therapy Association [AOTA], 2008), http://www.aota.org

z
educational, medical, social, and psychological factors. Plans, directs, or

conducts rehabilitative treatment programs to restore communicative
efficiency of individuals with communication problems of organic and nonorganic etiology. Requires a master's degree in speech-language pathology
and may require a certificate of clinical competence in speech-language
pathology (CCC). Expected to meet certain state licensing requirements.
Familiar with a variety of the field's concepts, practices, and procedures.
Relies on extensive experience and judgment to plan and accomplish goals.
Performs a variety of tasks. May lead and direct the work of others. A wide
degree of creativity and latitude is expected. Typically reports to a manager
or director.62
16.
Dentist
Dental hygienists are licensed oral health professionals specializing
in prevention and treatment of oral diseases, as well as protection of

patients' total health. Whether by administering a prophylaxis (tooth
cleaning) or taking X-rays, dental hygienists dentistry's advanced
defensive guards are often the first members of the dental team to treat
patients.63
17.
Optometrist
The role played as an optometric consultant in a nursing facility can
be as creative and unique as one desires. In the role of consultant, the

optometrist may be asked to assist the nursing home in developing policies
or to provide suggestions on ways to improve the function of residents other
than providing examinations. Optometrists certainly provide eye care
services to the residents, but many other areas of optometric expertise may
be needed. 64
18.
Finance Officer
The hospital CFO is assigned onsite financial responsibility for a. The
CFO administers, directs and monitors all hospital financial activities and
62
Speech and Language Pathologist - Nursing Home Job Description, http://swz.salary.com

Nayda Rondon, 2006-2014, Dental Hygienists: Helping You Maintain a Clean, Healthy Smile
http://www.yourdentistryguide.com
64 Mark W. Swanson, O.D, 1998 243 N. Lindbergh Blvd., St. Louis, Optometric Care of Nursing Home Residents
63

z
keeps the hospital CEO and the hospital Board of Trustees informed of the
financial condition of the facility.65
19.
Cashier
Cashier receives cash payments tendered in person, makes change
and prepares and issues receipts; balances and maintains logs of daily
remittance claims by third party payers and electronic payments; processes
all payments and adjustments; balances and reconciles any differences of
electronic payments; posts third party payer adjustments; prepares daily
deposit for all hospital cash transactions, endorses checks for deposit;
researches all documents to verify appropriate payments, including
unknown patient payments; receives, maintains and releases patient
property in accordance with established procedures; compiles and reviews
periodic reports; performs routine filing and other clerical duties.66
20.
Billing Officer
The primary purpose of your job position is to assist in the day-to-
day accounting functions of the facility in accordance with current

acceptable accounting and cost reimbursement principles relating to health
care and the hospital operation as may be directed by the Administrator or
Controller.67
21.
Disbursing Officer
Responsible for providing accounting services to the assigned

unit to ensure accurate and timely finance and accounting
service delivery.
Performs routine tasks relevant to assigned section in

accordance to the finance & accounting policies and
procedures set by the business unit.
Coordinates with concerned departments or parties for

pending supporting documents follow-up, correction and
reconciliation of entries, and other related inquiries.
65
HealthTech Management Services, http://www.cahcare.com

Hospital Cashier, http://www.erie.gov
67 Office/Billing, http://www.anberryhospital.com
66

z
Maintains and safe keeps pertinent files and documents for

audit references.
Prepares and processes Check and cash payments, Letter

Remittance (LR), and Debit Advice (DA), manually for
approval of authorized signatories as per Limits of Authority.
Posts all processed accounts payable transactions to check

tally with accounts receivables.
Monitors check accounts and the re-occurring monthly

payment from Accounting.
Conducts checks inventory to monitor usage and releases.
Processes cash advances, reimbursement, liquidation, and

transfer of funds representation.68
22.
Admission Officer
Reviews admitting department operations in a nursing home
environment. Ensures compliance with applicable standards. Oversees the

in-patient/out-patient functions, bed assignments, and completion of
preliminary paperwork for entering patients. Works with medical, nursing,
and accounting staff to ensure appropriate patient placement. Confirms that
all insurance benefits coverage meets standards of admission as dictated
by policy.69
23.
Social Service Director

The SSDs main responsibility will be to motivate all residents to
make healthy adjustments to the nursing facility, by their participation in

activities and social events. Informal counseling will be a part of the SSDs
job responsibilities and they will attempt to uncover any problems which
might be interfering with the residents socialization and participation in
home activities.70
24.
Budget Officer
Prepares the Annual Work and Financial Plan of the hospital.
Monitors and controls fund utilization in the hospital.
68Disbursement
Officer, 2010, http://www.home-harbor.com

Admissions Coordinator - Nursing Home Job Description, 2014, http://swz.salary.com
70 Job Description Social Service Director, http://elmbrookhomes.com
69

z
Reviews and consolidates budget estimates of the different

units of the hospital.
Allocates available funds to hospital programs and projects

based on approved guidelines, policies and priorities.
Reviews
fiscal
documents
and
accounts
relating
to
disbursement of funds.
Reviews expense vouchers covering payments, vis--vis,

authorized allotments.
Serves as the hospitals liaison officer for budgetary matters.
Directs the preparation of requests for the reprogramming of

funds and corresponding changes in the work plan.
Plans and directs the realignment of hospital expenditures in

accordance with the appropriation reserves and quarterly
allotments by items and projects.71
25.
Social Worker
Makes assessment of economic and other resources of

patients and their families.
Performs casework service to patients referred with social,

emotional or environmental problems affecting their medical
situation.
Consults with other disciplines in the setting concerned and

directs the implementation, coordination and collaboration of
the MSS activities with other disciplines.
Mobilizes external resources to meet the medical needs of

patients.
Ensures the systematic documentation, reporting and

preparation of monthly reports.
26.
Performs other related functions as may be assigned.72
Dietary Supervisor
To provide or to serve safe, nutritious foods through careful planning,
wise procurement and proper preparation of the balance and satisfying

meals within the budgetary limits.73
71
Andy Geff E. Cepe, The Administrative Subsystems Functions, Policies and Relationships, http://tdh.doh.gov.ph
Ibid.
73 Ibid.
72

z
27.
Food Service Worker
Shall assist in food preparation work such as:

o Peeling, washing and cutting of fruits and vegetables
o Weighing, cutting of meat, fish and poultry supplies
Shall apportion cooked foods for distribution in patients trays

and in wards.
Shall apportion raw food supplies for distribution to patients

receiving raw ration.
Shall collect, clean and return food containers and used trays
to the dietary after use.
Shall maintain orderliness and cleanliness in the Dietary

Service.74
28.
Cook
Prepares and cook menu items for hospitals in patients

especially those with modified diets and supervises food
service workers in the preparation and cooking in all hospital
categories.
Shall assist or give suggestions on menu planning and

preparation of duty schedules of subordinates.
Shall maintain sanitary standards in preparation, apportioning

and storage of foods.75
29.
Housekeeping/Laundry
Develop and maintain clean, safe and sanitary environment for
patients and hospital personnel. They also ensure adequate supply of clean
linens for patients and hospital units. 76
30.
Maintenance
Installation, operations and maintenance of electrical, mechanical

and communication equipment and allied facilities including buildings and
vehicles.77
74
Ibid.
Ibid.
76 Ibid.
77 Ibid.
75

z
31.
Security
Ensure safety of hospital patients, facilities/properties and personnel,
maintain peace and order, and enforce hospital rules and regulations.78
78
Ibid.

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Market Type Analysis

Once a patient is diagnosed with mental disturbance in a mental

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The following are the psychiatric disorders with their corresponding

Thought disorder that impairs judgment, behavior & ability to

Symptoms must be present at least 6 months to be able to

Men have an earlier onset, usually at 15 to 25 years of age.

Dopamine & abnormalities in Serotonin.

Many believe the family may be the cause of the patient's

Schizophrenia may be viral in origin.

Schizophrenia is more prevalent in the low socioeconomic

Physical & Psychiatric Presenting Symptoms

Hallucinations (mostly auditory)

Delusions (mostly bizarre)

Disorganized speech or behavior

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Usually experience social &/or occupational dysfunction

Physical exam usually unremarkable, but may find saccadic

Hospitalization is recommended for either stabilization or

Antipsychotics (Atypical): To help control both positive and

If no response, consider using Clozapine

Older patients (Onset is in their late twenties or thirties)

Presenting Symptoms: Preoccupation with delusions

Schizophrenia Disorganized Type

behavior. Flat or inappropriate affect. Marked regression

Risk Factors: These patients tend to be younger than 25 "

Schizophrenia Catatonic Type

ranging from severe retardation to excitation. Extreme

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Complications: Medical care may be necessary because

Schizophrenia Residual Type

Symptoms: Absence of positive symptoms (delusions,

Patients tend to have negative symptoms (Social

Schizophrenia Undifferentiated Type

Presenting Symptoms: Meet criteria for schizophrenia. Do

Other Psychotic Disorders

Presenting Symptoms: Same as in Schizophrenia

Difference from Schizophrenia: Symptoms are present > 1

Risk Factors: Many of these patients have affective

hospitalization, to assure safety of patient &/or

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Presenting Symptoms: Mood Disorders (major depressive

schizophrenia. Worse prognosis than patients with

Treatment: Must first determine whether hospitalization is

anticonvulsants to control the mood symptoms. If these

Presenting Symptoms: Non-bizarre delusions for at least

Types include erotomanic, jealous, grandiose, somatic,

Risk Factors: Mean age of onset is about 40 years (better

Associated with low socioeconomic status as well as

Associated with conditions in either the limbic system or

Presenting Symptoms: Same as in Schizophrenia

Difference from Schizophrenia: Symptoms are present > 1

Patient appears to be responding to internal stimuli

socioeconomic status as well as in those who have

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preexisting personality disorders or the presence of

Major Depressive Disorder (Major Depression)

Mood disorder that presents with at least a 2-week course

Must have depressed mood or anhedonia (absence of

Women > Men (2:1) due to several factors, such as

Incidence is higher in those who have no close

Norepinephrine & Dopamine

Other risk factors include family history, exposure to