Journal of Psychosocial Nursing and Mental Health Services

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Psychosocial Rehabilitation Nurses: Taking Our Place on the Multidisciplinary Team

Suzane Wilbur, MS, APRN; Paul Arns, PhD

Abstract

During the 1980s, California restructured the provision of psychiatric and mental health services in order to redirect scarce dollars away from institutional or hospital care toward rehabilitation services in the community. To accomplish this redirection, California Assembly Bill 3777 was passed in 1988. This legislation delineated and funded integrated mental health services agencies (ISAs) that would assist people with serious mental illnesses to reintegrate into the community (Figures 1 and 2).

Across the country, programs such as Fountain House in New York (Beard, Propst, & Malamud, 1982), and Training in Community Living teams in Wisconsin (Stein & Test, 1980) led the way in developing clientcentered, client-driven, and clientneed-driven services that were provided in the community, away from hospitals and traditional clinics. A psychosocial rehabilitation philosophy guided the development of such programs.

In ISAs in California, people with complex psychiatric problems are assisted to move beyond stabilization toward continuous personal growth. Nursing is uniquely suited to such programs, as core nursing values (Figure 3) have always embodied the values of psychosocial rehabilitation. (Thompson & Strand, 1994).

Palmer-Erbs & Anthony (1994) called for incorporating the principles of psychosocial rehabilitation into psychiatric nursing practice. Guy (1997), however, expressed concern that the psychiatric nurse may be underused on assertive community treatment teams. In an innovative ISA in Los Angeles, psychiatric mental health nurses (PMHNs) who practice psychosocial rehabilitation nursing are fully used on the multidisciplinary team.

The innovative ISA is called "A Better Life Endeavor" and is funded and directly operated by the Los Angeles County Department of Mental Health (DMH) in partnership with the South Bay Chapter of the National Alliance for the Mentally HI (NAMI). Services are provided by a multidisciplinary, multicultural team that is the "single fixed point of responsibility" for all mental health services that a client, now referred to as a member, might need. The ISA model of service delivery has greatly reduced the fragmentation of care often experienced by people with serious mental illnesses.

In the AMI/ABLE Program, PMHNs, like staff from all other disciplines on the team, perform the role of Personal Service Partner or PSP (Figure 4). PSPs were once called "case managers," but case management is only one component of the multitude of services provided by the Team. PMHNs, in addition to assessment, service planning, intervention, and evaluation of member outcomes, bring unique nursing knowledge and skills to the Team. In other words, PMHNs integrate biopsychosocial theories into the practice of rehabilitation nursing.

Table

Drop-in Services

Staff rotate responsibilities for assisting members on a drop-in basis 7 hours a day, 5 days a week. Members and their families do not need appointments to obtain assistance from someone on the Team. Crises are prevented because, in the drop-in area, there is ongoing availability of staff for assessment and early intervention. PMHNs with inpatient experience can role model the skill of milieu management for PSPs who do not have prior inpatient experience. Availability of services on a drop-in basis is important because members with serious illnesses cannot keep appointments as required by traditional outpatient clinics. At AMI/ABLE, no member is told to "come back when your PSP is here." The team member on duty each day takes care of any problems presented by the members who drop in.

The drop-in area has comfortable furniture, coffee, ping pong, board games, and a patio where members can socialize informally with each other and with staff. During drop-in times, PSPs help members to practice conversation skills with each other and to learn other interpersonal skills. Other drop-in activities include making craft items for sale to raise spending money for members,…

During the 1980s, California restructured the provision of psychiatric and mental health services in order to redirect scarce dollars away from institutional or hospital care toward rehabilitation services in the community. To accomplish this redirection, California Assembly Bill 3777 was passed in 1988. This legislation delineated and funded integrated mental health services agencies (ISAs) that would assist people with serious mental illnesses to reintegrate into the community (Figures 1 and 2).

Across the country, programs such as Fountain House in New York (Beard, Propst, & Malamud, 1982), and Training in Community Living teams in Wisconsin (Stein & Test, 1980) led the way in developing clientcentered, client-driven, and clientneed-driven services that were provided in the community, away from hospitals and traditional clinics. A psychosocial rehabilitation philosophy guided the development of such programs.

In ISAs in California, people with complex psychiatric problems are assisted to move beyond stabilization toward continuous personal growth. Nursing is uniquely suited to such programs, as core nursing values (Figure 3) have always embodied the values of psychosocial rehabilitation. (Thompson & Strand, 1994).

Palmer-Erbs & Anthony (1994) called for incorporating the principles of psychosocial rehabilitation into psychiatric nursing practice. Guy (1997), however, expressed concern that the psychiatric nurse may be underused on assertive community treatment teams. In an innovative ISA in Los Angeles, psychiatric mental health nurses (PMHNs) who practice psychosocial rehabilitation nursing are fully used on the multidisciplinary team.

The innovative ISA is called "A Better Life Endeavor" and is funded and directly operated by the Los Angeles County Department of Mental Health (DMH) in partnership with the South Bay Chapter of the National Alliance for the Mentally HI (NAMI). Services are provided by a multidisciplinary, multicultural team that is the "single fixed point of responsibility" for all mental health services that a client, now referred to as a member, might need. The ISA model of service delivery has greatly reduced the fragmentation of care often experienced by people with serious mental illnesses.

In the AMI/ABLE Program, PMHNs, like staff from all other disciplines on the team, perform the role of Personal Service Partner or PSP (Figure 4). PSPs were once called "case managers," but case management is only one component of the multitude of services provided by the Team. PMHNs, in addition to assessment, service planning, intervention, and evaluation of member outcomes, bring unique nursing knowledge and skills to the Team. In other words, PMHNs integrate biopsychosocial theories into the practice of rehabilitation nursing.

Table

FIGURE 1AMI/ABLE Objectives (based on California's Assembly Bill 3777 Mandates)

FIGURE 1

AMI/ABLE Objectives (based on California's Assembly Bill 3777 Mandates)

PMHNs' unique knowledge and skills include assessment of, monitoring of, and referral for general medical problems. Too often, we have seen members' general medical problems go unaddressed due to the focus on their more critical psychiatric problems. PMHNs' interventions can also include (but are not limited to) medication administration, the monitoring of medication side effects, medication education, patient and family health education, and the monitoring of general medical disorders that have psychosocial and physiological components (ANA, 1994; Wittig, personal communication, 1997).

This article uses a logic model (Figure 5) to describe the AMI/ABLE program. Also, the nurse's differentiated yet integrated role on a multidisciplinary team in an ISA will be discussed. The reader should keep in mind that all psychosocial interventions give the nurse PSP the opportunity to assess and intervene with respect to symptoms, medication efficacy, and general medical conditions.

Input

Input into the AMI/ABLE program forms the foundation for the conceptual framework for service development and implementation.

Mission, vision, philosophy

In 1991, families of NAMI South Bay accepted the DMH challenge to participate in developing a mental health program that would more aggressively and effectively address the needs of people with serious illnesses. Many of their sons and daughters have severe and persistent illnesses and are high users of psychiatric emergency and acute inpatient services and are thus eligible for AMI/ABLE services. The mission, vision, and philosophy statement (Figure 6) was developed jointly by DMH staff and NAMI South Bay. NAMI members and the team meet each year to renew their commitment to the program and to develop program goals for the following year. As well, monthly government meetings empower members to participate in ongoing program development, tailoring services to meet their individual needs.

Psychosocial rehabilitation

The underlying philosophy for the work of the AMI/ABLE program is that of psychosocial rehabilitation. All staff, including nurse PSPs, adhere to the belief that each member has an untapped capacity for personal growth. Stabilization and maintenance are no longer acceptable goals for service; recovery and community reintegration are the most valued member outcomes. Doing meaningful work is essential to reducing the disabilities that can result from years of coping with psychiatric illness (Cnaan, Blankerz, & Saunders, 1992; Hogarty, 1993).

Nurse PSPs support and assist members in finding something meaningful to do with their lives. Every step toward a goal, no matter how small, is celebrated, recognizing that the road to a better life is traveled one step at a time.

Target population

People with the most serious mental illnesses in Los Angeles County are eligible for services from the AMI/ABLE Program. A member's annual mental health treatment costs prior to enrollment must be high, usually because of the preponderance of emergency and acute inpatient care they receive. Members must live near the Harbor - UCLA Medical Center. Substance abuse problems are a secondary focus for about 40% of the AMI/ ABLE members; no high cost client is disqualified from membership for substance abuse problems.

Table

FIGURE 2Historical Perspectives

FIGURE 2

Historical Perspectives

Staff resources

The AMI/ABLE multidisciplinary team includes mental health professionals and paraprofessionals, NAMI family members who volunteer their time, and trainees in psychiatry, nursing, psychology, and social work. Three consumers of mental health services have been hired as support staff. Bachrach (1989) asserts that an essential feature of model programs is that expert staff are recruited and used to provide the kinds of complex services that persistently ill people need.

With this in mind, the team has been designed to include highly trained, experienced people from all disciplines: psychologists, nurses, psychiatrists, recreation therapists, and social workers. Augmenting their work are one assistant PSP who is a consumer of mental health services; a psychologist and program evaluator who is the clinical director; a psychiatrist; and psychiatry residents. The consumer was hired because of his ability to fulfill the role and because of the expectation that consumer-colleagues would positively influence staff attitudes about member abilities (Miya, Wilbur, Crocker, & Crompton, 1997).

Administrative support includes a secretary and two typist clerks (both consumers) who are responsible for the medical records, data entry, billing, and other office duties. The program director is a nurse who participated in writing the original program proposal, and has directed its development and implementation since its inception.

Table

FIGURE 3Psychiatric Mental Health Nursing Position Statement Issued by the California Nurses Association (1986)

FIGURE 3

Psychiatric Mental Health Nursing Position Statement Issued by the California Nurses Association (1986)

Working in a creative and highly innovative program provides staff with a sense of accomplishment, and breaking new ground and observing successful member outcomes are satisfying experiences. PMHNs quickly adapt to the PSP role and the unstructured, autonomous nature of aggressive rehabilitative work. PMHNs are accustomed to flexible work hours, which become necessary when activities with members are planned for evenings, weekends, and holidays. When planning activities, PSPs enjoy their own interests with the members, making work seem like fun much of the time.

Family participation

NAMI South Bay members were initially skeptical about working with the DMH, because most of these families had spent years "fighting the system" to obtain critically needed services for their sons and daughters. However, as they began working with DMH staff toward system change, these volunteers overcame their personal skepticism. They have met the challenge by donating more than 5,000 hours of work in the AMI/ ABLE program over the last 6 years.

Table

FIGURE 4Job Description: Personal Service Partner (PSP)

FIGURE 4

Job Description: Personal Service Partner (PSP)

FIGURE 5AMI/ABLE Integrated Services Program

FIGURE 5

AMI/ABLE Integrated Services Program

Program services have been strengthened by the involvement of NAMI South Bay in the AMI/ABLE program. These volunteers draw from their personal experience as they work with DMH staff in members' homes and in the clinic, providing support and education to families and members who cannot or will not come to the clinic for services.

Also, NAMI has an office in the dropin area; during their office hours (4 hours, 3 days a week), NAMI volunteers make themselves available for support of family members who are referred by any service at Harbor-UCLA. Staff in the in- and outpatient areas can send families to the NAMI office at AMI/ABLE for personal contact with a family member who has significant experience in dealing with mental illness in the family.

The partnership between NAMI South Bay and the DMH has been a fruitful one. It clearly demonstrates the effectiveness of collaboration between the community and the public sector. Because the DMH at Harbor-UCLA is a public academic institution, families from NAMI-South Bay have the opportunity to participate in training clinicians from all disciplines who rotate through the program.

Service setting

The AMI/ABLE Program is located on the grounds of the Harbor-UCLA Medical Center in Torrance, about 10 miles from downtown Los Angeles. Services are provided in the clinic, but about half of the PSPs' time is spent providing services in vivo, that is, in the community where the members live. Members are seen at home, at work, and at school. PSPs plan social activities such as movies, restaurant meals, and museum visits to assist members to use local resources as they become more integrated into the community.

Table

FIGURE 6South Bay AMI/A Better Life Endeavor (ABLE) Program-1991

FIGURE 6

South Bay AMI/A Better Life Endeavor (ABLE) Program-1991

Drop-in Services

Staff rotate responsibilities for assisting members on a drop-in basis 7 hours a day, 5 days a week. Members and their families do not need appointments to obtain assistance from someone on the Team. Crises are prevented because, in the drop-in area, there is ongoing availability of staff for assessment and early intervention. PMHNs with inpatient experience can role model the skill of milieu management for PSPs who do not have prior inpatient experience. Availability of services on a drop-in basis is important because members with serious illnesses cannot keep appointments as required by traditional outpatient clinics. At AMI/ABLE, no member is told to "come back when your PSP is here." The team member on duty each day takes care of any problems presented by the members who drop in.

The drop-in area has comfortable furniture, coffee, ping pong, board games, and a patio where members can socialize informally with each other and with staff. During drop-in times, PSPs help members to practice conversation skills with each other and to learn other interpersonal skills. Other drop-in activities include making craft items for sale to raise spending money for members, writing a program newsletter, reading the daily newspaper, and discussing current events. Drop-in hours also provide an opportunity for the nurse PSP to administer medications, and to monitor medication effects and side effects.

One unanticipated benefit of drop-in services has been a keen appreciation by the team for what families have experienced over the years. A related benefit is that NAMI volunteers (who work with staff in the drop-in area) learn to respond effectively to their disabled sons and daughters as a result of role modeling by the PSPs.

Domains

Virtually every domain (Figure 5) of a member's life is addressed by the AMI/ABLE program. Intensive involvement at many levels is needed to address the complexity of needs of people with severe and persistent mental illnesses.

Interventions

Individualized treatment/services

Upon enrollment into the program, each member is assisted by the Team to develop personal goals. Usually, members set the initial goal of staying out of the hospital. Once this goal is met, most members want to have jobs and to live independently. PSPs and members plan individualized services every 6 months as new goals become possibilities.

Instead of groups, the PSPs are each responsible for teaching rehabilitation classes that meet the current needs of members, with an emphasis on skills training. Activities in the community, such as attending plays, museums, amusement parks, and restaurants are most effective in teaching members to use existing community resources. Among the classes taught by the nurse PSPs are classes on the interaction of psychiatric medications with abused substances, on healthy lifestyles, and in needlework. PSPs use classes as an opportunity for assessment and education as well as for rehabilitation interventions.

Substance abuse services

The AMI/ABLE program integrates treatment of substance abuse into every aspect of program services. During initial assessments, each member is carefully evaluated with respect to past and current usage. The individualized service plan addresses the member's problem and includes member-designed interventions for changing substance abuse behavior. Members with dual diagnoses of mental illness and substance abuse are involved in a comprehensive program that includes linkage of the member with Alcoholics Anonymous meetings, sponsors, Alano Clubs, and other supports in the community. The AMI/ABLE staff rotate the responsibility of carrying a beeper so mat crisis intervention services are available 24 hours a day, 7 days a week, to members who need immediate support and assistance to refrain from using substances.

Housing

Moving a member into an apartment is an intervention designed to assist in changing his perception of himself. Once in an apartment, members report that they feel "more normal." They are more likely to take medication, which often improves the brain functions needed to be able to pay rent and to otherwise budget their money. PSPs work closely with government housing agencies with respect to obtaining subsidies for the members. AMI/ ABLE staff make regular home visits to members who are in their own apartments to give ongoing support for as long as it is needed.

A loan fund donated and managed by NAMI South Bay is available for members' first and last months' rent and security deposit. Loans are made to members who demonstrate the ability to save a portion of their income and pay back the loan over time. Without this vital fund, most members could not afford the initial costs associated with living on one's own.

Classes about apartment living are offered regularly by the PSPs. For example, one of the nurse PSPs organizes monthly lunches at a member's apartment. The member invites a few other members and all are afforded the opportunity for in vivo training in menu planning, shopping, cooking, and clean up.

Social and recreational activities

AMI/ABLE members, families and staff participate in social activities such as outings to Disneyland, museums, live theater, movies, sporting events, local parks, and the beach. A nurse PSP coordinates the use of donated tickets to a local Civic Light Opera. She encourages members to offer tickets to their families and to enjoy a family night at the opera. Attending these activities is rehabilitative and members are encouraged to try these experiences on their own after PSPs have taught them the basics. From a rehabilitation perspective, one indicator of the effectiveness of these interventions is that a member begins to socialize with people who do not have mental illnesses.

Employment services

Becker and Drake (1994) emphasize the importance of integrating employment services into the mental health services provided by the team. Work is a core value of the AMI/ ABLE program and an intervention that moves members closer to their need to be productive members of society. Everyone needs something meaningful to do with his or her life, and members are supported as they develop work habits and skills. Many members already have skills, but need support as they re-enter the work world. AMI/ABLE offers work reintegration opportunities in a small in-house business - a Mini-mart, which is operated solely by members and coordinated by one of the nurse PSPs. Working in the Mini-mart teaches members about work schedules, inventories, sales to the public, and paychecks.

Job Club is a weekly event during which one of the PSPs provides information and support as members choose, get, and keep a job. During Job Club meetings, members discuss their efforts at finding a job, and they help each other prepare for working. They read the classified ads, prepare their résumés, and role play for interviews. They also learn about effective social and interpersonal skills that are crucial to obtain and maintain employment. All PSPs are responsible for assessing the employment needs of the members. Work is seen as an intervention and an outcome. Work assessments are ongoing and members are assisted to find jobs for which they are suited.

Supported education

Assisting members to go to school, usually a trade school or junior college, is an intervention that further moves the individual toward living an independent, productive life. Although helping people apply to and stay in school is not a traditional nursing intervention, a rehabilitation perspective enables PMHNs and all PSPs to value and encourage experiences that further integrate the member into the community.

Financial Services

The AMI/ABLE PSPs assist members to manage their money, because independent money management gives the member a sense of personal efficacy. NAMI volunteers serve as bankers, and allowance withdrawals can be made three times a week. This teaches members how to make their resources last an entire month.

Other financial services include assistance with checking and savings accounts, assistance in obtaining and maintaining Social Security, housing, and other benefits, and coordination of benefit reductions once the member begins to earn income from employment.

Family education and support

Weekly case conferences include a member and his or her family or significant others to set goals, address problem behaviors, develop treatment strategies, and assess progress. Family members are also encouraged to attend weekly educational seminars taught by staff. These seminars focus on goal attainment and on effective behavior management strategies.

In addition to their availability during office hours, NAMI members coordinate a bimonthly "Caring and Sharing" support and education group that is open to all families in the South Bay community. Caring and Sharing groups are also conducted weekly in Spanish by a bilingual social worker PSP.

Twenty-four-hour access

Twenty-four-hour availability is essential to the program's crisis intervention services. These interventions are designed to prevent or reduce the frequency of members' crises, psychiatric emergencies, and hospitalizations. AMI/ ABLE members, family, and significant others such as residential care facility managers are provided with a phone number and instructions on how to use the program's 24-hour emergency on-call system. PSPs rotate responsibility for carrying a beeper after hours, on weekends, and on holidays. When necessary, PSPs respond in person to defuse or resolve crises, or, when needed, to facilitate hospitalization. Early intervention results in fewer trips to the psychiatric emergency department, fewer admissions to the inpatient services, and more relief of the families' sense of burden.

Assertive outreach

Members are not required to come in to the AMI/ ABLE program for services, although many use the drop-in services regularly. All AMI/ABLE services are available in the community, wherever a member lives or works. Outreach services are especially effective when members are discharged from hospitals. PSPs go the members' homes to provide assessments, crisis intervention, and social support. Nurse PSPs also administer and monitor medications in the home.

Outreach services include hands-on coaching in independent living skills at home. Such in vivo services enable members to live in the community of their choice, reducing the need for more restrictive living situations. One nurse PSP visited a member in his residential care facility upon discharge after orthopedic surgery. The nurse demonstrated transfer techniques from wheelchair to bed to bathroom. This enabled the member to stay in familiar surroundings rather than in a nursing home.

Outcomes

The most important outcome measure of an ISA for high-cost members is the reduction of time they spend in acute and subacute hospitals. Staying out of the hospital improves the quality of the members' lives, and reduces the cost of their services dramatically. At AMI/ABLE, there is ongoing research on other member outcomes as well: work, school, housing, finances, social contacts and supports, and substance abuse inventories. Reducing incarceration time and reducing family burden are additional factors that are studied systematically at AMI/ABLE.

Examining reductions in hospital costs for 50 members, data demonstrate that the average amount of time members spent in institutional settings each year has been approximately half of what it was in the year prior to enrollment. This decrease in the use of acute facilities has redirected an estimated average of $900,000 per year from institutional settings into community services.

Summary

Nurses have been working in the AMI/ABLE ISA for the past 6 years as part of a multidisciplinary team. The nursing contribution is important to the Team, not only because of nursing expertise in providing psychiatric mental health care, but also because nurses can provide services unique to nursing, such as health assessments and education, and medication support (Furlong-Norman, Palmer-Erbs, & Jonikas, 1997).

More than 80 people who are disabled by mental illnesses have been served by this innovative program since 1991, and members' hospitalization rates have been cut approximately in half by integrating services and reducing fragmentation, and by using aggressive outreach and a psychosocial rehabilitation approach. Psychosocial rehabilitation nursing has become a subspecialty that has expanded the profession. Experience in the AMI/ AB LE program demonstrates that nurses, as fully integrated members of multidisciplinary teams, adapt to working in partnerships with clients and their families, in nontraditional settings.

References

  • American Nurses Association. (1994). A statement on psychiatric-mental health clinical practice and standards of psychiatric-mental health clinical nursing practice. Washington, DC: American Nurses Publishing.
  • Bachrach, L. (1989). The legacy of model programs. Hospital and Community Psychiatry, 40, 234-235.
  • Beard, J., Propst, R., & Malamud, T. (1982). The Fountain House model of psychiatric rehabilitation. Journal of Psychosocial Rehabilitation, 5(1), 47-53.
  • Becker, D., & Drake, R. (1994). Individual placement and support: a community mental health center approach to vocational rehabilitation. Community Mental Health Journal, 30, 193206.
  • Cnaan, R., Blankerz, L., & Saunders, M. (1992). Perceptions of consumers, practitioners, and experts regarding psychosocial rehabilitation principles. Psychosocial Rehabilitation Journal, /6,93-119.
  • Furlong-Norman, K., Palmer-Erbs, V., & Jonikas, J. (1997). Strengthening psychiatric rehabilitation nursing practice with new information and ideas. Journal of Psychosocial Nursing and Mental Health Services, 55(1), 35-37.
  • Guy, S. (1997). Assertive community treatment of the long-term mentally ill. Journal of the American Psychiatric Nurses Association, 3, 185-190.
  • Hogarty, G.E. (1993). Prevention of relapse in chronic schizophrenic patients. Journal of Clinical Psychiatry, 54, 18-23.
  • Littrell, K., & Freeman, L. (1995). Maximizing psychosocial interventions. Journal of the American Psychiatric Nurses Association, 1, 214-218.
  • Miya. K., Wilbur, S., Crocker, B., & Compton, F. (1997). Addressing and resolving role issues between professionals and consumer employees. In CT. Mowbray (Ed.), Consumers as providers in psychiatric rehabilitation, (pp. 334-346). Columbia, MD: Colburn House Publishing.
  • Palmer-Erbs, V. (1996). Psychiatric rehabilitation: A breath of fresh air in a turbulent health care environment. Journal of Psychosocial Nursing and Mental Health Services, 34(9), 16-21.
  • Palmer-Erbs, V., & Anthony, W. (1995). Incorporating psychiatric rehabilitation principles into mental health nursing. Journal of Psychosocial Nursing and Mental Health Services, 33(3), 36-44.
  • Stein, L., & Test, M. A. (1980). Alternative to mental hospital treatment. Archives of General Psychiatry, 37, 392-412.
  • Thompson, J., & Strand, K. (1994). Psychiatric nursing in a psychosocial setting. Journal of Psychosocial Nursing and Mental Health Services, 32(2), 25-29.

FIGURE 1

AMI/ABLE Objectives (based on California's Assembly Bill 3777 Mandates)

FIGURE 2

Historical Perspectives

FIGURE 3

Psychiatric Mental Health Nursing Position Statement Issued by the California Nurses Association (1986)

FIGURE 4

Job Description: Personal Service Partner (PSP)

FIGURE 6

South Bay AMI/A Better Life Endeavor (ABLE) Program-1991

10.3928/0279-3695-19980401-15

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