010-Psychiatric-Mental Health Nursing, 5th Edition-Sheila L. Videbeck-160547861X-Lippincott Willi

THISCHAPTER 4 • TREATMENT SETTINGS AND THERAPEUTIC PROGRAMS 69housing for people with mental illness is that they mayhave to move many times, from one type of setting toanother, as their independence increases. This continualmoving necessitates readjustment in each setting, makingit difficult for clients to sustain their gains in independence.Because the evolving consumer household is a permanentliving arrangement, it eliminates the problem ofrelocation.Frequently, residents oppose plans to establish a grouphome or residential facility in their neighborhood. Theyargue that having a group home will decrease their propertyvalues, and they may believe that people with mentalillness are violent, will act bizarrely in public, or will be amenace to their children. These people have stronglyingrained stereotypes and a great deal of misinformation.Local residents must be given the facts so that safe, affordable,and desirable housing can be established for personsneeding residential care. Nurses are in a position to advocatefor clients by educating members of the community.Transitional CareIn Canada and Scotland, the transitional discharge model(Forchuk, Reynolds, Sharkey, Martin, & Jensen, 2007) hasproved successful. Patients who were discharged to thecommunity after long hospitalizations received intensiveservices to facilitate their transition to successful communityliving and functioning. Two essential components ofthis model are peer support and bridging staff. Peer supportis provided by a consumer now living successfully inthe community. Bridging staff refers to an overlap betweenhospital and community care—hospital staff do not terminatetheir therapeutic relationship with the client untila therapeutic relationship has been established with thecommunity care provider. This model requires collaboration,administrative support, and adequate funding toeffectively promote the patient’s health and well-being andprevent relapse and rehospitalization.Poverty among people with mental illness is a significantbarrier to maintaining housing. Residents often relyon government entitlements, such as Social Security Insuranceor Social Security Disability Insurance, for theirincome, which averages $400 to $450 per month. Althoughmany clients express the desire to work, many cannot doso consistently. Even with vocational services, the jobsavailable tend to be unskilled and part-time, resulting inincome that is inadequate to maintain independent living.In addition, the Social Security Insurance system is often adisincentive to making the transition to paid employment:the client would have to trade a reliable source of incomeand much-needed health insurance for a poorly paying,relatively insecure job that is unlikely to include fringebenefits. Both psychiatric rehabilitation programs andsociety must address poverty among people with mentalillness to remove this barrier to independent living andself-sufficiency (Perese, 2007).PSYCHIATRIC REHABILITATIONPROGRAMSPsychiatric rehabilitation, sometimes called psychosocialrehabilitation, refers to services designed to promote therecovery process for clients with mental illness (Box 4.3).This recovery goes beyond symptom control and medicationmanagement to include personal growth, reintegrationinto the community, empowerment, increased independence,and improved quality of life. Communitysupport programs and services provide psychiatric rehabilitationto varying degrees, often depending on theresources and funding available. Some programs focus primarilyon reducing hospital readmissions through symptomcontrol and medication management, whereas othersinclude social and recreation services. Too few programsare available nationwide to meet the needs of people withmental illnesses.Psychiatric rehabilitation has improved client outcomesby providing community support services to decrease hospitalreadmission rates and increase community integration.At the same time, managed care has reduced the“medically necessary” services that are funded. For example,because skills training was found to be successful inassisting clients in the community, managed care organizationsdefined psychiatric rehabilitation as only skills trainingand did not fund other aspects of rehabilitation suchas socialization or environmental supports. Clients andproviders identified poverty, lack of jobs, and inadequatevocational skills as barriers to community integration, butbecause these barriers were not included in the “medicallynecessary” definition of psychiatric rehabilitation by managedcare, services to overcome these barriers were notfunded.Box 4.3GOALS OF PSYCHIATRICREHABILITATION• Recovery from mental illness• Personal growth• Quality of life• Community reintegration• Empowerment• Increased independence• Decreased hospital admissions• Improved social functioning• Improved vocational functioning• Continuous treatment• Increased involvement in treatment decisions• Improved physical health• Recovered sense of self