Developing a psychiatric (nursing) program has become a potential program considered for agency development. We have seen an increase in questions regarding psychiatric nursing services for the patient suffering from bi-polar disorder with depression. More agencies are considering new mental health programs. One agency has shared that Palmetto is no longer asking to see resumes of psychiatric nurses, but note that agencies must verify requirements with EVERY MAC before beginning a psych program.

 The CMS Publication 100-2, Chapter 7, §40.1.2.14, simply says, “Psychiatrically trained nurses are nurses who have special training and/or experience beyond the standard curriculum required for a registered nurse.”  MACs can establish the special training and experience required.  A home health agency should contact its MAC and look at the MAC website for any special qualifications needed.

Working with patients diagnosed with bipolar disorders can be challenging in the home care setting, but establishing trust and forming a meaningful alliance can add such quality to their life. Patients frequently need to better understand their condition, to learn the symptoms, to understand medications and other interventions, and to understand risk mitigation strategies.

Introduction

CMS has recognized psychiatric home care as a reimbursable service since 1979, but nationwide, proportionately fewer home health agencies actually provide this service. The exact number of agencies that include psychiatric home care is unknown. There has been a reluctance of agencies to implement psych programs and there are many reasons for these decisions.

First of all, the skills of a psychiatric nurse are required and this specialist is usually more difficult to find. Second, the psychiatric patient is frequently more disorganized and needy than other patients causing the case management responsibilities to become time consuming and complex. Third, this patient is frequently homebound questionable.

CMS Publication 100-2, Chapter 7, §430.1.1, states that a patient with a psychiatric problem may be considered homebound if “the illness … is of such a nature that it would not be considered safe to leave home unattended, even if he or she does not have any physical limitations.”  The homebound status of patients with psychiatric needs require well written, clearly stated clinical visit notes, because there may not be physical impairments, and homebound status must be clearly delineated. Any patient in a certified home health program may leave their home for specific reasons, as identified in Chapter 7 of the Medicare Provider Benefits Manual. Homebound status for a patient suffering from a mental health issue may be just as painful and debilitating, but may not manifest itself with physical symptoms or behaviors.

Homebound status (for a patient suffering from a mental illness) may need to be evaluated as a clinician would evaluate a patient suffering from dementia or Alzheimer’s diseases That patient may have few or no physical limitations and yet would be deemed unsafe to leave his/her home unattended.

However, if the patient with a psychiatric condition leaves home regularly for reasons other than to visit the physician, he/she may not be considered homebound; the same as any other home health patient in the certified agency.  An example may be that of patient with a mental health issue attending partial hospitalization.

What is Psychiatric Home Health Nursing?

 What is unique about psychiatric home care? Although psychiatric home care is bound by the same CMS regulations that define other types of home care, these regulations are largely non-specific for the psychiatric patient. This means the clinician must be specific as to symptoms and needs while clearly documenting individualized plans and interventions based on sound evidenced based processes. Additionally, this specialty clinician tends to work closely with the physician.

On the surface, psychiatric care appears to be very eclectic, but there is much depth of choice for intervention strategies. Although psychiatric nurses may draw upon crisis intervention techniques as noted by Duffy, Miller, and Parlocha (1993) and Beck’s or Montgomery-Asburg Depression Inventories, Young Mania Scale, Sheehan Anxiety Scale along with Cognitive Restructuring therapy, there are a number of other psychiatric intervention models that can be very useful: psych-education, interpersonal reflective, supportive, individual, and/or brief therapy, as well as behavior therapy, relaxation strategies, contract binding, and reward provisions.

The psychiatric nursing home care plan must be intermittent. This short term program frequently focuses on improved problem-solving, stronger ego boundaries, and enhanced self-concept. This is important with patients of all ages, but the need is seen often with elder patients who are suffering significant losses in life; loss of friends, loss of status, loss of financial level, loss of relatives, loss of familiar surroundings, loss of physical strength, and loss of confidence in ability to maintain independence.

With patients suffering from depression, the psych nurse frequently seeks ways to displace internalized anger outwardly and safely. Activities designed by an occupational therapist can augment the skills of the psych nurse. An increasing number of home health agency psych programs are adding this discipline because of the physical activities that can be beneficial.

The Patient Suffering from Bipolar Disorder 

According to the Department of Health and Human Services, patients with Bipolar Disorder and Depression lose 25 years of life expectancy when compared to persons without a diagnosed mental illness (Federal Register: 6/22/2010, Vol 75, # 119). The common conditions causing an early death include heart and respiratory disease, stroke, and diabetes. The psychiatric nurse can provide preventive health information that may be needed in areas of self esteem so the patient may see value and purpose for adequate nutrition, weight, exercise, sleep, work, and relaxation.

The nurse will assist the patient to deal with depression using strategies involving physical and emotional symptomatology that can enhance their ability to adequately function. The patient may express anxiety, agitation, lack of concentration, and feelings of worthlessness and hopelessness. These feelings require a specialty RN to assist with evidenced based psychosocial treatments for the disorder that includes assisting the patient and family members to understand what the disorder is and how it can best be treated.

The psychiatric nurse will educate as to signs and symptoms as well as the risk signs of relapse. Developing strategies to cope with stressful life events will be a focus of home care. The nurse will assist the patient and their family to establish protective insulators to support successful treatment compliance. Once the patient is stable, understanding how to access the overall health care system to manage their illness is necessary.

Stress management and education of stress strategies are commonly taught. Many patients have weak or fragile coping mechanisms that require reinforcement or a new approach.

Forming linkages between the patient and needed community services is a vital component of the role of the psychiatric home care nurse. This type of nursing brings an existential/spiritual concern and dimension to patient care. The clinician frequently provides support to a patient with low self esteem and a belief that the community has prejudged them. The clinician can assist the patient to cope with behaviors and approaches patients with an attitude of respect, reinforcing or assisting to rebuild worth and dignity.

Demoralized individuals are frequently seen in this program. Assisting to redirect their focus, find purpose, and achieve goals is a frequent shared goal.  Patients may lack energy, frequently because of losses; losses of friends, of family, of job, of status, of money, of respect, and others. This patient frequently requires a nurse whose plan with the patient requires assessment of the patient, their role within the family, the family support system, teaching use of psychotherapeutic techniques to facilitate change, medication management, and supervising their care in a supportive fashion that sustains a physical, emotional, and a spiritual quality of life,

Cognitive Behavioral Therapy

This is but one therapeutic philosophy that may be employed to assist the patient to examine how their thinking can impact their feelings and behaviors. Encouraging participation in psychosocial therapies can augment other interventions and improve quality of life.

Relationship Building and Trust 

The clinician will build relationships established on trust, caring, compassion, empathy, education, and hopefulness. The RN will use verbal and non-verbal communication techniques to convey interest in the patient, to assess what the patient wants to accomplish, to assist with care planning and goal achievement, and to clarify the boundaries of the relationship, and lastly to affirm the patient has value and worth.

Medication Management

Medication management is frequently a need for patients and is one of the main reasons for hospitalization. CMS identifies a significant portion of hospitalizations are due to poor medication management. Some patients do not understand the reasons they has been prescribed certain medication. Sometimes, patients do not like the side effects and feel those effects are nearly as bad as the psychiatric condition. Some patients cannot afford their meds and still others do not wish to take their meds as they provide a constant reminder of a condition many wish could be forgotten. One patient once shared, “I look in the mirror, put the pill in my mouth, bring the glass to my lips, and know I am ill.” Unless this issue is addressed, the chance that this patient will become medication non compliant is great.

Medication management intervention must be individual. Certain patients may require a contract by which they contractually agree to take their medications as prescribed. It is this tangible “document” that assists with compliance reinforcement. Teaching about major effects of the medications can be an empowering experience. For those patients whose cognitive impairment is apparent, modified pictorial teaching tools may be necessary. Role-playing, coaching, and teaching can be a part of an empowering strategy.

Risks of Suicide and Substance Abuse 

Riser and Thompson in their study identified the high risk of both suicide and substance abuse for these patients. Because of the high risk, every home health clinician should screen for these areas of concern when visiting. Know that suicide risk is greater when there are mixed states of anxiety and agitation or when the patient mixes drugs and alcohol. Be prepared for transportation needs for further health care evaluation needs if suicidal behavior or ideations become apparent.  Be certain the family support system is taught all signs and symptoms and has the plan in place in case of needs. The psychiatric patient with a substance abuse problem intensifies their healthcare risk status. An empathetic alliance with the patient and family can assist them to see the negative link between substance abuse and they and their family’s quality of life.

Summary

Patients with stressors, depression, and cognitive impairments can frequently benefit by a psychiatric nurse. The program must be comprehensive aiding the patient through stabilization, caring, and reinforcement of strengths. A therapeutic relationship built upon trust can provide acceptance to teaching and compliance with medication. Leaving the patient more calm, organized, stronger, and knowledgeable can assist the individual to improve links with family, friends, and the community and be more compliant with their medication regime.

The psychiatric program can be a strong support to total quality care and improved outcomes.