Psychiatric Nursing in Home Health and Care of Patients with Depression

Depression is a common, debilitating mood disorder. It is commonly seen among patients over 65 years of age with chronic medical disorders. To provide care for these individuals, home health agencies are developing psychiatric nursing programs with more frequency.  Depressive disorders afflict about 17.6 million Americans each year.  Depression is far more common in individuals with medical illnesses with about 25% of general medical inpatients meeting diagnostic criteria for Major Depressive Disorder (MDD).

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.

Introduction

There are several psychological conditions that can predispose an individual to depression. These factors include anxiety, impulsive and obsessional personalities, negative cognitive styles, neurosis, and chronic medical conditions. Certain neurological disorders such as Parkinson’s disease, stroke, and multiple sclerosis cause greater risk for depression.

25% of patients suffering from cancer, diabetes, and MI experience MDD. Research indicates that a major life event will precede the first episode of major depression in 50% of all patients.

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 a psych program and there are many reasons for this decision.

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.”  Homebound status may need to be evaluated as a clinician would evaluate a patient suffering from dementia. That patient may have few or no physical limitations and yet would be deemed unsafe to leave his/her home unattended. The patient, in this example, could be considered homebound.  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.  An example may be that of partial hospitalization.


Partial Hospitalization

In 1999, CMS, then known as HCFA, stated that a patient in a partial psychiatric hospitalization program does not qualify for psychiatric homecare services.  The partial hospitalization program should be able to provide necessary psychiatric services. The homecare services must be psych-related. If they are not focused on a psychiatric issue, the home health agency must evaluate the patient’s needs, just as it would normally do with any other patient, and evaluate whether home care services are in keeping with medical necessity and homebound status.

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 document specific plans and interventions.

Evidence supports the fact that major depression involves an alteration in the balance of neurotransmitters and/or their function. This alteration causes a decrease in levels of epinephrine causing dullness and lethargy, and decreased serotonin can cause irritability and potential suicidal ideation.

On the surface, psychiatric care appears to be very eclectic. Although psychiatric nurses may draw upon crisis intervention techniques as noted by Duffy, Miller, and Parlocha (1993), they may also utilize a variety of assessment tools such as Beck’s or Montgomery-Asburg Depression Inventories, or the Young Mania Rating Scale (YMRS), Sheehan Anxiety Scale, or Mood Disorder Questionaire (MDQ). These may indicate the use of  Cognitive Restructuring therapy or a number of other psychiatric intervention models that can be very useful: such as psycho-education, interpersonal reflective, supportive, individual, and/or brief therapy, as well as behavior modification, reward provisions, and antidepressant psychopharmacology.

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.  With depression, the psych nurse frequently seeks ways to displace internalized anger outwardly. 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.

Stress management and education of stress strategies is 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 a existential/spiritual concern and dimension to patient care. The clinician frequently provides a degree of support to a patient with low self esteem and a belief that the community has prejudged them. The clinician approaches patients with an attitude of respect, reinforcing  or assisting to rebuild worth and dignity.

Demoralized individuals are frequently seen in this program. 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 physical, emotional, and spiritual life, promoting health.

Relationship Building and Trust

The clinician will build relationships established on trust, caring, compassion, empathy, 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, 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. Some patients do not understand the reasons they have 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.

Medication management intervention must be individual. Certain patients may require a contract by which they contractually agree to take their medications as prescribed. 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 an empowering strategy.

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 on trust can provide acceptance to teaching and compliance with medication. Leaving the patient more calm, organized, stronger, and knowledgeable can assist them 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.