Psychiatric Nursing in a Rural Outreach Program

TOPIC. A method of delivering mental health services to clients in rural areas PURPOSE. To describe the opportunities available for nurses to provide mental health services in rural areas SOURCE. Preliminary outcome data from program statistics and case studies CONCLUSION. Nurses were able to significantly decrease client hospitalizations and increase longevity in the community. Key words: Case management, outreach, rural nursing, social support Two nurses travel down a lonely, bumpy, dirt road in a government-issue car with a basket full of client records, a small lock box of medications, a plug-in cellular phone and, most importantly, compassion, energy, and common sense. They find the home of a recently discharged client and his family. Carefully, they walk the 50 yards to the front door, using the boards that serve as a makeshift bridge over the thick mud of the yard Hesitantly, a woman and her small children peek through the partially opened door. Introducing themselves as nurses from the community mental health center, they ask to talk with the woman's brother. Reluctantly, the woman reports that her brother is angry at the family because of his recent hospitalization and the subsequent hospital bills that began to arrive in the mail. Hearing about his recent behavior, the nurses concluded that the brother was paranoid and delusional, possibly posing a threat to his family. Gently, the nurses reassured the sister that help was available through the center's mobile crisis team if her brother returned and threatened the family. Leaving the telephone number of the crisis unit with the sister, the nurses return to the car. Using the mobile phone, they call the center's financial office to request that billing be suspended. Then they alert the crisis team to the potential emergency. With a quick check of their map, the nurses head for the next house on their list. Providing mental health services to clients in rural areas provides both challenges and satisfaction for psychiatric nurses, which include: * Cultural, educational, and economic impoverishment of clients, isolation from academic centers, poor funding of mental health services, and a lack of complementary social support services (Hollingsworth, Pitts, & McKee, 1993; Santos, Deci, LaChance, & Dias, 1993), and * The opportunity to use a wide variety of skills, function with autonomy, and to work collaboratively. Providing services to the severely and persistently mentally ill in rural areas is challenging because the array of social support services usually thought necessary to promote biopsychosocial wellness in this population (Bachrach, 1987; Kraus & Slavinsky, 1982; Mechanic & Aiken, 1987) are lacking. One model of service delivery that has proved effective in urban areas, and that is being adapted to rural settings, is the Program for Assertive Community Treatment (PACT) (Bond, Witheridge, Dincin, & Wasmer, 1990; Stein & Test, 1980). The idea is to work aggressively with a small case load of clients to reduce symptoms and prevent relapse. The team provides medication and counseling, teaches life management skills, encourages independent living, and is available 24 hours a day. Table 1 illustrates differences that exist between the PACT model of service delivery and that of more traditional community mental health centers. As can be seen, PACT brings active treatment, case management, and rehabilitative therapy into the client's home and community. Table 1. Comparison Between the PACT Model and Community Mental Health Center Services Elements PACT CMHC * Treatment base In the community In a clinic * Continuity of Team follows Individual care client through therapist or case hospital, legal, manager may be health, and social less likely to services systems follow client through health and social services systems * Staffing 10-to-1 ratio 30-50-to-1 ratio * Staff structure Multidisciplinary Multiple team provides providers who integrated clinical function fairly case management autonomously services * Emergency treatment Team on call, Hospital 24 hours a day emergency room * Frequency of Daily if needed Weekly to contact with monthly or less client * Frequency of Weekly Occasionally contact with families * Responsibility Home delivery by Client or family for medication team, if required * Responsibility Actively monitored Health care use for physical by team encouraged health * Responsibility Direct client contact Psychosocial for occupational in work setting programs rehabilitation * Responsibility Team Usually client for housing and family In many models of case management used at community mental health centers, an individual or team functions primarily with the client as a service broker. …