Patients' perceptions of psychiatric home care

Patients' Perceptions of Psychiatric Home Care

Melanie Morris

A qualitative study was designed to explore patients ' perceptions of psychiatric home care. Nine patients receiving psychiatric home care from a private home-care agency were interviewed using a tool developed by the researcher. Demographic data was collected from the patients ' charts. Descriptive statist ics were used to analyze characteristics of the patients. Content analysis was conducted on interview transcripts. The aspects of psychiatric home care that patients described as most valuable include companionship, counseling, assis tance with housework, and monitoring of vital signs. Patients described positive effects of psychiatric home care on their compliance with psychotropic medication regimens and on their relationships with family members . All patients in this sample received psychiatric services in addition to psychiatric home care. Psychiatric home care appeared to be a major factor in maintaining patients in the community. Nursing implications, limitations of the study, and recommendations for further research are presented. Copyright © 1996 by W.B. Saunders Company

p SYCHIATRIC HOME-CARE services is a growth industry. Earlier hospital discharge,

the need for alternatives to institutional care, and broader third party payment coverage fuel the movement.

Kozlak & Thobaben (1994) describe the goal of psychiatric home-care programs as assisting indi- viduals "to maintain their independence in the community while coping with chronic or serious mental illness." According to Pelletier (1988), the purpose of psychiatric home care is "to provide services which are adjunctive to outpatient treat- m e n t . . , or a viable alternative to hospitalization."

There is anectodal evidence in the literature regarding the benefits of psychiatric home care from case reports by psychiatric nurses (Lesseig, 1987; Harris, 1987) and from firsthand accounts by patients receiving psychiatric home care. Wagner (1994) describes her experience as a recipient of

From Yale University School of Nursing and Connecti- cut Mental Health Center, New Haven, CT.

Address reprint requests to Melanie Morris, RN, MSN, Connecticut Mental Health Center, 34 Park Street, New Haven, CT06508.

Copyright © 1996 by W.B. Saunders Company 0883-9417/96/1003-000853.00/0

this care. From her perspective, psychiatric home care nursing can be:

"extremely effective in keeping the mentally ill out of the hospital at a fraction of the cost while providing a service that can be a lifeline for those whose mental illness has left them isolated and vulnerable in a society that by and large ignores, or worse, abuses them." (p. 2)

The literature on psychiatric home care focuses on the goals of care (Kozlak & Thobaben, 1994; Pelletier, 1988), the effectiveness of home care in reducing the need for hospitalization (Braun et al., 1981; Davis, Dinitz, & Pasamanick, 1971; Fenton, Tessier, & Streuning, 1979; Keener, 1975; Kiesler, 1982; Muijen, Marks, Connolly, & Audini, 1992; Pasamanick, Scarpitti, & Dinitz, 1967; Smith, Fenton, Benoit, & Barzell, 1976; Stein, Test, & Marx, 1975), the financial savings (Bums, Raftery, Beadsmoore, McGuigan, & Dickson, 1993; Kiesler, 1982), the funding sources (Dittbrenner, 1994; Hellwig, 1993; Miller & Duffey, 1993; Pelletier, 1988), the populations receiving the care (Blazek, 1992; Dittbrenner, 1994; Pelletier, 1988; Richie & Lusky, 1987), and the role of the psychiatric nurse in providing the care (Blazek, 1993; Leissig, 1987;

176 Archives of Psychiatric Nursing, Vol. X, No. 3 (June), 1996: pp 176-183

PATIENTS' PERCEPTIONS OF PSYCHIATRIC HOME CARE 177

Miller & Duffey, 1993). Literature is scarce on the perceptions of patients about the care they receive.

The purpose of this study was to explore the perceptions of patients receiving psychiatric home c a r e .

BACKGROUND

The role of the community-based psychiatric nurse dates to the early 1900s. At that time, preventive mental-health organizations were formed and state public-health departments used mental- health consultants to instruct their staffs in mental- health principles (Hellwig, 1993). In 1961, the Joint Commission on Mental Illness and Health's recommendations heralded the era of deinstitutionalization and community care (Krauss & Slavinsky, 1982). Since this time, mental health policy in the United States has been the deinstitutionalization of hospitalized mental patients and the development of outpatient care through community mental- health centers. The trend toward community-based programs, new kinds of health workers, and the discovery of medications to control symptoms of psychosis became national policy with the Mental Retardation Facilities and Community Mental Health Centers Act of 1963 (Braun et al., 1981).

Outpatient care increased dramatically between 1955 and 1975 from 379,000 clinical episodes in 1955 to 4,600,000 in 1975 (Kiesler, 1982). Initially, there were few alternatives available to hospital care. According to Krauss and Slavinsky (1982), deinstitutionalization occurred too rapidly for ad- equate social, medical, and financial resources to have been developed for patient care in the community. The development of the system of community mental-health centers lagged behind the progressive phaseout of the large, public psychiatric hospitals. There was little scientifically based information for planning community programs and for identifying types of patients for whom deinstitutionalization would be appropriate. At this time, public health nurses and psychiatric nurses were em- ployed as liaison consultants between mental institutions and patients being returned to their commu- nities (Arafeh, 1968).

The use of psychiatric home care has been increasing and parallels that of overall home care (Richie & Lusky, 1987). This trend is based on earlier hospital discharge, increased demand for home care as an alternative to institutional care,

broader third party payment coverage, and greater physician acceptance of home care.

The idea of "least restrictive" methods and settings also promotes the use of psychiatric home care. Since 1961, when Erving Goffman (1961) wrote his seminal essay about the social psychological effects of institutionalization, much has been written about the potentially debilitating effects of total institutions and mental institutions in particular. Institutionalization is often seen as fostering institutional dependency, leading to progressive loss of social and vocational competencies, under- cutting one's ability to deal competently and inde- pendently with the world outside the institution, and often involving loss of contact with relatives and meaningful others (Kiesler, 1982). Psychiatric home care, in contrast, promotes independence and contact with family and meaningful others.

Research has compared the effects of psychiatric home care to hospitalization. Kiesler (1982) re- viewed ten studies in which psychiatric patients were randomly assigned to either inpatient care or some alternative mode of outpatient care, including home care. In no cases were the outcomes of hospitalization more positive than alternative treatment. Pasamanick et al. (1967) showed, in the Louisville Institute Treatment Center Study, that with the use of medication and public-health nursing care, people with schizophrenia could be treated more effectively in the community than in the hospital. They found that hospital patients were much more likely to be rehospitalized than patients receiving medication and nursing care in their homes.

METHODS

A qualitative study was conducted to identify patients' perceptions of psychiatric home care. The study involved a convenience sample of nine patients receiving psychiatric home care from a private, for-profit home care agency in Connecti- cut. Patients were enlisted to participate in the study by the psychiatric nurses at the agency. The nursing staff invited those patients to participate who met the criteria for inclusion and who the nurses determined would be able to tolerate the interviewing process. The nurses described the purpose of the study to these patients using a script provided by the researcher. The majority of patients invited to participate declined, which accounts for the small sample size.

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Audiotaped semistructured interviews were used to examine the patients' subjective experiences. The interviews were 30 minutes to 1 hour in duration, depending on the patients' depth of re- sponse. Content areas included: demographics, support services, physical health, hospitalizations for psychiatric illness, use of psychotropic medications, psychiatric home-care contact, and family contact. All of the patients in the study had been known to the home-care agency as a patient for at least 9 months, all were diagnosed with a serious mental illness and had a history of at least one psychiatric hospitalization. Diagnostic and standard demographic information were obtained from the patients' charts. The study was approved for protection of the rights of human subjects by an Institutional Review Board.

RESULTS

Common responses from open-ended questions were clustered and major themes identified. Table 1 summarizes patient characteristics.

Table 1. Subject Characteristics

Variable N = 9 %

Gender Female 4 44.44 Male 5 55.55

Marital Status Married 2 22.22 Single 7 77.77

Living Situation Lives alone 3 33.33 Lives with spouse 2 22.22 Lives with roommate(s) 3 33.33 Lives with child(ren) 1 11.11

Education Level Completed Completed sixth grade 2 22.22 Completed high school 7 77.77

Primary Funding Source for Home Care Medicare 5 55.55 Medicaid 4 44.44

Axis I DSM-IV Diagnosis Schizophrenia 3 33.33 Bipolar Disorder 2 22.22 Major Depression 2 22.22 Schizoaffective 2 22.22

Range Mean Median Mode

Age 27-83 42 36 36 Number of months

receiving psychiatric home care 9-15 12 12 12

Subjects" estimate of number of psychiatric hospitalizations (n = 8) 3-17 8.6 6 5

What Happens During the Visit With the Psychiatric Nurse ?

Patients varied in their description of the care they received from the psychiatric nurse, reflecting each person's unique circumstances, needs, and perceptions.

E describes the nurse's visit as an assessment of her psychiatric condition and her vital signs, and supervision of her medication use. "She asks me how am I doing, how is it seeing the shadows and voices. Then she takes my blood pressure and my pulse and she sits down and makes sure I 'm taking [the medication]." In addition, the nurse counsels E about parenting skills and problem-solving. "I talk about almost anything with [the nurse]," E states, "We talk mainly about how I 'm doing and the children. She used to try and help me with the children. I have roaches, and she's trying to help me to get the roaches away from here. And she makes phone calls to try to get me help."

G. views as the main focus of the interaction between herself and the nurse her use of medication and supportive counseling. According to G., "We just talk generally about my medication, if I 'm taking it, because I've been known to go off of it without telling [the nurse]. And I have complica- tions with my parents."

D. emphasizes assessment when describing his roommate's and his interaction with the nurse. "He just comes to talk about problems . . . and how we're doing and how's our medication . . . . He'll bring in a notebook and write down what we're do ing . . , and how active."

B. describes his interaction with the nurse in terms of companionship, help with problem- solving, and supervision of his use of medication. He states, "Once in a while, I have a letter or something that I give to her and say, 'Read this. I don't quite understand it.' She reads it to me. She goes over it with me. She hangs for five, ten minutes. I play a song for he r . . . . If I have a problem that day, I bring it up. She's like a little secretary. She's got the facility of taking care of it." The nurse administers B.'s medication to him, which B. states is a particularly important aspect of his care because he has a history of overdosing on drugs and medications.

A. talks with the nurse about her children and how she is feeling. The nurse takes her blood pressure and supervises her use of the medication box that the home-care agency provides to help


patients organize their medication doses. Accord- ing to A., "We usually talk, and she takes my blood pressure. I set this up when she's here. This is a box. I use the morning and bedtime slot in the box and put my medication in it."

H. emphasizes the social aspect of the interaction between herself and the nurse: "We shoot the breeze, talk about medication, talk about fun things, play with the birds."

Recurring themes in patients' descriptions of the interaction between themselves and the nurse include the nurse's assessment of patients' psychiatric symptoms and level of functioning, provision of supportive therapy, supervision of their use of psychotropic medication, and monitoring of vital signs.

What Do Patients Value Most About Psychiatric Home Care ?

The aspects of home care that patients describe as most valuable include companionship and reduced isolation, supportive therapy, and medication supervision.

Companionship. A. says of the home health aide, "Even though she's doing housework, I think her constant presence has been very therapeutic. . . I haven't felt so isolated. It 's not so much the housework, which is important . . . but just the knowledge that somebody's coming."

B. says of the psychiatric nurse, "I enjoy her company because I ' m here all alone . . . . [The nurse's] coming around once a day, twice a d a y . . . it releases that valve and makes me feel happy."

G. and H. described the support they receive from the nurse as particularly valuable. G. states, "They're there when I need them. If I have a bad day . . . I can call them up, and generally, [the nurse] will call me back. We'll talk. If it's early in the morning or something, he'll get one of the aides to come out . . . . [The nurse] dealt with me at the very beginning when I was really sick . . . . He's like my right arm. If I have any problems, I don't feel embarrassed to talk to him about it." Of the aides, G. states, "It 's just like having a buddy . . . . [The aides] don't treat you like a doctor . . . . They don't drill you."

Visits with the psychiatric nurses have helped H. with her self-esteem. According to H., "My self- esteem has gone sky-rocket since these nurses have come to see me. They tell me that I ' m a nice person. They give me courage and strength. [The nurse] is

constantly telling me I ' m pretty. I need to hear that. I needed those pats on the back because I just didn't have that."

Reduced Isolation. Isolation is a common side effect of chronic mental illness. People experienc- ing major depression tend to become withdrawn and isolative. People with paranoid schizophrenia often avoid contact with others. Psychotic thought processes and behavior tend to make social contact and the formation of relationships difficult, especially in light of the stigma of mental illness and the fear that it engenders in those who are not labeled mentally ill. Family members may become less available to a relative whose erratic behavior becomes burdensome over the course of many years. All of these factors contribute to a sense of loneliness and isolation in the chronically mentally ill.

Several patients emphasized companionship as the most valuable aspect of the home care they receive. For some, visits from a psychiatric nurse and home health aide may be the most consistent social contact they experience during the period of time that they receive the care. The therapeutic value of seeing a familiar face and connecting with another human being every day or several times a week should not be underestimated.

Psychotropic medications. The discovery and use of psychotropic medication in the treatment of chronic mental illness was a significant factor in moving patients from institutions back to the community in the 1960s and '70s. Many patients who in earlier times might have spent the bulk of their lives in institutions are now leading viable lives in the community. The issue of medication compliance has existed since psychotropic medications first gained widespread use in the 1950s with the introduction of the phenothiazines. Patients are noncompliant with their medication regimens for a variety of reasons, and noncompliance is often cited as the cause of the revolving door phenomena, whereby patients living in the community stop taking their medications and become symptomatic, requiring them to be hospitalized in short-term inpatient mental-health facilities long enough to be restabilized on their medications and to have their psychiatric symptoms brought under control. Drug monitoring and management is crucial in breaking this cycle. Psychiatric home care performs a vital function in assessing the effects of medication and in assisting patients to comply with their medica-

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tion regimens. Assistance varies, with some patients requiring direct administration of medication, others needing supervision with sorting doses of medication into a medication box, and still others requiring education about the effects and side effects of medication. Some patients need to be reminded or encouraged to take their medications day by day and even dose by dose, especially when psychotic thought processes interfere with their memory and judgment. Many of the patients interviewed attributed their improvement to the therapeutic effects of medication. A. states that her recent bout of depression had begun to lift after she was prescribed an antidepressant. G. learned from the psychiatric nurse that her past noncompliance with medication had put her at risk for acting on suicidal impulses.

One of the roles of the psychiatric nurse is to encourage and assist patients with medication compliance. All but one of the patients interviewed had medication prescribed to treat their psychiatric symptoms. The one patient who was not prescribed medication received biweekly electroconvulsive shock therapy (ECT). Depending on the particular needs of the patient, the psychiatric nurse per- formed a variety of functions related to assisting and encouraging medication compliance. These include monitoring for compliance, assessing the effects of medications, administering the medication directly, supervising patients' use of a medication box for organizing multiple doses of medication, and educating patients about the effects and side effects of medication and the effects of noncompliance.

B. described home care as having a significant effect on his use of medication, stating that if the nurse did not administer his medications to him, he "might take too much or take too much at once, and then cut down for a couple of days [and] start shaking." Having the nurse administer the medication, "protects me in a way. It helps me out. It keeps me monitored. It keeps me sedated. It's just more proper, I think."

The nurse who visits E prepares a medication box for her. E states that before she had this assistance, "sometimes I would forget to take i t . . . I learned that if I don't take them, it won't work for me, and that's why I take them, because it helps me with the voices and the shadows."

G. has a history of medication noncompliance. She cites education and encouragement from the

nurse as significant factors in her compliance with medication. G. states that she has learned from the nurse that she needs to stay on her medication to control her symptoms of depression and psychosis.

Patients' contact with family members. All of the patients interviewed either live with or are in daily or weekly contact with members of their families. The psychiatric home-care nurses are in contact with family members of some of the patients interviewed. E states that, if her children are at home when the nurse visits, the nurse will talk with them and demonstrate for E more effective ways of communicating with them. The nurse talks with B.'s parents about his progress and alerts them to changes in his mental status. She collabo- rates with them in helping B. to manage his medication when he spends weekends with them.

Some of the psychiatric nurses, though not in direct contact with patients' family members, have an indirect impact on patients' family relationships. The nurse who cares for G. has supported her in her decision to move with her husband from h.er parents' home into their own home. As a result of the move and supportive counselling from the nurse, G. states she has gained a deeper understanding of the impact that living with her alcoholic father and bedridden mother had on her. H. at- tributes her decision to move from a chaotic situation in her parents' home into an apartment with a roommate to the encouragement she received from the psychiatric nurses who have visited her.

Support services. All of the patients interviewed received outpatient psychiatric services in addition to psychiatric home care. All met with psychiatrists who prescribed their medications or ECT treatments. Several of the patients met once or twice weekly with a therapist for supportive counseling. Some attended therapy groups.

Psychiatric home care is an essential adjunct to other forms of psychiatric treatment. In inpatient facilities, the emphasis is on the treatment of pathology. In contrast, psychiatric home care emphasizes the facilitation of healthy functioning. The objectives of care are the creation of a physical and psychological environment that facilitates develop- mental and psychological growth. In inpatient and outpatient facilities, staff are in control. With psychiatric home care, the patient is in her/his own territory, and it is the nurse and aide who are on unfamiliar ground. In addition, although the home


health aide does not have professional authority and prestige, this can be an advantage in facilitating the patients' sense of autonomy.

Home-care treatment plans are tailored to fit the unique needs of each patient. No two patients interviewed for this study had the same arrange- ment. Visits by psychiatric nurses varied from once a week to twice a day every day. Visits by the home health aides varied from twice per week to every day. Patients' accounts of home care indicate that visits by the nurses and aides were more frequent and of longer duration when a patient is in the acute phase of her/his illness. As the patient's condition improved, services were gradually decreased. Inten- sity of services was adjusted as the patient's need changed. The abilities of the psychiatric nurse in assessing patients' evolving needs and the flexibility of home-care agencies in tailoring services to meet those needs are critical components in the delivery of optimal care to the chronically mentally ill population.

The opportunity that psychiatric home-care nurses have to assess patients in their home environment provides a level of information that is not available to clinicians in an inpatient or an outpatient psychiatric facility. A. captures the assessment aspect of the psychiatric nurse's role with her statement, "[The nurse] seems to be very much in touch with what's going on with the patient . . . . It 's a very finely tuned operation . . . where they show that they're professional."

D I S C U S S I O N

Patients' perceptions about psychiatric home care and what patients value about it correlates with the goals ascribed to psychiatric home care in the professional literature: providing services that are adjunctive to outpatient treatment and a viable alternative to hospitalization (Pelletier, 1988), and assisting patients to maintain their independence in the community while coping with chronic mental illness (Kozlak & Thobaben, 1994).

The results of this study suggest that psychiatric home care is helpful in reducing patients' sense of isolation, providing support, assisting with problem solving, and facilitating compliance with medication regimens. The results also indicate that psychiatric home care impacts on patients' relationships with their families, both by alleviating family burden and by providing patients with counseling about dysfunctional family situations. Patients were

less cognizant of the more subtle aspects of the psychiatric nurse's role in assessing their mental status and level of functioning.

Virginia Henderson (1966) described the function of nursing as assisting "the individual, sick or well, in the performance of those activities contrib- uting to health or its recovery . . . that he would perform unaided if he had the necessary strength, will, or knowledge. And to do this in such a way as to help him gain independence as rapidly as possible." In earlier times, nursing leaders tended to emphasize the nursing services directed toward the care of the sick. More recently, nursing has stressed the maintenance and promotion of health, as well as the prevention of illness.

The subtle ways that psychiatric home care works to promote and maintain health are difficult to delineate or to measure, which partially explains why insurers have been reluctant to include psychiatric home care in their compendium of care. Much of what patients describe as their experience of psychiatric home care seems trivial or inconsequen- tial, but it is the companionship, advice, encouragement, education, and the continuity of care that contributes to maintaining patients in the community. Wagner (1994) conveys the subtlety of the benefits for recipients of psychiatric home care thus:

"It would be trite and inaccurate to say [the nurse] saved my life. I'm sure I would have lived had I not met her. But she did something equally, if not more, important: She helped me to find ways to have quality in the life I lived." (p. 2)

The goal of stabilizing those with chronic mental illness in the community necessitates the coordina- tion of support services and continuity of care. Without this, patients have and will continue to fall through the cracks of the system.

Psychiatric home care helps patients create within their homes a physical and psychological environment that facilitates healthy functioning. As a guest in patients' homes, the psychiatric nurse has a unique opportunity to thoroughly assess patients' functioning and to establish a therapeutic relationship that promotes independence and autonomy. Another advantage of home care, according to Leissig (1987), "is that one is less uncertain about the client's ability to apply in 'real life' what he or she has learned. Adaptation or lack of it can be observed directly."

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The complexity of case management with psychiatric patients requires flexibility on the part of home-care providers. It is vital that insurers of psychiatric home care continue to afford agencies the latitude to provide care that can be tailored to fit the unique needs of its patients.

The fact that Medicare and Medicaid have broadened their coverage of psychiatric home care suggests that insurers have realized that home care is cost effective in reducing patients' need for hospitalization. Though psychiatric home care has been reimbursable by the Health Care Financing Administration since 1979, the use of these services has undergone significant expansion in recent years. And although the literature indicates that psychiatric home care is effective in reducing the need for hospitalization, its effectiveness in contrib- uting to the long-term stability of the chronically mentally ill remains to be determined.

The chronically mentally ill are among the most disenfranchised members of our society. Psychiat- ric care is offered to and sometimes forced on them. Rarely are patients given the opportunity to express their views about psychiatric treatment. Patients' perceptions of psychiatric home care raises questions about how clinicians and patients can establish a more collaborative relationship through a mutually expanding understanding of the therapeutic alliance and its effects on both patients and clinicians.

FUTURE RESEARCH

Future studies involving larger samples with greater ethnic and socioeconomic diversity and drawn from more than one home-care agency would provide a more representative view of patients' perceptions about psychiatric home care. A study correlating patients' perceptions with those of the home-care providers would yield a broader perspective on the scope of this modaiity.

A longitudinal study of recipients of psychiatric home care is needed to determine the effects of psychiatric home care on patients' lives over a more extended period than the 9 to 15 months that patients in this study received these services. Studies are also needed to determine if psychiatric home care has lasting effects beyond the period of care.

As psychiatric home-care services continue to expand, further research is also needed to deter-

mine if psychiatric home care is, in fact, reducing patients need for hospitalization, and if so, what aspects of care are producing this effect. Research is also needed to determine how psychiatric treatment modalities can be most effectively coordi- nated to ensure comprehensiveness and continuity of care.

The training of psychiatric nurses has been structured more around acute episodes of care than around a longitudinal approach. The research literature on chronic mental illness is persuasive about the needs for aggressive and persistent efforts over a long span of time. Psychiatric nurses have an opportunity, in providing home-care services to those with chronic mental illness, to combine acute care with long-term rehabilitation.

ACKNOWLEDGMENT

The author acknowledges and thanks Donna Diers, RN, MSN, for her editorial assistance.

REFERENCES

Arafeh, M.K., Fumiatti, E.K., Gregory, M.E., Reilly, M., Wolff, I.S. (1968). Linking hospital and community care for psychiatric patients. American Journal of Nursing, 68(5), 1050-1055.

Blazek, L.A. (1993). Development of a psychiatric home care program and the role of the CNS in the delivery of care. Clinical Nurse Specialist, 7(4), 164-168.

Braun, P., Kochansky, G., Shapiro, R., Greenberg, S., Gudeman, J., Johnson, S., & Shore, M.F. (1981). Overview: Deinsti- tutionalization of psychiatric patients, a critical review of outcome studies. American Journal of Orthopsychia- try, 138(6), 736-749.

Bums, T., Raftery, J., Beadsmoore, A., McGuigan, S., & Dickson, M. (1993). A controlled trial of home-based acute psychiatric services. II: Treatment patterns and costs. British Journal of Psychiatry, 55-61.

Davis, A.E., Dinitz, S., & Pasamanick, B. (1972). The prevention of hospitalization in schizophrenia. American Jour- nal of Orthopsychiatry, 42(3), 375-388.

Dittbrenner, H. (1994). Psychiatric home care: An overview. Caring Magazine, 13(6), 26-29.

Fenton, ER., Tessier, L., & Struening, E. (1979). A Comparative trial of home and hospital psychiatric care. Archives of General Psychiatry, 36, 1073-1079.

Goffman, E. (1961). Essays on the social situation of mental patients and other inmates. Garden City, New York: Doubleday, 1961.

Harris, P.E. (1987). Psychiatric assessment in the home. Quality Review Board, 13(4), 131-134.

Hellwig, K. (1993). Psychiatric home care nursing: Managing patients in the community setting. Journal of Psychoso- cial Nursing, 31(12), 21-24.

Henderson, V. (1966). The nature of nursing. New York: MacMillan.


Keener, M.L. (1975). The public health nurse in mental health follow-up care. Nursing Research, 24(3), 198-201.

Kiesler, C.A. (1982). Mental hospitals and alternative care: Noninstitutionalization as potential public policy for mental patients. American Psychologist, 37(4), 349-360.

Kozlak, J., & Thobaben, M. (1994). Psychiatric home health nursing of the aged: A selected literature review. Geriat- ricNursing, •5(3), 148-150.

Krauss, J.B., & Slavinsky, A.T. (1982). The chronically ill psychiatric patient and the community. Boston: Black- well Scientific Publications.

Leissig, D.Z. (1987). Home care for psych problems. American Journal of Nursing, 1317-1320.

Miller, M.R, & Duffey, J. (1993). Planning and program development for psychiatric home care. Journal of Nursing Administration, 23(11), 35-41.

Muijen, M., Marks, I., Connolly, J., & Audini, B. (1992). Home based care and standard hospital care for patients with

severe mental illness: A randomized controlled trial. British Medical Journal, 304, 749-754.

Pasamanick, B., Scarpitti, ER., & Dinitz, S. (1967). Schizophren- ics and the community. New York: Appleton-Century- Crofts.

Pelletier, L.R. (1988). Psychiatric home care. Journal of Psycho- social Nursing, 26(3), 22-27.

Richie, F., & Lusky, K. (1987). Psychiatric home health nursing. Community Mental Health Journal, 23(3), 229-235.

Smith, EA., Fenton, ER., Benoit, C., & Barzell, E. (1976). Home-care treatment of acutely ill psychiatric patients: A review of 78 cases. Canadian Psychiatric Association Journal, 21(5), 269-274.

Stein, L.I., Test, M.A., & Marx, J.J. (1975). Alternative to the hospital: A controlled study. American Journal of Psy- chiatry, 132, 517-521.

Wagner, P.S. (1994). CNA member in the news: A lifeline for the mentally ill. Connecticut Nursing News, 67(8), 1-2.

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Patients' perceptions of psychiatric home care