Psychiatric Nursing in a Rural Outreach Program

Nancy K. Worley, PhD, RN, and Theresa Sloop, RNC

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

Nancy K . Worley, PkD, XN, is Associate Professor, College of Nursing, Medical University of South Carolina, Charleston. Theresa Sloop, RNC, is u Program Nurse, CkarlestonlDorckester Community Mental Health Center, Charleston, SC.

T w o 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 cellu- lar phone and, most importantly, compassion, energy, and common sense. They find the home of a recently dis- charged 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 impover- ishment of clients, isolation from academic centers, poor funding of mental health services, and a lack of complementary social support services

10 Perspectives in Psychiatric Care Vol. 32, No. 2, April-June, 1996

(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 collabora- tively.

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

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. In the PACT model the team functions as the provider of services. The Charleston Area Community Mental Health Center (CMHC) is seeking to adapt the urban PACT model to service delivery in rural areas, namely the program ROADS (Rural Outreach, Advocacy, and Direct Services) (Santos, et al., 1993). The center serves two large counties in South Carolina. In addition to the his- toric urban area of Charleston, boundaries include large rural farming areas and as well as a number of isolated island communities. A grant from the National Institute of Mental Health made possible the development of the Community Support Program (CSP).

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 care

Team follows client through hospital, legal, health, and social services systems

Individual thera- pist or case manager may be less likely to follow client through health and social services systems

30-50-to-1 ratio Staffing

Staff structure

10-to-1 ratio

Multidisciplinary team provides integrated clinical case management services

Multiple providers who function fairly autonomously

Emergency treatment 24 hours a day

Frequency of contact with client

Team on call, emergency room

H o s p i t a1

Daily if needed Weekly to monthly or less

Frequency of contact with families

Weekly Occasionally

Responsibility for medication

Home delivery by team, if required

Actively moni- tored by team

Client or family

Responsibility for physical health

Health care use encouraged

Responsibility for occupational rehabilitation

Direct client contact in work set- ting

Team

Psychosocial programs

Responsibility for housing

Usually client and family

Perspectives in Psychiatric Care Vol. 32, No. 2, April-June, 1996 11

Psychiatric Nursing in a Rural Outreach Program

Model of Rural Care

The CMHC did a needs assessment that revealed approximately 150 severely and persistently mentally ill clients were either underserved or unserved in the center's area. These clients had been hospitalized multiple times, but had not implemented aftercare plans. Illiteracy, poor health, limited or nonexistent transportation/ telephone services were variables that made it extremely difficult to provide services in traditional, agency- based, mental health programs.

Goals of outreach programs. ROADS seeks to reach out to clients who are not accessing the traditional CMHC services. Community mental health concepts of primary prevention, health promotion, health mainte- nance, and rehabilitation remain relevant. Comprehensive and continuous care is delivered within the client's own community, using the client's natural support system of family, friends, and neighbors.

The ROADS program is attempting to reach out to those clients who have had limited success with traditional mental health services by:

1. Improving compliance with the prescribed after-

2. Decreasing the number of psychiatric hospitaliza-

3. Promoting social and prevocational activities, 4. Providing supportive and rehabilitative services to

enhance the client's capacity for independent living, and

care treatment program,

tions,

5. Promoting optimal mental and physical wellness.

The treatment team. Such a nontraditional approach requires clinicians who are not office-bound, are creative problem- solvers, and are compassionate yet profes- sional with clients. Such staff need to like working with these clients and sincerely believe that people's lives can improve. They need to be comfortable with a generalist' approach to service delivery, because they must provide a wider range of services than their colleagues in traditional settings. The ROADS clinical team consists of two

community mental health nurses and one part-time psy- chiatrist. Nurses on the team are able to perform in accord with the full scope of nursing practice, social and rehabilitative functions in addition to assuming medication monitoring, physical health assessments, and client teaching.

Target population. From the estimated 150 CMHC clients designated as candidates for the ROADS program, 24 clients were chosen who had the highest rates of recidivism and histories of noncompliance. The team "co-managed an additional six (6) clients. Co-management occurred when specific nursing functions, primarily the administration of medications, were assumed by a nurse other than the case manager. Criteria for admission to the ROADS program included:

Age 18-65; Primary diagnosis of schizophrenia, schizoaffective disorder, manic depressive disorder, and/or other psychotic disorder; Long-term and/or multiple admissions to state or community hospitals, or ongoing use of psychiatric services more intense than outpatient care; and Resident of the rural areas of the catchment area.

Establishing the program. Because an important task of the ROADS team was to link clients with other essential services, the team used every opportunity to inform hospitals, healthcare providers, social services agencies, law enforcement personnel, and families about the service. Staff also served as members of various community boards, which facilitated interaction with residents of rural communities.

To efficiently use time, energy, and resources the team found that having days "on the road and "in the office" works best. Three days a week are spent seeing clients on established routes, while two days a week are reserved for paperwork, staff meetings, and other liai- son/case management activities. Although nurses rou- tinely travel together, they may work separately if they are familiar with the client and family. New clients are always assessed by all team members.


A well-maintained and equipped car is a necessity, for the car serves as an office, medicine room, communication center, and source of personal security. Rapid communication with CMHC staff and other community resources aids the efficiency and safety of staff. Pay telephones are not readily available and many clients do not have telephones in their homes, so pagers and a car telephone are crucial pieces of equipment. Battery cables, a spare tire, first aid kit, fire extinguisher, gaso- line can, gas credit card, telephone book, and rain gear are all necessary pieces of equipment. A locked box for medications, a portable file carrier, and a bag containing equipment necessary for a rudimentary physical assessment round out the basic equipment requirements for the team.

Locating the client in sparsely populated areas may pose some problems. The post office, local fire depart- ment, law enforcement, and other local officials can assist in this effort. Clearly marked and detailed maps are essential in locating clients.

Assessment and Intervention

A comprehensive mental health assessment is obtained in an unobtrusive manner over three to four visits. Nurses must be skilled at gathering information about the client’s support network, living conditions, access to transportation, and source of income and other resources. Establishing rapport in these first few visits is essential if valid data are to be gained. Staff also must possess the interpersonal skills to convey warmth and interest toward the client and his/her family.

Several procedures are performed during each appointment. First, the client’s current status, compliance with the medication regimen, and treatment goals are assessed. Further, staff assess any changes in the client’s living environment or additional stresses pre- sent. Medication is administered as needed, and ongoing assessment of medication side effects continues as needed.

Some clients require assistance with basic living skills, such as housekeeping, budgeting, meal preparation, and

personal hygiene. Stressing routine bathing, grooming, and wearing clean clothes seems hollow in homes where there is no running water, indoor plumbing, or basics like a comb, soap, or toothbrush, which staff may need to supply. The ideal nurse will be creative in teaching skills that can be modified to fit the client‘s environment. In addition, the nurse may be called upon to provide a variety of psychiatric interventions with the individual’s family. Both clients and their families are taught about medication and symptom monitoring, as well as relevant community resources available. Such information is indispensable to those who live in rural areas, where self-reliance often must take the place of immediate pro- fessional help.

Discussion

During the five years prior to admission to the ROADS program, the 23 clients had accumulated a total of 2,961 hospital days, in an aggregate 115 hospitalizations. During the first 18 months of the program’s operation, only one client had to be hospitalized, for a nine-day stay. Clients also improved in their role functioning. Several clients who had isolated themselves in their rooms, for example, began to partiapate a bit more in family activities. Several others used transportation available to them for the first time. A number of other clients were able to live independently and/or became employed.

The innate expense of providing this level of intense, individualized service with limited funds makes it imperative to point out that psychiatric nurses are cost- effective providers whose integrated physical and psy- chological approach ensures a highly competent health provider (Worley, Drago, & Hadley, 1990). Moreover, numerous studies have shown that client satisfaction with nurses who function as primary providers was significantly higher than with physician care providers (Ramsey, Edwards, Lenz, Odem, & Brown, 1993). Such an intensive and assertive outreach program can have a signhcant impact on clients, families, and communities.

To illustrate, John, 53-years-old, was referred to the ROADS program because of a long history of erratic and

Perspectives in Psychiatric Care Vol. 32, No. 2, April-June, 1996 13

Psychiatric Nursing in a Rural Outreach Program

turbulent behavior. He had eight previous psychiatric hospitalizations and was noncompliant with his treatment plan. He lived alone in a small house that had no running water. His mother, who was his primary s u p port, lived three miles away.

The treatment team first sought to ensure that John received his injections of Haldol regularly, which involved gaining the trust of both John and his mother. With consistency and patience the staff was eventually able to accomplish this difficult task. John can ride in a car with the staff and has learned to ride the "Medicaid van to the CMHC for appointments with program staff. Because John lives alone, ROADS staff have made a spe- cial effort to become acquainted with his neighbor. They have become allied with the team and have promised to contact staff if John needs help between visits.

Joe was referred to the ROADS team because he couldn't leave his house, refused to bathe or change clothes, and exhibited behavioral outbursts that fright- ened his family. Joe, who once attended college, had been diagnosed with a mental illness that had become so severe he was unable to function independently. During the initial assessment, the team found a severely psychotic and paranoid young man, who in addition to his mental illness, exhibited symptoms of possible thrombophlebitis. Over four months of weekly visits the nurses encouraged Joe and his family to allow a hospitalization for a complete mental and physical evaluation. After a brief hospital stay, Joe returned home and began to make remarkable progress. Using a psychoed- ucation model, the nurse helped the family to better understand Joe's illness. The team helped Joe apply for appropriate entitlements, which allowed him to pay for his medications and become financially independent. Gradually, Joe became an active family member and began to participate in church and social activities in his community.

Conclusion

Such success stories illustrate how mental health nurses can transcend traditional institutional settings to bring the finest mental health services into the communities and homes of mental health clients in rural areas.

References

Bachrach, L. (1987). Leona Bachrach speaks: Selected speeches and lec- tures. N m Directions for Mental Health Services, no. 35. San Francisco: Jossey-Bass.

Bond, G., Witheridge, T., Din&, J., & Wasmer, I. (1990). Assertive community treatment for frequent users of psychiatric hospitals in a large city: A controlled study. American Iournal of Community PsyChologY, 28,865-872.

Hollingsworth, E., Pitts, M., & McKee, D. (1993). Staffing patterns in rural community support programs. Hospital and Community Psychiaty, 37,1076-1081.

Kraus, J., & Slavinsky, A. (1982). The chronically ill psychiatric patient and the community. Boston: Blackwell.

Mechanic, D., & Aiken, L. (1987). Improving the care of patients with chronic mental illness. New England Journal of Medicine, 327, 1634-1638.

Ramsey, P., Edwards, J., Lenz, C., Odem, J., & Brown, B. (1993). Types of health problems and satisfaction with services in a ruraI nurse- managed clinic. journal oJCommunify Health Nursing, 10,161-170.

Santos, A., Deci, P., Lachance, K., & Dias, J. (1993). Providing assertive community treatment for severely mentally ill patients in a rural area. Hospital and Community Psychiat y , 4.4,34-39.

Stein, L. & Test, M. (1980). Alternatives to mental hospital treatment I: Conceptual model, treatment program, and clinical evaluation. Archives of General Psychiat y , 37,392-397.

Worley, N., Drago, L., & Hadley, T. (1990). Improving the physical health-mental health interface for the chronically mentally ilk Could nurse case managers make a difference? Archives of Psychiatric Nursing, 4,108-113.


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Psychiatric Nursing in a Rural Outreach Program