Research Article :
Implementation of a Psychiatric Nurse-Led Outreach Service at Older Adult Homes: A Hong Kong Experience
Yuen-ling Fung
Abstract
This
article reports on the implementation of a local pioneering psychiatric nurse- led
service that was designed to address the unmet mental healthcare needs of
adults residing at older adult homes. It also describes features of potentially
wider relevance to nurses interested in developing healthcare service for other
underserved populations. We highlight the view that the crux of developing a successful
service involves understanding existing service gaps, grasping the pulse of
changing healthcare service policies, involving relevant stakeholders in the planning
process, validating service outcomes, and seeking support from management. A
central goal of the service was to enhance the accessibility of mental
healthcare services to people with unmet needs. This model of service is
preferred by service users (both the care providers and the residents in the
older adult homes), is efficient in terms of providing prompt psychiatric nursing
interventions, is able to supply primary care providers with practical advice
in response to their enquiries, and helps primary care providers to detect and
manage the mental healthcare needs of older adults.
Full-Text
Introduction
Mental health problems
account for 12% of the global burden of disease [1]. Some mental and behavioral
disorders are age-specific, such as dementia and people
feeling suicidal as a result of their advanced age. The prevalence of dementia
increases exponentially with age [2]. The risk of developing dementia doubles
every 5-7 years of age after age 65. According to Chiu et al., [3], the suicide
rate for people aged 65 is around 30 per 100,000, rising to 50 per 100,000 for
those aged over 80. In addition, 86% of elderly people who committed suicide suffered from
a mental health problem, with major depression being the
common diagnosis [4]. In view of the progressive nature of dementia, treatment
at the early stage of the illness is important. Meanwhile, suicide is a
preventable death because depression is treatable. Older adults who received
treatment for depression, their depressive symptoms were significantly reduced
[5,6]. This means that effective early detection and intervention is beneficial
for older adults with mental healthcare needs.
Mental
health in primary care is focused primarily on the provision of preventive and
curative mental health at the first level of the health care system, where a
nonspecialist can refer cases to a specialized mental health professional to
provide mental healthcare [1]. Most people receive primary care services first,
before being referred for specialist services. Enabling primary care nurses to
provide first-level psychiatric
services enhances early diagnosis and intervention. Chien et al., [7] stated that a nurseled, needs-based
service can improve the mental health status of people experiencing their first
onset of mental illness.
Fung et al.,
[8] further added that developing a partnership between psychiatric nurses and
non-mental health service providers enhances the accessibility of mental health
services to those in need of them. Thus, the partnership advocated here
transfers specialist services into primary care, where first contact with
medical care occurs. This article describes the process by which a psychiatric
nurse-led, primary mental healthcare outreach service targeting adults residing
at older adult homes (OAHs) was developed.
Background
Services
for older adults in Hong Kong
In
Hong Kong, services for older adults aim to promote the wellness of older
adults through the provision of community care and support services to help
them residing in the community, and to give support to their caregivers.
Services include: (1) community center services to provide a diverse range of
community support services for older adults and their caregivers; (2) community
care services to provide on-site personal care, rehabilitation training, social
activities, and day respite services; and (3) other community support services,
such as the Senior Citizen Card Scheme and the Holiday Centre for the Elderly
[9].
Older
age homes in Hong Kong
In
order to cater to the long-term care needs of the population, at the government
level the social welfare department has the responsibility to provide
residential care and facilities for adults aged 65 or above who cannot be taken
care of at home [10]. The OAH provides residential care, meals, basic medical
and nursing care for older adults who have been assessed as moderately to severely
impaired under the Standardized Care Need Assessment Mechanism for Elderly
Services. Residents at OAHs receive care mainly from general nurses and health care assistants
who do not receive any psychiatric/mental health training. This means that,
regardless of the reasons given for a residents need to reside at OAH, that
persons mental health care needs may be underrecognized.
The
process of service development
One
of the public mental hospitals in Hong Kong sought to provide a
community-oriented and holistic service to the older adult population in its
hospital service cluster. In 1994, researchers in the hospitals Department of
Old Age Psychiatry therefore conducted a survey on the need for such a mental health outreach
service at both private-run and government-supported OAHs within the hospitals
service cluster. There were a total 13 government-supported and 67 private-run
OAHs at the time of the survey. The findings showed that nearly all of the
surveyed OAHs rated the need, importance, and usefulness of such a mental
health outreach service as very high. There are a couple of reasons why such a
service might be in demand. First, under current health care policies, no
mental health services are provided until a patient has first had a
consultation with a psychiatrist. Due to limited resources, the list of newly
referred cases awaiting consultation and treatment from a psychiatrist is long,
with waiting times of over six months being routine. This means that there is a
pool of untreated older adults residing at OAHs, some of them already known to
be in need of mental health services. They subsequently do not receive mental
health treatment until later stages of their illness. Second, care providers in
OAHs are not prepared to care for residents with mental healthcare needs
because they lack training in psychiatric/ mental healthcare.
Subsequent to the survey, a doctor-led mental healthcare outreach service was
gradually expanded and to its fullest extent, using available resources. In
2006, nine governmentsupported OAHs did not receive mental healthcare outreach service.
This undesirable situation requires the development of alternative healthcare
for residents in OAHs. A survey on these nine OAHs confirmed that they are in
need of mental health outreach service and they welcomed the service to be
provided by the nurses. There were examples of good nurse-led practice globally:
psychotherapy
provided by clinical nurse specialists significantly reduced the patients
clinical symptoms [11]; psychosocial interventions by psychiatric advanced
practice nurses decreased adolescents mental distress [12]; implementation of a
new nursing model increased the accountability for patientcentered interventions
[13]; and the life review therapy provided by advanced geriopsychiatric nurse
decreased disempowerment themes in older adults [14]. Although global
literature provides examples of evidence-based practice, these could not be
applied directly to Hong Kong context due to differences in practice culture
and healthcare policy.
Before
this development, there was no nurse-led primary mental healthcare outreach
service in Hong Kong. A literature search conducted in 2006 also showed no
local guiding model that matched the vision of how services can be delivered to
meet the needs of users. It was determined by the chief of the service that a
locally innovative service delivery model led by psychiatric nurses would be
developed, in a departure from the traditional practice of having doctors run
the service. The motivations for this service development had two folds. The
first one was to address the problems of unmet mental healthcare needs of
adults residing at older adult homes and another one was to expand the service
scope of psychiatric nurses.
In
starting a new nurse-run service, it is important to clearly define the
practice roles and responsibilities of the outreach nurses. Developing practice
protocols together with the relevant stakeholders will enhance collaborative
practice [15]. With the combined efforts of the OAHs staff and our working
group members, using the case management model, the protocols and guidelines
were developed. The protocols include: (1) the procedures that the OAH staff
should follow in referring clients to the outreach service; (2) the criteria
that the outreach nurses should use to refer clients to the psychogeriatric
specialist outpatient clinic; (3) the tools that the outreach nurses should use
to conduct mental health assessments; (4) the scope of services provided to the
residents and OAH staff; and (5) the logistics that the outreach nurses and the
OAH staff must deal with when addressing clinical problems. In offering this
locally innovative and pioneering service, the aims are to: (1) enhance the
accessibility of mental healthcare services to people with unmet needs residing
in OAHs and (2) enhance the mental healthcare knowledge and skills of the OAH
staff. The outreach nurses are the key persons delivering the service. The
roles and functions of the outreach nurses were defined based on the aims of
the service. These include: providing an on-site service; conducting mental
state assessments; referring appropriate clients to the psychogeriatric
specialist outpatient clinic; providing psychiatric nursing interventions using
non-pharmacological approaches; discussing the management of cases with the OAH
staff; and teaching OAH staff psychiatric nursing skills through educational
talks.
In
addition, both the OAH and our staff expressed the opinion that the
effectiveness of the partnership between the outreach nurses and OAH staff in
enhancing the mental
healthcare of residents depends on a close and direct liaison between the
two parties. It was agreed that an outreach nurse should be designated for each
home and that each home should have an assigned contact person. The outreach
nurses make an on-site visit twice each month to conduct direct psychiatric
nursing assessments and interventions to the residents. In addition, a phone
consultation service is made available to the OAH staff. The framework of the service
delivery model is shown in Figure 1.
We
introduced a new and advanced nursing practice into the mental healthcare service,
i.e., the assumption of complementary and independent roles by psychiatric
nurses to screen and assess clients, intervene in their treatment, and refer
them to other healthcare professionals as necessary. Since this is a locally innovative
and pioneering service, there is no practice model for outreach nurses to
follow. Thus, it was thought that outreach nurses might find it hard to carry
out their new roles when providing services and working alongside the OAH
staff. In order to ensure that the outreach nurses would be competent and
confident in carrying out this outreach service, for the first three months
they were mentored by the psychiatric advanced practice nurse. This enabled the
outreach nurses to learn the required knowledge and skills, and familiarize
themselves with the service model. Additional support to the outreach nurses
was also available when the model was in practice.
Method
This
study was implemented in two phases. Phase one involved a pilot study and phase
two involved a service review.
Phase
One – Pilot Study
As
this service delivery model was new to both the OAH staff and the outreach
nurses, in 2006, three homes were selected for the pilot study. In order to
collect feedback and identify areas in need of improvement, we conducted a
survey in 2008. A purposive sample was obtained that included all of the OAH
staff nurses who had worked in the OAHs since the implementation of the service
delivery model. The opinions of the OAH staff were collected using an anonymous
survey form. Two open-ended questions on the strengths of the service and the
areas in need of improvement were included in the survey form. There were 32
staff nurses eligible to participate in the survey. A total of 18 survey forms
were returned. In addition, three on-site meetings were held between the administrators
of the Department of Old Age Psychiatry and the OAHs
to collect their feedback and comments. The survey and the on-site meetings
revealed that the psychiatric nurse-led outreach service model has a valuable
role to play in providing mental healthcare services. The key areas of value in
this service were: (1) the provision of a platform between the OAHs and the
Department of Old Age Psychiatry; (2) the provision by the outreach nurses of a
one-stop service in rendering support throughout the process of managing a
client; (3) the residents benefitted from the prompt advice offered by the
outreach nurses on the use of nonpharmacological approaches to manage the
psychological and behavioral
problems of clients; and (4) the function of the outreach nurses as
gatekeepers to minimize the inappropriate use of costly resources at the
psychogeriatric specialist out-patient clinic and the Accident & Emergency
Department. Recommendations about how to enhance the service were not
collected. Thus, after the trial, this service model was applied to the
remaining six OAHs in 2008.
Phase
Two – Service Review
When
the service had been implemented for five years, we collected data to gain a
better understanding of the profile of the services delivered by the outreach
nurses. From 2006 to 2011, we conducted a chart review of all of the clients
who had been referred to this service. Information about the educational
activities conducted by the outreach nurses was also assembled. The data included
statistics on: (1) the number of clients assessed; (2) the response time for
the nurses to assess the client after receiving the referral; and (3) the
number of educational talks conducted. The results were positive and
encouraging.
Results
From
October 2006 to May 2011, a total of 525 clients (of whom 339 were known to the
psychogeriatric specialist out-patient clinic and 186 were not) were assessed
by the outreach nurses. All of the clients were assessed by the outreach nurses
within 14 days, leading to early therapeutic
interventions. The waiting time for the first psychiatric consultation was
shortened by at least 165 days when compared with the routine waiting time of
over 180 days. Among the clients not known to the psychogeriatric specialist
outpatient clinic, 53 were referred to the psychogeriatric specialist out-patient
clinic and 133 clients were solely cared for by the outreach nurses using
non-pharmacological approaches. It means that around 72% of the unnecessary
referrals to the psychogeriatric specialist out-patient clinic have been screened
out by the outreach nurses. In addition, a total of 14 educational talks on the
detection and management of adults with mental problems were conducted by the
outreach nurses, with 96 OAH staff in attendance. A booklet containing mental
health problems common in older adults and nursing management of these
conditions was produced by the Department of Old Age Psychiatry. Initially,
the booklet was distributed by the outreach nurses during the educational
activities. It is now available for distribution to other primary care
providers.
Discussion
The
opportunity
While
some advanced and expanded roles in psychiatricmental health
nursing practice were demonstrated in this service, such as the gatekeeper role
of referring residents of OAHs to the psychogeriatric specialist out-patient
clinic and the clinician role of providing psychiatric nursing interventions,
certain restrictions on the scope of the services remained, due to opposition
by other members of the health team and to legal stipulations. Such restrictions
included not being able to admit OAH residents to a mental hospital, make
referrals to allied health services, order diagnostic tests, and prescribe
drugs. By contrast, in the U.S. nurse practitioners can practice independently
and have the authority to prescribe medications [16]; and in Australia,
Victorian legislation allows nurse practitioners to prescribe limited
medication [17]. The abovementioned limitations certainly restricted the
outreach nurses in their efforts to provide comprehensive healthcare services.
Nevertheless, psychiatric-mental
health nursing is a specialized nursing practice that provides
comprehensive services along the continuum of the identification of mental
health issues, prevention of mental health problems, and provision of care and treatment
for people with various mental health problems [18]. While acknowledging the
restrictions on the scope of nursing practice in the local context, in the
search for opportunities to develop mental health service within a broad area, a
new nursing service can emerge. From the example of this psychiatric nurse-led service,
it can be concluded that the key to setting up a successful service and to
developing the role of advanced nursing practice in primary mental healthcare
involves the following:
Identifying local service needs
The
introduction and implementation of an advanced nursing service must be
sensitive to national conditions as well as to the perception of needs at a
local level [19]. These include the need to contain health care costs, improve
access to care, reduce waiting times, serve the underprivileged, and maintain
health among specific groups. Understanding the local mental healthcare
situation will help in identifying unmet service needs. The local service needs
are those of clients and their care providers. It is suggested that nurses use
a survey to try to understand what the needs of their targeted clientele are.
The data will provide evidence and justification for the development of the new
service and nursing roles. This mental healthcare outreach
service was developed based on the results of the surveys conducted in 1994 and
2006. A service gap was identified by care providers. The combination of the
unmet mental healthcare needs of the residents while they are waiting to
receive services and the mental healthcare knowledge deficit of the care providers
became the focus in the development of the outreach service. The effort to
address these identified needs within the hospital service cluster led to the
successful development of this service. This service is successful because it
ensures that the right care is provided to the right client in the right
context.
Mobilizing primary care providers
Each
professional has his or her own area of expertise and scope of practice.
Although mental health professionals are responsible for providing mental
health services, the Hospital Authority is under enormous pressure to meet the
increasing demand for specialist mental health services. This growing demand could
be due to inadequate support at the primary care level and to changes in the socio-economic environment
[20]. Primary care providers have a role to play in the mental healthcare
service. Rabins et al. [21]
reported that the Psychogeriatric Assessment and Treatment in City Housing
model intervention is effective at reducing psychiatric symptoms in persons
with psychiatric disorders and those with elevated levels of psychiatric
symptoms. This is achieved through educating building staff to be case finders,
performing assessments, and providing care to the residents in their
apartments. The literature suggests that developing a partnership between
mental health nurses and primary care providers reduces the barriers to using
mental healthcare services [22,23]. The primary care providers in the OAHs
become the first point of contact in accessing mental health services. They are
in a key position to detect the mental healthcare needs of residents. By developing
a partnership with the OAH staff, residents with mental healthcare needs can be
referred to outreach nurses. Such residents can be seen by outreach nurses
within 14 days. Yet the participation of primary care providers depends on
their perception of the benefits of doing so. In this service, the benefits
included providing prompt and direct mental healthcare services to the
residents, and enhancing the mental healthcare competency of primary care providers
through educational talks and the transferring of skills.
Familiarizing oneself with contemporary policies on mental health
services
Understanding
the trends in mental health is crucial for developing a timely psychiatric nursing
service. A strategic review of mental health policies will give rise to
opportunities and resources to develop new services [24]. Grasping the pulse of
policy change in the local context will give direction to the development of
mental health services. It will ensure that the services will be developed and
rolled out at the right time. The Hospital Authority delivers a comprehensive
range of subsidized healthcare services to the general population [25]. The
priorities in the provision of services are guided by the strategic directions
outlined in the strategic plan. The need for a mental health outreach service
for the OAHs was identified in 1994. Yet the service providers had to wait until
mid-2000, when a change in policy took place. The new policy emphasized the
need for changes to be made to the current service model to enhance
cost-effectiveness and improve the health of the population, through enhancing
the community-oriented services for the older adults [26]. The study by Wong et
al. [27] found that there was a saving around US$1,510 for each diabetic
patient who joined an early discharge program that were followed up by the
diabetic clinical nurse specialist when compared with the routine hospital care
in the control group. Although this service could not be evaluated
quantitatively using cost-benefit analysis, the residents can be benefitted
from early intervention through community outreach service. Program initiatives
that were in line with the policy direction would have a higher chance of
getting support from management. Eventually, the nurse-led mental healthcare
outreach service was successfully rolled out in 2006. To summarize, the opportunity
to develop a new mental healthcare service and advanced nursing practice roles
emerges when the service can provide the right care to the right clients in the
right context and at the right time.
The
challenges
In
order to maximize the functions of psychiatric nurses in the healthcare system, all
obstacles to the new service and to developing nursing roles should be removed.
This service is an innovative practice that can replace the outreach role of
medical staff. To tackle the challenges that we encountered while developing
the service, we developed the following strategies:
Collecting evidence of the effectiveness of the interventions
Having
the credentials to engage in an advanced nursing practice is one of the major
challenges that should be considered when implementing a new service [24,28].
In addition, identifying the competencies of nurses in primary healthcare
practice serves as a reference and instrument for the education and practice of
health professionals. It is widely recognized that clinical competence is essential
to establishing trust and respect from service users as well as other
healthcare professionals. In the U.S., national licensing and certification
bodies set the requirements for the practice of advanced psychiatric-mental health
nursing [29]. However, the situation is different in Hong Kong, where no
credentials or licenses are issued in the field of psychiatric advanced nursing
practice. When there is no agreement on recognizing an advanced practice, it is
important to clarify and specify the role of the advanced practice [30].
Measuring performance outcomes can provide a benchmark for setting practice
standards and produce evidence of how the advanced nursing practice role can
make a difference in patient outcomes [31], and also provide data to support
the efficacy of innovative mental health care
delivery models [32]. However, where a regulatory mechanism is not available,
nurses might find it difficult to have their advanced practice outcomes
recognized through credentialing. Alternatively, evidence of the efficacy of
the advanced nursing practice outcomes can be provided by auditing objective
criteria on the key aspects of the nurses roles and practice outcomes. This
will help to pave the way for official recognition of clinical competence in
nursing.
Developing effective teamwork
With
the expansion of roles that occurs in advanced nursing practice, the roles of
the nurses may inevitably overlap with those of other members of the healthcare
team, particularly when they take over or duplicate the roles previously
performed by other members of the health team. However, rather than an
encroachment on the practices of other members of the healthcare team, the
advanced nursing practice should be considered only as supplementary and
complementary to them. Otherwise, a lack of understanding and opposition from
other healthcare professionals may lead to anxiety and even role
conflicts among the team members. This may adversely affect the optimal
development of mental healthcare services. Re-negotiating relationship with
other healthcare colleagues was seen as one of the barriers to the
implementation of advanced nursing practice [33]. Developing effective
collaboration among healthcare team members will help to reduce such barriers [15].
Therefore, all members of the health team should have a good understanding of
the aims and scope of the planned service. Otherwise, role confusion and
unclear role boundaries can cause difficulties for psychiatric nurses
when performing advanced practice roles [34]. The direction of the nurses scope
of practice is achieved through exploration and discussion [17]. Hence, it is
also important to discuss and clarify the extent to which the practice will be
autonomous, as well as the advanced nursing functions within the team.
Obtaining a consensus among health team members can prevent conflicts from
arising over accountability and lead to the achievement of the desired
healthcare goals for the service users.
Availability of additional manpower
Manpower
constraints will hinder the creation of the new service and advanced nursing
practice in the healthcare system. Service is delivered through people, and the
development of a service involves the allocation by management of additional
manpower [31]. For example in a hospital in Scotland, four additional psychiatric
nurses were funded by the local board to implement a new advanced nursing
service [24]. In order to ensure that management allocates the right persons
and the relevant resources to support the development of the service, it is
important for nurses to be able to produce evidence that the new nursing
service input will be able to improve client care or address unmet service
needs. To summarize, nurses need to demonstrate the effectiveness of their work
via evidenced-based practice, and work in harmony with other health team
members. Understanding the regulatory mechanism in the local context is also
important for the successful implementation of the new nursing service. It is
noted that nurses who are interested in developing healthcare service for
underserved populations will be able to do this.
Conclusion
This
locally innovative service succeeded in addressing the mental healthcare needs
of adults residing at the OAHs. The introduction of psychiatric outreach nurses
to work collaboratively with non-mental healthcare providers enhanced both the residents
accessibility to mental
healthcare services and the primary care providers competence in caring for
their clients, after they had learned practical skills from the psychiatric
nurses. It is hoped that the opportunities and challenges described here will provide
inspiration for psychiatric nurses to develop an innovative mental healthcare
service to address the unmet needs of their clientele. This pioneering
psychiatric nurse-led, primary mental healthcare outreach service has the
potential to serve those living in the community who are awaiting their first
consultation with a psychiatrist. This study only involved a small pilot
survey; a further study involving a wider context is indicated. Declaration of
Interest The author reports that there is no conflict of interest.
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Keywords
Psychiatry; Healthcare; Behavioral Disorders
