Mental health problems account for 12% of the global burden of disease . 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 . The risk of developing dementia doubles every 5-7 years of age after age 65. According to Chiu et al., , 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 . 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 . 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.,  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.,  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.
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 .
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 . 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 ; psychosocial interventions by psychiatric advanced practice nurses decreased adolescents mental distress ; implementation of a new nursing model increased the accountability for patientcentered interventions ; and the life review therapy provided by advanced geriopsychiatric nurse decreased disempowerment themes in older adults . 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 . 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.
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.
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.
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 ; and in Australia, Victorian legislation allows nurse practitioners to prescribe limited medication . 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 . 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 . 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 . Primary care providers have a role to play in the mental healthcare service. Rabins et al.  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 . 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 . 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 . The study by Wong et al.  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.
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 . 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 . 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 , and also provide data to support the efficacy of innovative mental health care delivery models . 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 . Developing effective collaboration among healthcare team members will help to reduce such barriers . 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 . The direction of the nurses scope of practice is achieved through exploration and discussion . 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 . For example in a hospital in Scotland, four additional psychiatric nurses were funded by the local board to implement a new advanced nursing service . 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.
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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Yuen-ling Fung, Department of Child and Adolescent Psychiatry, Castle Peak Hospital, Hong Kong, Tel: + 852 2468 6405; Fax: +852 2468 5504, E-mail: firstname.lastname@example.org
Fung YL. Implementation of a Psychiatric Nurse-Led Outreach Service at Older Adult Homes: A Hong Kong Experience (2015) POA 101: 1-6