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Psychiatric-Mental Health Nursing

25.1 Identifying Varying Types of Care

Psychiatric-Mental Health Nursing25.1 Identifying Varying Types of Care

Learning Objectives

By the end of this section, you will be able to:

  • Identify varying types of care in the community
  • Describe the varying types of care available for clients across the life span
  • Determine the most appropriate type of care for a client

Mental health is not always seen as the public health issue that it is. When an individual has unaddressed mental health issues—approximately one in five people with mental health disorders seek mental health services (Bruckner et al., 2019)—these can turn into issues for the public as a whole. These issues may manifest as safety concerns, homelessness, unemployment, poverty, or effects on the local economy (Substance Abuse and Mental Health Services Administration [SAMHSA], 2013). Resolving these underlying issues is a large part of the purpose of public community care.

All nurses will encounter clients with mental health diagnoses and needs. According to the American Hospital Association, about one in four clients who are admitted to a general hospital have a mental health diagnosis (2022). Additionally, the evolution of the modern American mental health-care system has placed the burden of care increasingly on the community level. Over 100 million people live in areas with shortages of psychiatric providers. There is also a nationwide shortage of in-facility psychiatric beds that has led to an increase in emergency department visits for behavioral health-related issues.

Community mental health offers services to these clients who might otherwise have difficulty in accessing mental health care. Nurses should be able to identify the different types of care available in the community and help identify the most appropriate type of care for the client to connect them with the best services for them.

Types of Care in the Community

Mental health treatment and activities that occur outside of an institution compose community mental health (American Psychological Association [APA], 2018). Care in the community may be classified into a number of different groups: ambulatory care programs, support groups, community-based behavioral health programs, home visiting services, school-based programs, intensive community/outpatient programs, programs in treatment settings, partial hospitalization or day treatment, and substance misuse services. Federal and state funds, financial grants, fundraising efforts, and donations support community mental health. Some clients have Medicare, Medicaid, private health insurance, or children’s health programs to pay for covered services.

Client-centered care with shared decision-making is a critical aspect of community mental health care. It involves tailoring treatment and support to the specific needs of each person with mental illness. Negative public attitudes and stigma regarding mental health may make clients resistant to receiving care in a public setting.

Different geographic or catchment areas offer different types of services; they can be dependent on the demographics (National Alliance on Mental Illness [NAMI], 2023c). For those with limited resources or lack of support, or who are unhoused or uninsured, community health programs can be crucial to their health, support, and safety. Often, medication adherence can mean the difference between stability and relapse. Community mental health programs can assist individuals to manage medications and access prescriptions, therapy, education, and support to help them remain consistent with their treatment regimens. These community programs can support people in their communities and help to prevent hospitalization. There are a number of different types of mental health-care workers in the area of community health who are trained to respond to crises or provide psychotherapy, education, and consultation to those in need. Community health programs do not end with prevention, access, and education. Mental health clients may also recover at cooperative living environments, halfway houses, or group homes that are supportive and supervised residences. These clients may also benefit from supportive work arrangements in which mental health-care workers can help with maintaining employment. Adolescents and children may access special education or integrated educational program services. Clients across the life span can benefit from in-home or home care services, family support, personal-care assistance, case management and services coordination, and the use of mental health clinics. Telehealth may also be an option for clients who cannot attend an in-person treatment program.

The quality of this vast array of services and support groups depends highly on the commitment of the community itself. Cultural norms, local government funding, political climate, and environment can all affect the types of community services available. People in the community may have to work together to create needed services if they do not currently exist.

Private Care within the Community

Community mental health care offers a range of care options that cater to the unique needs of individuals seeking mental health support. Private treatment, which does not receive governmental support, can vary widely in availability and cost. Because of this, it is not accessible to everyone. A portion of the cost of care may be covered by insurance, or the client may be required to pay out of pocket (NAMI, 2022). Some private treatment services accept Medicaid or Medicare as payment for services while others may not. Private services may take place in a variety of settings and at different intervals depending on the treatment plan. For example, faith communities can play a central role in the mental health of individuals in many communities by providing education and support to both the client and their family. Many private faith-based services offer their own counseling centers or support groups.

Some other private care options available in community mental health care include individual therapy, group therapy, medication management, and case management. Individual therapy involves one-on-one sessions with a mental health professional that are tailored to the individual’s specific needs and concerns, while group therapy involves participating in therapy sessions with a group of people who are facing similar challenges. Medication management involves working with a licensed mental health provider, such as a psychiatric nurse practitioner or psychiatrist, to develop an appropriate medication regimen to manage symptoms. Case management involves working with a mental health professional who can help coordinate care and connect individuals with additional resources and support as needed. Some of these resources include the following:

  • Supportive community living services: Housing with support services focused toward independent living
  • Day habilitation: Provision of regular activities scheduled to enhance self-care skills and maintain or improve functional ability, such as assistance with adaptation to the environment for adults or reaching developmental milestones for children
  • Transitional/day programs: Assist with clients progressing between levels of function, from dependent or assisted to self-care, that is, personal care, social skills, money management, transportation, or employment training

Community Care: Public Resources

Public resources in community mental health care play a vital role in filling the gaps in access for clients who may not be able to use private resources. Public forms of community mental health care can include crisis intervention services, outpatient counseling, substance misuse counseling, and medication management. Crisis intervention services offer immediate support to individuals who are experiencing mental health emergencies, such as suicidal ideation or psychosis. Additionally, community mental health care can provide support groups, case management, and vocational services to help individuals achieve their goals and improve their quality of life. The availability of these services may vary depending on the location and resources of the community.

Community health centers have expanded over the last decade and aim to target underserved populations in specific communities, offering treatment and preventative health services. These facilities are also known as Federally Qualified Health Centers. These types of health centers offer an array of medical services, including mental health, and are important safeguards in limited resource areas, qualifying for specific reimbursement systems (such as Medicare and Medicaid) and other government funding. Clients seen at Federally Qualified Health Centers typically are on Medicaid or do not have health insurance and are offered adjusted payment options; many community health centers strive to remain affordable.

Places that provide care to clients with all levels of mental illness and substance use, including those with complex needs or at high risk, and specialize in treating these individuals is a community mental health center. They can assist with medication, case management, community services, or intensive community services (NAMI, 2022). In addition, they may be used when a referral to a private provider is not possible for a variety of reasons. These centers are often interdisciplinary, with a team working to provide care to the client. Clients who are seen at these public facilities often are eligible for Social Security disability income and Medicare benefits.

Certified Community Behavioral Health Clinics (CCBHCs) represent a significant advancement in the provision of comprehensive mental health and substance use disorder services in the United States (SAMHSA, 2023a). These clinics are part of a federal initiative designed to offer a holistic and integrated approach to mental health care and are funded through federal and state grants. They are required to provide timely treatment to any client requesting care for mental health or substance use issues, regardless of the client’s ability to pay.

CCBHCs provide a broad range of services, including community mental health treatment, substance use disorder services, crisis intervention, and even primary care services in some cases. These clinics play a pivotal role in addressing the gaps in the traditional mental health-care system, ensuring that individuals receive the full spectrum of care they need to manage their mental health conditions effectively. Every state is required to meet the federal guidelines and deadlines for the CCBHC programs.

Psychosocial Considerations

Peer Support Centers

Peer support centers are a free or low-cost resource for people recovering from severe mental illness. Individuals use their own recovery experience and training to provide support, encourage hope, and promote social interaction. The goal is to aid people with mental illness on their recovery journey to live meaningful lives in their community. Resources offered at peer support centers can range from counseling to different therapies, such as art or pet therapy, crisis support, and long-term programs for those who may have greater needs as they transition back to the community. H.E.A.R.T.S. Peer Support of Greater Nashua, New Hampshire, is one example of a peer support center that offers a wide range of resources for those seeking peer support in mental health recovery.

Community Care: Individual-Focused

Individualized care in the community can include individual counseling, psychotherapy, medication therapy, or rehabilitation (CDC, 2011). Some of the different kinds of individual-focused care available in community mental health care include cognitive behavioral therapy, dialectical behavior therapy, and trauma-focused therapy.

Community mental health-care providers may also offer specialized services for individuals with specific mental health issues, such as addiction treatment or eating disorder treatment. Integrated Health Homes (IHH) are offered in nineteen American states. IHH are team-based professionals collaborating in holistic care for adults or children with severe mental illness.

Housing and transportation circumstances can affect an individual’s ability to access treatment options. Individuals with stable housing may be more likely to participate in treatment, as the treatment may be located at their home (U.S. Department of Health and Human Services, 2021a). As more treatment shifts to a virtual environment, this has become more commonplace. The COVID-19 pandemic required many treatments to move to an online environment, and many clients who either would not previously engage in therapy due to stigma or lack of transportation were now able to receive services. Many of these services were found successful and even preferred by the clients, and thus many of these community treatment options have continued in a virtual environment.

Psychosocial Considerations

Telehealth for Mental Health Services

Telehealth has emerged as a transformative approach to delivering mental health services, offering a multitude of benefits for clients seeking support and treatment. One significant advantage is enhanced accessibility, allowing individuals to receive care regardless of geographical location or physical mobility. This is especially crucial for clients residing in remote or underserved areas, as well as those with mobility challenges or transportation barriers. Telehealth eliminates the need for travel and enables clients to engage in therapy or consultations from the comfort of their homes, promoting regular attendance and reducing the likelihood of missed appointments.

Telehealth promotes convenience and flexibility. Clients can schedule sessions that align with their daily routines, making it easier to integrate mental health care into their lives. This flexibility extends to the availability of therapists and specialists, allowing clients to access a wider range of expertise and therapeutic modalities that may not be readily available locally. For clients who experience anxiety or discomfort in traditional clinical settings, telehealth offers a more relaxed and private environment, potentially fostering increased openness and engagement. Additionally, telehealth preserves anonymity, making it an appealing option for those concerned about social stigma associated with seeking mental health support (NAMI, 2023f).

Community Care: Family-Focused

Family-focused care is an important part of community mental health care. Family-focused care recognizes the role that family members and caregivers can play in supporting individuals with mental health issues. Different kinds of family-focused care available in community mental health care include family therapy, education, support groups, and respite care.

Family therapy involves working with the family as a whole to address issues within the family unit and to develop strategies to support the individual with mental health issues, including communication techniques for improved understanding and coping skills for family members. Family therapy may be helpful in cases of clients with severe, chronic illness, such as schizophrenia, or someone who is in active recovery from substance misuse. It is especially valuable when working with children and adolescents with mental health issues. Family education involves educating family members about mental health issues, treatment options, and other ways to support their loved one. Support groups are a way for family members to connect with others in similar situations, share their experiences, and receive education and emotional support.

Respite care varies by state, with some states capping the number of days that the service may be provided in their managed care contracts. Respite care provides temporary relief for family member caregivers and can be provided in the home or in a facility where respite workers assume care, provide therapies, and supervise the client.

Community mental health-care providers also may offer services specifically for children and adolescents, such as family-based interventions for early-onset psychosis (SAMHSA, 2022a). NAMI provides support groups for families who are supporting people with mental illnesses; these group sessions are virtual or in person. The family may also participate in group therapy with the affected client.

Community Programs: IOPs and PHPs

An intensive community program, or intensive outpatient program (IOP), is a type of community care that provides structure and support for clients in a community setting, allowing them to receive intensive treatment without the disruption of hospitalization (New York Office of Mental Health, 2023). IOPs are an important component of community mental health care because they offer a higher level of care than traditional community services but do not require the same level of commitment as hospitalization with twenty-four-hour supervision. IOPs typically involve frequent and intensive therapy sessions, as well as additional support services, such as medication management and group therapy. Clients attend these sessions as scheduled.

IOPs can be an effective way to provide targeted and intensive care for individuals with mental health disorders and substance use disorders while allowing them the flexibility to continue to live in their communities and maintain their daily routines. They can also be a more cost-effective option than hospitalization; they do not require the same level of resources, and can help prevent hospital readmissions. Community mental health-care providers may offer IOPs for a variety of mental health issues, including depression, anxiety, and eating disorders. For those with substance use disorders, an IOP can be helpful for those who do not require detoxification in a hospital setting (National Institutes of Health [NIH], 2014) or have recently completed the detoxification or hospital stay and are receiving treatment in the community. Other IOPs may be for adolescents with behavioral or psychiatric conditions; this may involve participation of the adolescent’s family.

A partial hospitalization program (PHP) is a step-down program for clients who require a higher level of care and support than that offered by IOPs, but who do not need twenty-four-hour supervision. These programs require more of a time commitment than IOPs, ranging from several hours per day to full-day sessions, multiple days per week. They take place in a hospital or clinic setting, providing a highly structured and supportive environment for participants. PHPs offer a comprehensive range of therapeutic services, including individual therapy, group therapy, family therapy, medication management, medical monitoring, and other specialized interventions. The treatment team usually includes psychiatrists, psychologists, nurses, social workers, and other mental health professionals. PHPs often serve as a step-down program for people who have recently been discharged from hospitalization and still require support before transitioning to less intensive levels of care.

Types of Care across the Life Span

Different age groups have varying psychosocial needs to consider when developing an effective community health-care plan. Certain mental health conditions may be more prevalent in certain age groups. For instance, ADHD is more commonly diagnosed in children, while depression and anxiety disorders are more common in adults. Also, different age groups may require different approaches to treatment. For example, children and adolescents may benefit from play therapy and family therapy, while adults may benefit from individual therapy and group therapy. Older adults may require more assistance and support due to physical and cognitive limitations and may benefit from interventions that address their social isolation and loneliness. It is important for nurses to consider age when developing treatment plans and interventions for individuals.

Care of Children and Adolescents

Mental health disorders in children can be defined as a disturbance in thoughts, emotions, and/or behaviors that deviate from developmental norms for a child’s age, and which cause distress, impairment in functioning, or both. Like adults, adolescents and children may experience a variety of mental health disorders, such as ADHD, anxiety, depression, behavior disorders, or substance misuse. Children are not “little adults,” however, and often respond differently to medications and treatments than adults (U.S. Department of Health and Human Services, 2021b). Additionally, the diagnosis process for mental health disorders in children and adolescents is complex and usually includes in-depth family interviews, gathering information from the child’s school related to behavior, and professional observation and testing. It is important to know the adolescent or child’s diagnosis and coordinate with the appropriate support systems to be able to provide care in the community.

Evaluating a child’s developmental milestones can provide crucial insights into their mental health because these milestones are closely linked to the child’s cognitive, emotional, social, and physical development. Children who experience delays or difficulties in achieving these milestones may be at risk for mental health problems, such as anxiety, depression, and ADHD (Centers for Disease Control and Prevention [CDC], 2021). For example, if a child is not meeting their developmental milestones for language, it could be an early warning sign of communication or social difficulties that could affect the child’s mental health and development.

A child’s school and certain test results can be an important source of information on their behavior. Records can help reveal if children are reaching important developmental and emotional milestones. A thorough family history and interview about the history of the child will be part of a mental health evaluation. Home visits or in-clinic evaluations by professionals can also reveal any issues with developmental milestones. Early identification and intervention can help prevent or minimize the impact of mental health issues and support healthy development.

Bullying can have a significant impact on the mental health of children and adolescents; research has uncovered correlations between bullying and generalized anxiety disorder, panic attacks, agoraphobia, and depression (U.S. Department of Health and Human Services, 2021b). Bullying can also lead to social isolation, which can further exacerbate mental health issues. Children who are bullied may struggle with making friends, and may feel like they do not belong, which can lead to feelings of loneliness and depression. In some cases, bullying can also lead to more serious mental health issues, including suicidal thoughts. Suicide is a major concern as the third leading cause of death for those fifteen to twenty-four years old (U.S. Department of Health and Human Services, 2021b). Children who experience severe or chronic bullying may be more likely to struggle with these issues. It is important for parents, teachers, and other adults to be aware of the signs of bullying and to take steps to intervene when necessary. Providing support and resources for children who have experienced bullying can help to mitigate the negative effects on their mental health.

Prevention is a major intervention in the care of the adolescent or child in the community. There are several effective ways that prevention can be used as an effective strategy for managing community mental health care for children and adolescents:

  • Early identification and intervention take place through screening programs, regular check-ins with mental health professionals, and outreach programs that target high-risk populations.
  • Promoting mental health and well-being in children and adolescents happens through programs that focus on building social and emotional skills, promoting healthy lifestyles, and addressing risk factors for mental health problems. Such programs can be conducted in schools, through community health centers, or with assistance from individual health-care workers.
  • Education can help increase awareness and understanding of mental health issues in the community, reduce stigma, and encourage people to seek help when they need it. Schools can also be a major influence in identifying behavioral disorders in children, and in providing services that can support these children. Studies have shown that of those adolescents with a diagnosable psychiatric disorder, only half of them finish high school (U.S. Department of Health and Human Services, 2021b).
  • Targeted interventions are aimed at specific mental health issues, such as depression, anxiety, or substance use. For example, prevention issues related to alcohol and drugs can delay the first drink of the individual, thus decreasing the risk of binge drinking, heavy alcohol use, and drug use (U.S. Department of Health and Human Services, 2021b). This can decrease the likelihood of the individual developing a substance use disorder as an adolescent or even later in life.

Adolescents and children with mental health disorders may receive their mental health services in conjunction with their educational services. The Individuals with Disabilities Education Act (IDEA, 2004) provides public funding for special education services, mandating that the services be provided in the least restrictive environment.

Life-Stage Context

Services for Children and Adolescents

There are multiple community-based services and toolkits to support mental health in the child and adolescent populations. One community-based program supporting children and adolescents is Project Advancing Wellness and Resiliency in Education (AWARE). Project AWARE partners state mental health agencies (SMHAs) with state educational agencies (SEAs) to increase mental health awareness and resiliency among this population (SAMHSA, 2022b). Another is the Toolkit for Community Conversations about Mental Health produced by the U.S. Department of Health and Human Services, which provides those in the community with information, discussion guides, planning guides, and infographics that can assist with creating community care for the adolescent and child population (U.S. Department of Health and Human Services, 2021b). SAMHSA also offers a toolkit specifically for high schools to provide education, support, and intervention for those at risk.

For those children or adolescents with anxiety or depression, behavior therapy or cognitive behavioral therapy may work using an individual, group, or family approach (CDC, 2022a). Individuals can find a provider for this type of therapy in the community through a variety of locator tools (for example, the APA Psychologist Locator or the American Academy of Child and Adolescent Psychiatry Finder) or through the parent’s insurance network.

As part of the mental health-care community, parents, educators, and health-care partners all play a role. Schools can provide care in the community by referring students to mental health services, integrating social-emotional learning into their curriculum, training staff appropriately, supporting mental health of the staff, maintaining equitable discipline policies for students, and providing a safe and supportive environment. Parents and caregivers should communicate openly and honestly with their children, support healthy decision-making, enjoy shared activities together, volunteer or be engaged in school activities, provide help with homework, and communicate on a regular basis with teachers and administrators. Health-care providers can use routine appointments to provide education about development and risky behaviors, screen about relationships, and encourage positive parenting (Division of Adolescent and School Health, 2023).

Care of the Adult

The adult population is a large one that encompasses people from ages eighteen through sixty-four. It is important to note that younger adults can have different mental health issues than older adults. For instance, in 2020, young adults aged eighteen to twenty-five years had the highest prevalence of mental illness (30.6 percent) compared with adults aged twenty-six to forty-nine years (25.3 percent) and adults aged fifty and older (14.5 percent) (U.S. Department of Health and Human Services, 2022a). Nevertheless, the percentage of young adults aged eighteen to twenty-five years with mental illness who received mental health services was the lowest of all three groups at 42.1 percent, with adults aged twenty-six to forty-nine years at 46.6 percent and aged fifty and older at 48 percent. Table 25.1 compares the unique challenges that can affect the mental health of the young adult and middle-aged adult populations.

Rank Young Adults, Ages 18–44 Middle-Aged Adults, Ages 45–64
1 Transitional challenges: Younger adults may experience difficulties adjusting to new life stages, such as leaving home, entering the workforce, and starting a family. These transitions can be stressful and may lead to depression, anxiety, and other mental health problems. Stress-related disorders: Middle-aged adults often experience significant stress from work, family, and other responsibilities, which can lead to stress-related disorders, such as anxiety and depression.
2 Substance misuse: Younger adults may be more likely to engage in risky behaviors, such as experimenting with drugs and alcohol. Substance misuse can lead to addiction, as well as other mental health problems. Substance misuse: Middle-aged adults may turn to alcohol or drugs as a way to cope with stress, leading to substance misuse and addiction.
3 Academic and career pressures: Younger adults may face pressure to succeed in their academic and career pursuits. These pressures can lead to stress, anxiety, and depression. Health problems: As people age, they become more vulnerable to physical health problems. Chronic illnesses and physical disabilities can increase the risk of depression and other mental health problems.
4 Social media and technology: Younger adults are more likely to use social media and technology, which can lead to issues such as social isolation, cyberbullying, and addiction. Relationship issues: Divorce, loss of a spouse or significant other, and other significant relationship changes can be especially difficult for middle-aged adults, leading to depression, anxiety, and other mental health issues.
5 Mental health stigma: Younger adults may face stigma and discrimination related to mental health. This can prevent them from seeking help when they need it and can exacerbate mental health problems. Caregiving responsibilities: Many middle-aged adults are caring for aging parents or other family members, which can be emotionally and physically demanding, leading to caregiver burnout, depression, and anxiety.
6 Trauma and adverse childhood experiences: Younger adults may have experienced trauma or adverse childhood experiences, such as abuse or neglect, which can lead to mental health problems later in life. Empty nest syndrome: When children leave home, parents may experience feelings of sadness, loneliness, and a sense of loss, leading to depression and other mental health problems.
7   Financial stress: Middle-aged adults may experience financial stress due to mortgage payments, college expenses, and other financial obligations, leading to anxiety, depression, and other mental health problems.
Table 25.1 Mental Health Challenges Affecting Adult Populations

Depending on the severity of their illness and functional ability, clients may need assistance with determining what care is needed, finding resources for housing, securing public health insurance if unemployed, managing medications, and locating mental health therapies. NAMI (2023d) provides support groups in both English and Spanish, either in person or virtual. Additionally, community outreach and education programs can help reduce stigma and increase awareness about the importance of mental health. Support groups, individual counseling, and other resources can provide much-needed support and guidance to this population. Those with income limitations or serious mental health illnesses may benefit most from a community mental health center.

There are successful Assertive Community Treatment (ACT) model-based programs for the adult population. The Assertive Community Treatment (ACT) program delivers individualized mental health services to individuals in the community and aims to reduce clients’ dependence on hospitalization. For clients with the most severe, persistent mental illnesses and the greatest level of functional impairments, an evidence-based practice model, such as the ACT model, can be beneficial in providing a framework for strategies to identify at-risk individuals (SAMHSA, 2019). ACT teams work with individuals in their homes, workplaces, and other community settings to help them achieve their goals and improve their quality of life and to prevent institutionalization. Research has shown that the ACT model is effective in reducing hospitalizations, improving housing stability, increasing social functioning, and enhancing overall quality of life for people with severe and persistent mental illness.

One example is the Center for Urban Community Services (CUCS) in New York City. CUCS operates an ACT program that serves adults with serious mental illness, many of whom have experienced homelessness. The program employs a multidisciplinary team of mental health professionals, including psychiatrists, nurses, social workers, and employment specialists, who provide 24/7 support to clients in their homes, at work, and in the community (New York City Department of Homeless Services, Department of Social Services, n.d.). The program also operates at the national level as the CUCS Institute, providing training and assistance to organizations that help mentally ill and homeless individuals across the country.

Care of the Older Adult

The older adult population in the United States is expected to approximately double in size by 2060. In addition to its economic impacts, this growth could also have a significant effect on the treatment of mental health in older adults. Research by SAMHSA (2019) has shown that 1.4 to 4.8 percent of the 49.2 million older adults over age sixty-five in the United States suffer from a serious mental illness. A serious mental illness, as defined by the Substance Abuse and Mental Health Services Administration (SAMHSA), requires that the client have “a diagnosable mental, behavior, or emotional disorder that causes serious functional impairment that substantially interferes with or limits one or more major life activities” (2023b, para 3). Yet due to the nature of aging, many older adults exhibit impairments in functioning that may or may not be related to mental health issues, making diagnosing and caring for a mental health disorder difficult.

Many people who work in mental health care may not be aware of the signs and symptoms of mental illness in older adults, or how to treat those symptoms (SAMHSA, 2019). Others may consider some signs and symptoms, such as confusion or forgetfulness, as signs of aging, and ignore what is really affecting the client. Caring for the mental health of older adults requires specialized knowledge and an awareness of what is typical and atypical for a particular individual.

Nurses should be aware that older adults are more likely to have co-occurring health conditions, such as diabetes, heart disease, or dementia, which can complicate the treatment of mental health issues. Also, older adults are at a much higher risk for polypharmacy, or taking multiple medications, which, along with differences in drug metabolism, can increase the risk of negative drug interactions or adverse effects. A thorough and accurate medication list must be on hand during every client encounter.

There are many access issues for older adults in community mental health care. Older adults face stigma and ageism related to mental health issues, which can prevent them from seeking help and accessing appropriate care due to fear of being judged. Additionally, numerous older adults live in rural or remote areas, which can make it difficult to access mental health-care services. Older individuals may not have access to technology or transportation or may have mobility issues that make it difficult to travel to appointments. Individuals over age sixty-five are more likely to rely on family members or other caregivers for support, and these caregivers may experience stress and burden related to managing the individual’s mental health issues, or may no longer be available.

Some older adults live in institutional types of settings, such as nursing homes or skilled nursing facilities, which are located in the community, but not necessarily community-based services. For those who are diagnosed with a chronic mental illness, they may be living in a behavioral health-specific facility that offers interdisciplinary services for the client. Many older adults, on the other hand, do not live in such facilities and are socially isolated, which can exacerbate mental health issues and make it more difficult to physically access care.

Clients in older age groups may be prone to substance use. Older adults may misuse medications unintentionally through forgetfulness or error. Some older adults may turn to substance use to cope with losses in life, such as changes in employment or living situations, general health, or interpersonal relationships (NIH, 2020). The rate of substance use disorders is 0.2 to 1.9 percent in this population, and while this may seem like a small percentage, the 2016 National Survey of Drug Use and Health data noted that only 240,000 of the 863,000 older adults with a substance use disorder were receiving treatment (SAMHSA, 2019).

Community groups, such as Alcoholics Anonymous or Narcotics Anonymous, are essential for this age group. These meetings may be available in their institutional-based facility, online, or at local community centers or churches.

Life-Stage Context

Resources for Older Adults

Community-based senior centers can be an excellent resource for older adults. They often offer an array of services to improve the physical and mental well-being of older adults. Services include screenings, such as blood pressure checks, cholesterol tests, and vision and hearing tests. Many places also offer exercise and fitness programs tailored to the needs of older adults, as well as transportation services.

Centers often partner with mental health professionals to offer services, such as individual or group therapy, and education sessions to address issues, such as depression, anxiety, grief, or cognitive decline. Additionally, senior centers offer opportunities for recreation and socialization, which are crucial for good mental health in older adults.

Suicide in older age groups is also a risk. Men over the age of fifty are at higher risk for suicide, and attempts by older adults generally result in more deaths (SAMHSA, 2019). A client in an institutional facility may require more frequent supervision than others. Crisis lines and community support groups are significant community resources for care. The 988 Suicide & Crisis Lifeline offers national 24/7 call, text, and chat access to trained counselors who can assist those experiencing emotional distress. Anyone worried about a loved one can also dial 988 for support and information.

There are various resources specific to older adults. Aside from senior centers, there are also geriatric mental health clinics that specialize in the diagnosis and treatment of mental health disorders in older adults. Home health services can provide older adults with access to mental health care in their own homes, including in-home assessments, medication management, and psychotherapy. This can be especially helpful for those with limited mobility or transportation issues. Resources vary by location, so it can be helpful to speak with case managers, social workers, and other health-care professionals from the client’s community to familiarize yourself with the available resources.

The Psychogeriatric Assessment and Treatment in City Housing (PATCH) is an example of a program specifically for older adults that is based on the ACT model. It is a collaborative program between mental health professionals and housing providers, which aims to improve the quality of life of older adults with mental health issues (Robbins et al., 2000). It provides them with access to comprehensive assessments, individualized treatment plans, and ongoing support. The program is focused on addressing the specific needs of older adults, such as age-related health concerns, cognitive impairment, social isolation, and the impact of physical disabilities. Other resources, such as the Health Care Innovations Exchange through the Agency for Healthcare Research and Quality, provide care to this population as well (Agency for Healthcare Research and Quality, 2021).

Determining Appropriate Care for a Client

Determining the appropriate community-based mental health care for a client is important because it can be more cost-effective, motivate client engagement, increase access to care, and improve mental health outcomes.

The first step in determining the appropriate care involves a thorough assessment. This includes gathering information about the client’s mental health status, including their symptoms, behaviors, and overall functioning. This may involve using standardized screening tools that can identify a client’s risk for suicide, depression, anxiety, and other concerns. The nurse may conduct interviews with the client and their family, perform a mental status exam, and review medical records. Other relevant factors include age, income, medical history, access to health insurance, transportation, and social support. This assessment can help the nurse identify the client’s specific needs and preferences, which can guide the selection of appropriate community-based mental health-care services that meet the client’s unique needs and goals. The nurse can also collaborate with other members of the health-care team, such as the client’s provider and mental health professionals, to develop an effective and coordinated care plan for the client.

Real RN Stories

Nurse: B.T., MSN RN
Years in Practice: 24
Clinical Setting: Rural hospital
Geographic Location: Atlanta, Georgia

When I worked as a float nurse in a rural hospital, I was frequently assigned to psychiatry and I became known among other nurses as somewhat of an expert. I had an associate’s degree at the time and had not sought a specialty area, though I truly felt an affinity for mental health nursing practice.

One evening when I was working on a med-surg unit, a colleague approached me for advice working with an older adult who was being “stubborn” and refusing home health and other support services as part of the discharge plan. I explored how the discharge teaching was being delivered and heard words such as “told,” “pointed out,” and “tried to convince.”

I offered the nurse a strategy of therapeutic communication, which included empowering the older adult with choice and placing the emphasis on prevention—as opposed to correction. I encouraged the nurse to listen to the older adult’s concerns and possibly provide a list of five or six services and have the older adult select two to try, recognizing the importance of the person’s autonomy.

A week later, I found a thank-you note and gift card in my mail slot from the nurse I had spoken to; she wrote, “It really worked!” I smiled as I read the message, thinking that it “worked” because the nurse did.

Planning care will involve exploring a range of community-based services suitable to the individual client. When determining a plan of care for a client, the nurse should seek as much of the client’s input as possible; when people have input into their own plan, they are much more likely to follow it. After implementing the plan of care, the nurse should periodically check with the client at appropriate intervals to see how they are progressing. If necessary, the nurse can make adjustments to the plan depending on how effective the care is. Ongoing evaluation of the plan’s effectiveness will help ensure that the client is receiving the best possible care.


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