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Learning Objectives

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

  • Describe follow-up care for psychiatric-mental health clients after hospitalization
  • Explain what mental health and psychosocial support (MHPSS) entails and provide examples

Follow-up care is critical for the successful recovery and overall mental health of clients who have been discharged from a hospital for psychiatric care. The transition from the hospital back to the community can be challenging for clients, and the nurse’s role in follow-up care is crucial in providing continuity of care and helping clients navigate their recovery journey.

Follow-Up Care after Hospitalization

Mental health care for an acute episode does not stop when the client is discharged from the hospital; follow-up care after hospitalization is a critical component of ensuring successful recovery and reducing the risk of relapse. Often, providers recommend that the client follow up with a mental health provider within thirty days of discharge; ideally, they would follow up within seven days (Medicaid, n.d.).

As coordinator of care for the client, the nurse plays a vital role in assisting with this follow-up care, collaborating with other health-care professionals to provide comprehensive care for clients with mental health concerns. The nurse’s central role in the interdisciplinary team entails addressing a client’s overall health needs after discharge. Nurses can provide updates on the client’s mental health status and collaborate with the team regarding any changes that should be made to the care plan to address the client’s physical and mental health concerns. Nurses can also support clients in a number of other aspects of follow-up care.

Medication Management

One of the most important aspects of follow-up care for mental health clients is medication management. Nurses can help clients understand the importance of taking their medication as prescribed, monitor side effects, and work with the client’s providers to make adjustments as necessary. Nurses can assess barriers to medication adherence, such as the ability to access pharmacies and locations to fill prescriptions and the high cost of some medications. The nurse can also ensure that the client’s follow-up appointments with their providers are made prior to discharge in order to increase ease of access to medication.

Counseling and Psychotherapy

Counseling and psychotherapy are other crucial components of follow-up care for clients after discharge. Nurses can provide emotional support, monitor progress, and help clients identify and address any ongoing concerns or challenges related to their therapy. They can also help clients identify and manage triggers for their mental health concerns, such as stress or certain situations, and provide support in developing coping strategies to address these triggers. Nurses may also facilitate group therapy sessions or provide referrals to specialized therapists, depending on the client’s individual needs. The nurse should ensure that the client’s follow-up appointments with relevant providers are made prior to discharge.

Family and Friends

Family and friends serve a basic human need for companionship and support. The support of loved ones can help reduce the feelings of isolation and stigma that clients may experience and provide practical support, such as transportation to appointments or assistance with daily activities. Nurses can encourage family and friends to provide emotional support, offering encouragement, empathy, and listening without judgment. Additionally, loved ones can help identify triggers for the client’s mental health concerns and assist in developing coping strategies to manage these triggers. Nurses can support the involvement of family and friends as support persons by including them in the discharge planning process, with the client’s permission. Caring for a loved one with a mental illness can be stressful and overwhelming. Nurses provide support for family and friends as well as the client. Educating and promoting self-care and appropriate boundary-setting will help support persons avoid burnout when caring for someone with a mental illness.

Community Resources

Support groups and other community resources are also important aspects of follow-up care for mental health clients. Nurses can provide clients with information about available support groups or community resources, such as vocational training programs or housing assistance programs, and help connect them to these resources as needed. This can help clients build a support network and improve their overall well-being. There are many organizations that facilitate support groups for families and clients. These support groups may be educational in nature, or peer-led, and help to foster a sense of community and caring for people in recovery and their support network.

Real RN Stories

Nurse: Ryan, BSN
Years in Practice: 7
Clinical Setting: Inpatient dual diagnosis unit
Geographic Location: Large midwestern city

Claire was admitted to our inpatient dual diagnosis unit for treatment for major depressive disorder and alcohol use disorder (AUD). She required medication-assisted detox for her AUD and was put on antidepressant medication to stabilize her depression. Part of our inpatient treatment for our dual diagnosis clients includes daily twelve-step group sessions, mostly Alcoholics Anonymous (AA), which has a long and established history and good reputation in the recovery community. Our clients are encouraged to continue with this peer-based treatment as outpatients. Continuing to learn from and socializing with peers who are clean and sober is not just helpful, but necessary for clients with a substance use disorder, including AUD. Because twelve-step programs like AA are commonly available in the community, we like to familiarize our clients with them while they’re in the hospital, then encourage them to continue to participate after discharge so that they have the community support.

Claire told me that she had tried AA several times in the past but that she didn’t feel like it worked for her. She had objections to certain aspects of the program, such as the emphasis on spirituality, and did not like being constantly told that she must label herself “an alcoholic.” She didn’t feel that continuing to attend AA after discharge would help her and admitted that she probably wouldn’t go to any meetings due to her past experience.

As ongoing community support is crucial for clients with AUD, I decided to help research other peer support groups in the community. I found two abstinence-based peer support programs, Self-Management and Recovery Training (SMART Recovery) and Women for Sobriety (WFS), that are available in our area. I discussed these programs with Claire and together we identified meeting days and times that would work for her schedule. She was excited to find alternatives to AA that still offered the element of peer support. I was happy to find that abstinence-based peer support groups exist as alternatives to twelve-step programs. Having alternatives for clients like Claire helps encourage the recovery process as it continues long after discharge, and as the nurse, it is part of my job to ensure that our clients are set up for success after their hospitalization is done.

Personalized Safety Plan

When clients are discharged from a psychiatric hospital, they are still vulnerable to experiencing a relapse or other mental health crises. Knowing how to respond in such situations can help clients manage their symptoms and prevent a potential relapse. One of the best ways to provide clients with information on how to respond in a mental health crisis is by creating a personalized safety plan with them. This document outlines the client’s specific warning signs, coping strategies, support systems, and emergency contacts. Safety planning can begin at admission and should be reviewed and updated at discharge. A personalized safety plan can help clients feel more in control of their mental health and provide them with a clear road map for what to do in case of an emergency. The nurse can also provide the client with information on crisis hotlines, mobile applications, online platforms, and other resources for crisis situations.

Mental Health and Psychosocial Support (MHPSS)

The range of interventions and services that promote mental health, prevent and treat mental health disorders, and support individuals and communities affected by crises and disasters is called mental health and psychosocial support (MHPSS) (U.S. Agency for International Development, 2022). It is a critical component of overall health care and well-being.

MHPSS interventions can include individual and group counseling, psychoeducation, peer support programs, and community-based activities aimed at promoting resilience and improving mental health outcomes (Figure 7.3). The role of health-care professionals, particularly nurses, is critical in providing MHPSS services to individuals in need. Nurses play a key role in assessing and identifying mental health concerns and in providing emotional support, counseling, and education to people with mental health concerns. Nurses also administer medications, collaborate with other health-care professionals, advocate for the rights and needs of individuals with mental health challenges, and promote mental health awareness and education within their communities.

MHPSS Guidelines Pyramid: Base level: Special considerations in basic services and security; second level up: Community and family supports; third level up: Focused, nonspecialized services; top level: Specialized services
Figure 7.3 This pyramid represents MHPSS guidelines. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Mental health and psychosocial support (MHPSS) is used by organizations worldwide. Table 7.1 identifies groups that provide MHPSS services.

Organization How It Utilizes MHPSS
United Nations Refugee Agency Supports local health staff and communities and the management of mental, neurological, and substance use conditions in health facilities. Emphasizes issues particularly relevant to the refugee population, including community-based protection, child protection, and gender-based violence protection and response.
UNICEF Uses the MHPSS model to support children, their families, and the community around them using a holistic approach. The guidelines are used to assist “UNICEF staff and partners support and promote safe, nurturing environments for children’s recovery, psychosocial wellbeing and protection” (Snider, 2018, p. 8).
International Organization for Migration IOM’s MHPSS initiatives encompass a range of activities, such as conducting individual and group counseling sessions, and facilitating art, informal learning, and recreational activities for individuals impacted by crises. Additionally, IOM establishes temporary psychosocial support hubs in both camps and host communities, implements referral systems for severe mental disorders, aids in interpretation and mediation, strengthens national mental health systems, and engages in advocacy work while developing policy documents, guidelines, and manuals to enhance the effectiveness of MHPSS programming (International Organization for Migration, 2023).
International Medical Corps The International Medical Corps provides worldwide disaster relief. It has put extra effort into expanding remote services for its clients using technology, such as internet, mobile units, hotlines, and radio and TV broadcasts. These remote services help bypass issues, such as travel-related dangers, restrictions, or expenses; physical disabilities limiting travel options; and stigma and other cultural barriers (International Medical Corps, 2023).
Table 7.1 MHPSS Organizations

Clinical Safety and Procedures (QSEN)

QSEN: Client-Centered Care Competency

The QSEN client-centered care competency recognizes the client as the source of control and a full partner in providing compassionate and coordinated care that respects the client’s preferences, values, and needs.

Care for PMH clients following discharge is an example of client-centered care. Follow-up care improves the transition of health care from inpatient to the home/community setting and facilitates continuity of care. The following is a sample KSA created for follow-up PMH care.

Knowledge Skills Attitude
Understands client needs and includes client preferences that enable client control and participation in care. Develops individualized plan of follow-up care. Communicates with an interprofessional team to coordinate follow-up care. Communicates therapeutically with the client/significant others. Encourages client to actively participate in decision-making, which empowers the client. Caring, supportive, knowledgeable, available, a good listener

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