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7.1 Collaboration and Coordination of Care

The four evidence-based case management service models are the brokerage model, the intensive case management model, the clinical case management model, and the strengths-based case management model. They differ in who serves as the case manager and in the degree of closeness and interaction between the case manager and client. The nurse as case manager helps plan and coordinate care for each client to address their unique needs. Virtual health care may be used in coordination of care as a way to more easily access and exchange information and navigate the health-care system.

7.2 Recovery and Rehabilitative Needs

Recovery is a journey throughout which clients improve their mental and physical health and wellness, and try to live a fulfilling, self-directed life. The four dimensions of recovery are health, home, purpose, and community. Rehabilitative treatments, which support recovery, include medication management and therapy. Examples of rehabilitative resources, which also support recovery, include housing assistance, job coaching, educational assistance, and social support.

7.3 Discharge and Transfer

Discharge planning is a critical aspect of psychiatric-mental health nursing. It involves developing a comprehensive and individualized plan for a client’s safe and successful transition from an inpatient psychiatric facility or unit to their home or community or to another facility. Transferring a client with mental illness into or out of a mental health unit or between departments can be a complex and sensitive process that requires careful planning and, above all, consideration for client safety. Transferring a psychiatric client’s health information is also a sensitive process, requiring informed consent, effective communication, and careful attention to privacy and confidentiality concerns.

7.4 Continued Support

Discharge and transfer of clients are critical times in client care. Clients should follow up with a mental health provider within thirty (preferably seven) days of discharge. As coordinator of care for the client, the nurse plays a vital role in assisting with this follow-up care in collaboration with other health-care professionals. Mental health and psychosocial support (MHPSS) is a critical component of overall health care and well-being. It refers to a range of interventions and services that promote and treat mental health and health care after disasters and crises.

7.5 Online Self-Help and Therapy

Types of online therapy include online support groups, self-guided therapy, teletherapy, online self-help, and online coaching. Benefits include accessibility, cost, anonymity, and access to resources. There are other considerations involved in the decision to use online mental health applications, such as access, communication, quality, legal and licensing issues, and ethical concerns like privacy. Nurses play a valuable role in supporting individuals who are seeking help or therapy online, though the specific role can vary depending on the platform and the services it offers.

7.6 Challenges to Continuity of Care

The complexity of mental health involves the types of services available, the challenges in accessing these services, and the variability of the conditions that mental health professionals treat. Effective communication helps to ensure that clients continue to receive consistent, comprehensive care that is tailored to their individual needs and preferences even as they move between health-care providers. When communication is inadequate, it can contribute to misunderstandings between nurses and clients; it may also lead to a lack of information, or misinformation being exchanged between health-care professionals. The nurse’s role in promoting continuity of care in mental health services is crucial. The nurse works as a liaison between different mental health-care providers and coordinates care to ensure that clients receive comprehensive and consistent care.


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