Planning; a Continuum of Care in ChildY Psychiatric Nursing A Collaborative Effort
CHARLOlTE A. HERRICK, PhD, RN, CS, LYNNE GOODYKOONTZ, PhD, RN, CNAA, ROBERT H. HERRICK, MD, and BRENDA HACKETT, RN From the University of South Alabama, Mobile, Alabama; the University of North Carolina, Greensboro, North Carolina; and the Charter Hospital of Mobile, Mobile, Alabama.
A guide for providing a continuum of care for children in need of psychiatric services from the least restrictive services (outpatient care), to a moderately restrictive setting (partial hospitalization), to the most restrictive setting (inpatient care) is described. Movement along the continuum is facilitated by the nurse case manager. Concepts from three theoretical frameworks are integrated to define goals, criteria, and expected outcomes for each level of care along the continuum. They are Neuman’s (1982) systems model for nursing practice and education, Caplan’s (1961)model for primary prevention of mental disorders in children, and Frances, Clarken and Perry’s (1984) differential therapeutics. The continuum provides a guide for nurses and other health care providers to achieve high quality care as economically as possible. It also enhances self-care and self-responsibilityfor families of disturbed children by offering a sequential graded system of care along the health-illness continuum.
may include facilities other than their own. Consequently, planning a continuum of care to provide for continuity is important. Nurses in child and adolescent psychiatric mental health services have a key role in coordination of care through case management. A nurse educator and nurse manager on a child psychiatric unit collaborated to develop a continuum of care for children. The goal was to ensure accountability, advocacy, and provide continuity to improve the quality of care within the constraints of cost containment. Figure 1 outlines or represents a continuum of care for nurses and other health care providers to achieve high quality care for children as economically as possible. A continuum of care includes a series of mental health services along the health-illness continuum. A holistic perspective incorporating self, family, hospital, and the community along the continuum provides for continuity of care. Continuity is the absence of disruption or a succession of parts that are intimately united (Stedman 1982). Services may be aimed at health or keeping people well, early interventions, or restoring health and keeping people out of the hospital. Services may be directed at care and rehabilitation for those experiencing psychiatric symptoms. The continuum of care presented in Figure 1 integrated concepts from the Newman (1982), Caplan (1981), and Frances, Clarkin, and Perry (1984) models that provide the basis for planning care for children and adolescents. Neuman’s (1982) model provides a holistic conceptual framework to examine stressors and responses to determine appropriate settings and interventions along a continuum from health to illness. Caplan’s (1961) model for the prevention of mental disorders identified three levels of care along a
T
WENTY-FIVE YEARS AGO, the most prestigious inpatient
centers for emotionally disturbed children and adolescents relied on long-term treatment. Each child and family were assigned to one psychotherapist who coordinated the care throughout the hospital stay (Bettleheim, 1955; Szurek, Berlin, & Boatman, 1972). Today, according to Jemerin and Phillips (1988), services for children and adolescents have become fragmented because of the shortened length of stay on children’s units and the emergence of a myriad of agencies providing services at various levels of care. Previously, acute care inpatient units were solely involved in the assessment, planning, treatment, and evaluation of children and families. Currently, this process occurs at various depths in various agencies. Therefore, members of an interdisciplinary team need to determine a plan of care that
Reprint requests: Lynne G. Goodykoontz, PhD, RN, CNAA, Acting Dean and Professor, The University of North Carolina at Greensboro, School of Nursing, Office of The Dean, 108 Moore Building, UNCG, Greensboro, NC 27412-5001. Accepted for publication December 19, 1990.
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Illness
Health
I Symptoms
I
Least t-------------)Health Restrictive 7
I
Prevention Secondary Level of Care
Primary Level ot Care
+ crisis t
+
Education
b
or
Consultation
.1
Tertiary Level of Care
Acute Care Setting
Symptoms
Illness P Most I Restrictive
Residential Treatment
I
Marketing
A
out Patient Services
Partial Hospitalization
FIG. 1 . A continuum of care in child and adolescent psychiatric mental health nursing.
continuum, from the least restrictive to the most restrictive settings, which also provides guidance in the process of selecting the appropriate treatment setting. Differential therapeutics defined by Frances, Clarkin, and Perry (1984) as the “art and science of treatment selection” is a useful guide for establishing criteria for selecting a setting or a level of care “based upon target symptoms rather than a diagnostic label” (p. xxiii). Concepts from the three models incorporated in Figure 1 are described. The goals, selection criteria, and the expected outcomes for each level of care are outlined and the role of case manager to coordinate the interface among the various levels and to avoid fragmentation are presented. A case example will illustrate the movement of a child from one level of care upon admission to less restrictive levels along the continuum.
Models for Planning Neuman’s Systems Model for Nursing Neuman’s (1982) model is a systems approach to the care and treatment of people and the community along the health illness continuum. The human being is perceived as multidimensional, a composite of biological, psychological, sociocultural, and environmental variables (Cross, 1985). Illness is the result of the interaction of the individual with various stressors. Two components resulting in symptomatology are involved: the stressor component and the response component. The source of stressors can be identified as extrasystem, intersystem, and intrasystem. Extrapersonal and extrasystem stressors are stressors that come from outside of the individ-
ual. The outside stressors are the demands put on the individual to adapt to change, such as a job loss. Initial intervention is aimed at the identification of those who are at risk in order to prevent symptoms of mental illness. Primary prevention strategies include education, consultation, marketing of available services for easy access, and lobbying to increase public awareness and promote the acquisition of funds for mental health. Interpersonal or intersystem stressors are stressors that arise from the interaction between persons or systems. Parental conflicts that focus on the child and away from the marital dyad in order to stabilize the marriage, reinforce the child’s maladaptive behaviors. The child’s symptoms may reflect a dysfunctional family system. Parental conflicts require a secondary level of intervention that focuses on family dynamics and changing patterns of interaction within the family system. A secondary intervention keeps the family together as a unit and works with them in an outpatient setting or in partial hospitalization. Intrapersonal or intrasystem stressors are forces that occur within the individual, either psychological, sociocultural, or biological. An example of an intrasystem problem in a child is severe impulsivity and/or hyperactivity to the point of being dangerous to the child and others. A tertiary care setting is a more restrictive one, usually an acute care setting that is appropriate for children who are in need of a structured and protective environment. Impulsive and/or hyperactive children need to be monitored closely by nursing staff at the initiation of a medical regime, in order to observe their responses to medication and to implement interventions consistently for behavioral changes. Responses to stressors very according to individual idio-
PLANNING A CONTINUUM OF CARE
syncrasies, the type of stressor, and the length of the encounter. Therefore, an examination of the source of the stressors and the individual’s or system’s response is necessary to design a treatment plan. The severity of the response is a product of the type of stressor and the vulnerability of the patient as well as the length of the exposure. The selection of the setting for treatment is dependent on the severity of the response and the need for a combination of interventions from a multidisciplinary team, as well as the need for protection, structure, and supervision. For example: If the child presents selfdestructive symptoms and he/she is beyond parental control, the level of care required would be a tertiary acute care setting, an extrasystem intervention. Medication is an intrasystem intervention while the intersystem approach involves the family and is the focus for helping the parents to deal with not only the child’s behaviors, but also their own grief responses. If a child presents symptoms that do not involve selfdestructive behaviors, an outpatient primary level of care would be more appropriate than admission to an acute care setting. The focus then is on the family (intersystem) and the school (extrasystem) to intervene and modify the symptoms. Using Neuman’s (1982) model, the degree of distress, the source of the stressors, and the system targeted for change are all considered in the selection of the setting and the specific interventions.
Caplan’s (1 961) Levels of Prevention Caplan’s (1961) levels of prevention guide the selection of an appropriate setting. Caplan’s (1961) model for the prevention of mental disorders in children delineated levels of care according to primary, secondary, and tertiary prevention, which combines public health concepts for prevention of illness and psychiatric concepts for the treatment of mental illness. Prevention, according to Caplan (1961), is a term that refers to a population rate and not to change in an individual. Primary prevention “is conceived in terms of what might have been done in the past to prevent the patient from becoming ill” (Caplan, 1961, p.3). Interventions focused on primary prevention are community outreach programs “to lower the risk of a child becoming ill with a specific disorder” (Caplan, 1961, p. 4). Secondary prevention is the “prevention of the disability of a mental disorder through early and adequate treatment” (Caplan, 1961, p. 4). Secondary prevention is provided in outpatient clinics or in partial hospitalization programs where the family rather than the child alone remains the focus of treatment. Early diagnosis and treatment may shorten the duration of a mental disorder. “Successful treatment is . . . synonymous with secondary prevention, since disability is being prevented” (Caplan, 1961, p. 17). “Tertiary prevention is the diagnosis and treatment of sick
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children” which usually occurs in an acute care setting (Caplan, 1961, p. 15). The treatment focus in on the child. The family may or may not be involved. “Rehabilitation of the child is regarded as synonymous with tertiary prevention, since defect and invalidism are being prevented” (Caplan, 1961, p. 17). During planning, the level of care required is identified.
Di@erential Therapeutics Lastly, treatment settings and interventions may be planned according to specific criteria defined by Differential Therapeutics based on outcome studies (Frances, Clarken, & Perry, 1984). Although differential therapeutics is purported to be incomplete, it is an emerging field that is a systematic attempt to select the appropriate setting and treatment modality based on targeted symptoms, the severity of the symptoms, and other human response patterns (Frances, Clarkin, & Perry, 1984). Specific criteria have been delineated to guide treatment selection, based on age, targeted symptoms, and the severity and urgency of the problems, level of prior functioning, available support and structure, and response to previous treatments (Frances, Clarkin, & Perry, 1984).
A Design for a Continuum of Care In planning the continuum of care for children, the concepts from the above three models were integrated to delineate levels of care, the appropriate settings, and to determine selection criteria. Goals for providing a continuum of care are listed below. A continuum of care will: 1. Assist patients to become better able to take responsibility for themselves and to invest more energy in their treatment. 2. Allow patients and families to follow a ‘‘normal schedule” within the limits of their abilities (for example, some children are able to be at home with their families). 3. Promote self-care and self-responsibility. 4. Forestall regression. 5. Provide a practical transition within each level of care to the end goal of fully functioning in the community, school and home. 6. Lower chances of rehospitalization, especially for hospitalized children returning to home, school, peers and family. 7 . Provide treatment in the least restrictive environment. 8. Provide support and accountability for patients to follow through with treatment goals within each level of care. 9. Provide continuity of care as the patient progresses at each level. 10. Decrease fragmentation of services among different levels along the continuum of care.
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Until now, outpatient and inpatient services were the only alternatives. Partial hospitalization or day treatment “can best be conceptualized as a bridge which facilitates its traveler’s movement to a meaningful and productive place in the community” (Swearingen, 1987, p. 110). Outcome research has shown that partial hospitalization has proven therapeutic and economic benefits (Frances, Clarkin, & Peny. 1984; Parker & Knoll, 1990). The problem with the development of partial hospitalization programs is poor third-party reimbursement in spite of the knowledge that children should remain in their own homes if possible, the cost is lower than acute care, and the outcomes are superior. Therefore, partial hospitalization will probably be the future setting for the psychiatric care of children and adolescents. Figure 2 illustrates the flow of the referral process from one setting to another along the continuum of care so that a child may move along the continuum without disruption of the continuity of care. The goals, selection criteria, and the expected outcomes for each level of care are outlines and described in Tables 1-3. These are based on the integration of concepts from the three models previously discussed. Outcome criteria are related to the goals. Selection criteria are based on the needs of patients for structure, protection, and support.
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coordination of services along the health illness continuum is recommended. Case management ensures continuity along the continuum and provides for the coordination of services. Coordination of care through a system of case management is a necessity to deliver mental health services adequately, using an array of treatment settings (Lamb, 1980). The case manager acts as an advocate, facilitating the interface among the delivery systems (Baier, 1987; Slavinsky, 1984; Young, 1990), so that needed resources are available to meet the goal of improving the quality of care. “The gatekeeping functions of case management assure that clients receive appropriate and cost-effective care within a system of services” (Fuszard, et al., 1988, p. 1). According to Pittman (1989), case management optimizes the family’s self-care capacity. Nurses in child and adolescent psychiatric services are important in case management. The case coordination assignment is maintained by one person from admission to discharge but may be transferred to another case manager in a different setting if it is deemed appropriate by the assigned coordinator. However, it is the responsibility of the case manager to orchestrate an orderly transition of case coordination activities to another professional in a different setting and to provide follow up to evaluate the outcome of the treatment plan.
Case Management To facilitate the movement of children from one level of care to the next, coordination to facilitate the interface of formal and natural support systems because of the “need to overcome unintended fragmentations of services provided by 2 or more agencies or programs” is needed (Young, 1990, p. 124). Therefore, a system of case management for the
Case Example
The following example of a child and his family along the continuum of care illustrates movement from acute care to partial hospitalization to outpatient services. This illustration occurred in a community mental health center where there was an established continuum of care. The partial hospital-
Outpatient Treatment
I
I
1
1
Inpatient Hospitalization
Partial Hospitalization
I
TI
r-----lResidential Treatment
FIG. 2. Flow of referral process among clinical services.
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TABLE1. Components of ptimory Level of the Coniinuum of Care Goals To teach mental health concepts to service providers and enhance public awareness, in order to reduce the incidence of mental illness. To provide assessments for individuals, families, and communities, as well as to provide information about available services for early intervention to enhance early access to care. Services Provided Education Criteria Identification of high-risk groups (e.g., abused children, Attention Deficit Hyperactive (ADHA) children) for referral to mental health services. Identification of community stressors (humcanes, disasters). Provide knowledge about child mental health to service providers, community leaders and others who work with children. Provide knowledge about child mental health to the family. Provide knowledge about child mental health to the general public. Outcomes Populations with increased risks would receive early intervention services in order to reduce mental illness. Populations at high risk because of disasters affecting large numbers of the community would be provided crisis intervention services to decrease the impact of the disaster. Service providers will have increased knowledge about psychiatric needs of children and the available services. Families will develop self-care knowledge and skills. The public will be knowledgeable about the mental health needs of children. Marketing Criteria To foster community awareness. To advertise services for easy access. Outcomes Referral sources will be aware of programs to meet the needs of the community. Increased public awareness of available services through advertisement and other marketing programs. ConsultationlLiaison Criteria Respond to requests for consultation to identify program needs and for specific needs of high-risk children (e.g., daycare programs, elementary schools). Assist service personnel who serve high risk populations. Outcomes Service providers will receive continuing education in order to enhance children’s mental health and will know where to refer in cases of emergencies. Children will be identified as high risk and referred for early intervention, in order to reduce the incidence of mental illness.
TABLE 2. Secondaty Level of the Continuum ~~
~
Goals To identify the source of the stressors and reduce their impact by providing access to an early intervention or counseling program. To achieve the highest level of family functioning so there is no disruption to the family unit. To prevent hospitalization. To facilitate re-entry to school and community following hospitalization and to integrate the patient (child) into the family to achieve the highest level of family functioning. To decrease the stigma of hospitalization. Services Provided Outpatient services offer the least restrictive environment. Criteria Acuity of symptoms is minimal enabling the school, family and community to provide a safe and healthy environment for the child. The family is committed to involvement in outpatient family therapy and exhibits a willingness to keep appointments regularly. The stressful encounter for the patient is recent, and the symptoms are manageable in the home, school and community. Partial hospitalization offers more intensive treatment in the least restrictive setting. Criteria The need for a structured environment and for the intensity of a combination of treatment modalities in the least restrictive setting in order to effect behavioral changes. There is no evidence of suicidal or homicidal ideation. The family can provide care, but the school cannot meet the behavioral needs of the child. Outpatient treatment had a limited response. Patients with special needs (i.e., eating disorders, school phobias) who require continued treatment in special programs after hospitalization can be moved into partial hospitalization. The patient has a history of rapid response to medications so that longer, 24-hour inpatient supervision is not necessary. Outcomes Patients who have early symptoms receive psychiatric services in the least restrictive setting. Families are supported in caring for their own children. The family’s and child’s level of functioning will increase due to continuing emphasis of self-care and support, in order to prevent hospitalization. Children who have been hospitalized experience structure similar to the hospital for an easy transition into the community. Partial hospitalization acts as a “bridge” from the hospital to the community for children with special needs. The stigma of mental illness will be reduced because hospitalization is avoided by offering the “least restrictive alternative.”
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TABLE3. Tertiary h e 1 of the Continuum Goals To provide multiple treatment modalities within a structured, protective and supportive environment. Reconstitution and stabilization. Personality restructuring and prevention of further deterioration of the personality. Reintegration of patient into the family and/or the community at the time of discharge. Provide a “safe haven” for children living in a severely dysfunctional home whose behavior prohibits foster home placement. Services Provided Acute care inpatient hospitalization provides multiple treatment modalities in a protected environment for a limited period of time to achieve treatment goals. Criteria Poor response to community interventions. The severity of the symptoms has reached crisis proportions with a sufficient degree of dangerousness to self or others, or an acute psychosis is present. Need for supervised diagnostic tests, observations, or supervised administration of medication. Patient requires a structured environment to prevent deterioration. Limited family coping skills to care for the child. Provide the family with time, a “respite” to learn skills for self-care. Residential treatment provides multiple treatment modalities in a protective environment for a greater period of time in order to maintain care, to provide rehabilitation and enhance the highest level of wellness. Criteria Poor response to community care or acute care and further treatment is needed. The symptoms are severe and chronic, requiring supervision as well as combination of treatment interventions in a structured and protective environment to prevent further deterioration and promote the highest level of wellness. A sufficient degree of dangerousness to self or others. Needs further evaluation and observation. Noxious family environment that is resistant to therapeutic interventions. Requires custodial care of “asylum” - a “safe haven” because of a lack of a family support system and thus a social service network is required. Outcomes The patient will be stable enough to return to lesser restrictive environment and is no longer in need of the structure and protection of an inpatient setting. The patient has stabilized to the point that a combination of modalities is no longer necessary. The patient’s personality has changed to the point that interpersonal relationships are no longer a problem and patient can handle family and community stressors. Foster home placement is a viable option. Patient has a stable social support network in a less restrictive setting. The family and patient can cany out self-care activities. Familv has stabilized to the mint that thev can orovide adeuuate suomrt and care.
ization program was a joint venture funded by the state and the local public school district. Parents were charged according to a sliding scale. Don, aged 12, was admitted to the acute care hospital because he was anxious and could not remain in school all day. He frequently wandered from school and home without permission, usually to follow a dog. He was obsessed with dogs. Assignments or chores such as mowing the lawn were frequently left undone because Don stopped to play with a dog that had entered the yard and then followed the dog all over town, ignoring where he was and unable to find his way home. At times he heard the dogs speak to him, suggesting that he run away from home and live with them. The parents and teachers became increasingly frustrated at not being able to supervise him and worried that the behavior might be dangerous because of his inability to distinguish between the demands of parents and school, and the demands of his friends, the dogs. The family was severely dysfunctional due to a series of events. Father, an alcoholic, was drinking heavily after having been laid off from work. He viewed himself as a failure and tried to find solace in drinking. Mother was overwhelmed by trying to meet the needs of six children and particularly Don’s need for constant supervision. She resented the lack of physical and emotional support from her husband. Consequently, she was depressed and exhibited some vegetative signs of depression including sleeplessness, anhedonia, and
chronic fatigue. She did not have the energy to supervise Don appropriately. There were severe marital conflicts that usually centered around Don, with father verbally abusing mother and occasionally physically abusing Don. Limit setting and clear expectations of Don were inconsistent. The school was frustrated by Don’s behaviors, which included his inability to perform in school, his distractibility, his verbal conflicts with peers, and his wandering behavior. Don assumed the role of scapegoat and was a target of aggression for father, siblings and peers.
Don was admitted to an acute care child adolescent psychiatric unit because (a) the severity of the symptoms reached crisis proportions that were distressing to Don, the family, and the school; the behavior was escalating, bizarre, and potentially dangerous; (b) there was a lack of structure, protection, and supervision provided by the family including the potential for abuse by an alcoholic father that pointed to the need for removal from the home; and (c) the school could not provide Don protection by preventing the wandering behavior. The admitting nurse was the family’s case manager. Don did not remain in the inpatient setting long, because after further observation, it appeared that Don’s wandering behavior was the result of an obsession with dogs rather than
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command hallucinations that were dangerous in terms of suicidal or homicidal ideations. The parents were willing participants in the family therapy program, and the father was willing to attend Alcoholics Anonymous. Within a period of 14 days, Don was transferred to partial hospitalization, based on the following criteria: (a) partial hospitalization was the least restrictive setting that could provide for a combination of treatment modalities, provide the structure and limit setting for inappropriate behaviors and the supervision needed to intervene in the obsessive behaviors; (b) the crisis of hospitalization caused the father to confront his problem drinking that interfered with family functioning and contributed to the potential for child abuse (once the father joined Alcoholics Anonymous and stopped drinking, the family was capable of dealing with Don’s behaviors with support and guidance from the staff); (c) the parents were willing participants in family therapy and parenting groups; (d) the severity of the symptoms required consistent daily interventionsprovided by the structured milieu that could not have occurred in an outpatient setting with weekly family therapy; and (e) Don remained highly distractible and could not remain in school all day. Because the day treatment program was housed in the same facility as the inpatient program, the case manager remained the same person. Once Don was able to tolerate a full day of school and his behaviors were more acceptable in a school setting, he was transferred to outpatient/aftercare services. The outpatient therapist supported the parents in their use of behavioral techniques and consistent limit setting. She provided emotional support for the parents and child as they examined their dysfunctional communication patterns that reinforced blaming behaviors. The mother and child’s passive aggressive behaviors that invited aggression were also examined, as well as the child’s symptoms that provided a focus away from the dysfunctional marital dyad. They remained in outpatient therapy for the remainder of the year until Don entered high school. The primary nurse who admitted Don met with the child and family periodically for repeated assessment and monitoring. She provided the exit interview at the time of discharge to evaluate Don’s progress and the ability of the family to provide the necessary support to one another in a healthy way. By then, father was working again. The mother was no longer depressed and was actively involved in church affairs. The parents had established a system of rewards for Don in response to his requests to leave the premises and chores successfully completed. Don now had his own dog and a new friend who was a girl and not a dog, a healthy sign of normal growth and development. He was discharged from the facility.
care. A step-by-step examination of the following is required to determine an adequate plan of care: (a) the magnitude and source of the stressors and the severity of the response, as well as the organ system involved, (b) the behaviors targeted for change, (c) the level of care required, and lastly (d) interventions selected to effect behavior changes. Specific criteria for the selection of a treatment setting and interventions along a continuum provides goal directed planning to enhance the continuity of care. The focus remains on the least restrictive setting based on concepts of prevention. Case management can provide coordination among delivery systems along the continuum. Goals that were once achievable because of the ability to provide long-term care can also be obtained by providing a continuum of care facilitated by a case manager. It requires careful planning and coordination. Nurses as part of a health care team are expected to participate in planning for a continuum to ensure accountability to the patient while maintaining cost containment. Brief hospitalization does not necessarily mean poorer care (Nurcombe, 1989). If a continuum of care is available and there is appropriate planning, brief hospitalization may provide an opportunity to attain a better quality of care, because of the required involvement of families with the treatment team, and the fact that the child remains at home. Long-term treatment provided families with time to stabilize without the identified child-patient. Now, families have the opportunity for a respite and a brief time to remobilize their resources. The family system has the opportunity for longterm stabilization with the identified child-patient remaining as an integral member of the family. Cost containment may be perceived as an opportunity rather than a crises. Nurses may use the current crisis in the delivery of mental health care to demonstrate their holistic perspective. A continuum of care to include partial hospitalization as a “bridge” between inpatient and outpatient care is the wave of the future. Case management may facilitate movement along the continuum. The health care delivery system must provide a continuum to ensure high quality of care for children and their families while maintaining cost containment. Perhaps too, third-party payors will also see the wave of the future. Case management may facilitate movement along the continuum. The health care delivery system must provide a continuum to ensure high quality of care for children and their families while maintaining cost containment. Children need to be treated within the family system, when possible, to promote the mental health of all. Self-care and self-responsibility are goals of child and family psychiatric nursing.
Summary
Baier, M. (1987). Case management with the chronically mentally ill. Journal of Psychosocial Nursing. 25 (6). 17-21. Bettelheim, B . (1955). Love is not enough: The treatment of erno~ionally disturbed children. New York: Free Press.
Contemporary economic pressures to shorten hospitalization have produced questions as to how to provide quality
References
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Caplan, G. (1961). Prevention of mental disorders in children. New York: Basic Books. Cross, J.R. (1985). Betty Neuman. In J.G. George. Nursing theories: The base for professional nursing (2nd ed.) (pp. 258-286). Englewood Cliffs, NJ: Prentice Hall. Frances, A,. Clarkin, J., & Peny, S. (1984). Diflerential therapeutics in psychiatry. New York: Brunner/Mazel. Fuszard, B., Bowman. R., Howell. H.T., Malinoski, A., Morrison, C., & Wahlstedt, B. (1988).Nursingcasemanagement. KansasCity, MO: The American Nurses’ Association. Jemerin, J . M . , & Phillips, I. (1988). Changes in inpatient child psychiatry: Consequences and recommendations. Journal of the American Academy of Child and Adolescent Psychiatn, 27 (4), 397-404. Lamb. H.R. (1980). Therapist-Case managers: More than brokers of services. Hospital and Community Psychiatv, 31 ( I I ) , 762-764. Neuman, B. (1982). The Neuman systems model: Application to nursing education and practice. Norwalk, CT: Appleton-Century-Crofts. Nurcombe, B, (1989). Goal-directed treatment planning and the principles
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of brief hospitalization. Journal of the American Academy of Child and Adolescent Psychiatry, 28 (l), 26-30. Parker, S., & Knoll, J. (1990). Partial hospitalization: An update. The American Journal of Psychiatry, 147 (21, 156-159. Pittman, D.D.(1989). Nursing case management: Holistic care for the deinstitutionalized chronically mentally ill. Journal of Psychosocial Nursing, 27 (1 I ) , 23-27. Slavinsky, A.T. (1984). Psychiatric nursing: Nursing in the year 2000, from a non-system of care to a caring system. Image, 26 (I), 17-20. Stedman, A.T. (1982). Stedman’smedicaldicrionary(24thed.). Baltimore: Williams & Wilkins. Swearingen, L. (1987). Transitional day treatment: An individualized goal-oriented approach. Archives of Psychiatric Nursing, I (2), 104-1 10. Szurek,S.A., Berlin, I.N., &Boatman,M.J. (1971).Inpatientcareforthe psychotic child. Palo Alto, CA: Science & Behavior Books. Young, T.M. (1990). Therapeutic case advocacy: A model for interagency collaboration in serving disturbed children and their families. American Journal of Orthopsychiatry, 60 (I), 118-124.
CHARLOlTE A. HERRICK, PhD, RN, CS, LYNNE GOODYKOONTZ, PhD, RN, CNAA, ROBERT H. HERRICK, MD, and BRENDA HACKETT, RN From the University of South Alabama, Mobile, Alabama; the University of North Carolina, Greensboro, North Carolina; and the Charter Hospital of Mobile, Mobile, Alabama.
A guide for providing a continuum of care for children in need of psychiatric services from the least restrictive services (outpatient care), to a moderately restrictive setting (partial hospitalization), to the most restrictive setting (inpatient care) is described. Movement along the continuum is facilitated by the nurse case manager. Concepts from three theoretical frameworks are integrated to define goals, criteria, and expected outcomes for each level of care along the continuum. They are Neuman’s (1982) systems model for nursing practice and education, Caplan’s (1961)model for primary prevention of mental disorders in children, and Frances, Clarken and Perry’s (1984) differential therapeutics. The continuum provides a guide for nurses and other health care providers to achieve high quality care as economically as possible. It also enhances self-care and self-responsibilityfor families of disturbed children by offering a sequential graded system of care along the health-illness continuum.
may include facilities other than their own. Consequently, planning a continuum of care to provide for continuity is important. Nurses in child and adolescent psychiatric mental health services have a key role in coordination of care through case management. A nurse educator and nurse manager on a child psychiatric unit collaborated to develop a continuum of care for children. The goal was to ensure accountability, advocacy, and provide continuity to improve the quality of care within the constraints of cost containment. Figure 1 outlines or represents a continuum of care for nurses and other health care providers to achieve high quality care for children as economically as possible. A continuum of care includes a series of mental health services along the health-illness continuum. A holistic perspective incorporating self, family, hospital, and the community along the continuum provides for continuity of care. Continuity is the absence of disruption or a succession of parts that are intimately united (Stedman 1982). Services may be aimed at health or keeping people well, early interventions, or restoring health and keeping people out of the hospital. Services may be directed at care and rehabilitation for those experiencing psychiatric symptoms. The continuum of care presented in Figure 1 integrated concepts from the Newman (1982), Caplan (1981), and Frances, Clarkin, and Perry (1984) models that provide the basis for planning care for children and adolescents. Neuman’s (1982) model provides a holistic conceptual framework to examine stressors and responses to determine appropriate settings and interventions along a continuum from health to illness. Caplan’s (1961) model for the prevention of mental disorders identified three levels of care along a
T
WENTY-FIVE YEARS AGO, the most prestigious inpatient
centers for emotionally disturbed children and adolescents relied on long-term treatment. Each child and family were assigned to one psychotherapist who coordinated the care throughout the hospital stay (Bettleheim, 1955; Szurek, Berlin, & Boatman, 1972). Today, according to Jemerin and Phillips (1988), services for children and adolescents have become fragmented because of the shortened length of stay on children’s units and the emergence of a myriad of agencies providing services at various levels of care. Previously, acute care inpatient units were solely involved in the assessment, planning, treatment, and evaluation of children and families. Currently, this process occurs at various depths in various agencies. Therefore, members of an interdisciplinary team need to determine a plan of care that
Reprint requests: Lynne G. Goodykoontz, PhD, RN, CNAA, Acting Dean and Professor, The University of North Carolina at Greensboro, School of Nursing, Office of The Dean, 108 Moore Building, UNCG, Greensboro, NC 27412-5001. Accepted for publication December 19, 1990.
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Illness
Health
I Symptoms
I
Least t-------------)Health Restrictive 7
I
Prevention Secondary Level of Care
Primary Level ot Care
+ crisis t
+
Education
b
or
Consultation
.1
Tertiary Level of Care
Acute Care Setting
Symptoms
Illness P Most I Restrictive
Residential Treatment
I
Marketing
A
out Patient Services
Partial Hospitalization
FIG. 1 . A continuum of care in child and adolescent psychiatric mental health nursing.
continuum, from the least restrictive to the most restrictive settings, which also provides guidance in the process of selecting the appropriate treatment setting. Differential therapeutics defined by Frances, Clarkin, and Perry (1984) as the “art and science of treatment selection” is a useful guide for establishing criteria for selecting a setting or a level of care “based upon target symptoms rather than a diagnostic label” (p. xxiii). Concepts from the three models incorporated in Figure 1 are described. The goals, selection criteria, and the expected outcomes for each level of care are outlined and the role of case manager to coordinate the interface among the various levels and to avoid fragmentation are presented. A case example will illustrate the movement of a child from one level of care upon admission to less restrictive levels along the continuum.
Models for Planning Neuman’s Systems Model for Nursing Neuman’s (1982) model is a systems approach to the care and treatment of people and the community along the health illness continuum. The human being is perceived as multidimensional, a composite of biological, psychological, sociocultural, and environmental variables (Cross, 1985). Illness is the result of the interaction of the individual with various stressors. Two components resulting in symptomatology are involved: the stressor component and the response component. The source of stressors can be identified as extrasystem, intersystem, and intrasystem. Extrapersonal and extrasystem stressors are stressors that come from outside of the individ-
ual. The outside stressors are the demands put on the individual to adapt to change, such as a job loss. Initial intervention is aimed at the identification of those who are at risk in order to prevent symptoms of mental illness. Primary prevention strategies include education, consultation, marketing of available services for easy access, and lobbying to increase public awareness and promote the acquisition of funds for mental health. Interpersonal or intersystem stressors are stressors that arise from the interaction between persons or systems. Parental conflicts that focus on the child and away from the marital dyad in order to stabilize the marriage, reinforce the child’s maladaptive behaviors. The child’s symptoms may reflect a dysfunctional family system. Parental conflicts require a secondary level of intervention that focuses on family dynamics and changing patterns of interaction within the family system. A secondary intervention keeps the family together as a unit and works with them in an outpatient setting or in partial hospitalization. Intrapersonal or intrasystem stressors are forces that occur within the individual, either psychological, sociocultural, or biological. An example of an intrasystem problem in a child is severe impulsivity and/or hyperactivity to the point of being dangerous to the child and others. A tertiary care setting is a more restrictive one, usually an acute care setting that is appropriate for children who are in need of a structured and protective environment. Impulsive and/or hyperactive children need to be monitored closely by nursing staff at the initiation of a medical regime, in order to observe their responses to medication and to implement interventions consistently for behavioral changes. Responses to stressors very according to individual idio-
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syncrasies, the type of stressor, and the length of the encounter. Therefore, an examination of the source of the stressors and the individual’s or system’s response is necessary to design a treatment plan. The severity of the response is a product of the type of stressor and the vulnerability of the patient as well as the length of the exposure. The selection of the setting for treatment is dependent on the severity of the response and the need for a combination of interventions from a multidisciplinary team, as well as the need for protection, structure, and supervision. For example: If the child presents selfdestructive symptoms and he/she is beyond parental control, the level of care required would be a tertiary acute care setting, an extrasystem intervention. Medication is an intrasystem intervention while the intersystem approach involves the family and is the focus for helping the parents to deal with not only the child’s behaviors, but also their own grief responses. If a child presents symptoms that do not involve selfdestructive behaviors, an outpatient primary level of care would be more appropriate than admission to an acute care setting. The focus then is on the family (intersystem) and the school (extrasystem) to intervene and modify the symptoms. Using Neuman’s (1982) model, the degree of distress, the source of the stressors, and the system targeted for change are all considered in the selection of the setting and the specific interventions.
Caplan’s (1 961) Levels of Prevention Caplan’s (1961) levels of prevention guide the selection of an appropriate setting. Caplan’s (1961) model for the prevention of mental disorders in children delineated levels of care according to primary, secondary, and tertiary prevention, which combines public health concepts for prevention of illness and psychiatric concepts for the treatment of mental illness. Prevention, according to Caplan (1961), is a term that refers to a population rate and not to change in an individual. Primary prevention “is conceived in terms of what might have been done in the past to prevent the patient from becoming ill” (Caplan, 1961, p.3). Interventions focused on primary prevention are community outreach programs “to lower the risk of a child becoming ill with a specific disorder” (Caplan, 1961, p. 4). Secondary prevention is the “prevention of the disability of a mental disorder through early and adequate treatment” (Caplan, 1961, p. 4). Secondary prevention is provided in outpatient clinics or in partial hospitalization programs where the family rather than the child alone remains the focus of treatment. Early diagnosis and treatment may shorten the duration of a mental disorder. “Successful treatment is . . . synonymous with secondary prevention, since disability is being prevented” (Caplan, 1961, p. 17). “Tertiary prevention is the diagnosis and treatment of sick
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children” which usually occurs in an acute care setting (Caplan, 1961, p. 15). The treatment focus in on the child. The family may or may not be involved. “Rehabilitation of the child is regarded as synonymous with tertiary prevention, since defect and invalidism are being prevented” (Caplan, 1961, p. 17). During planning, the level of care required is identified.
Di@erential Therapeutics Lastly, treatment settings and interventions may be planned according to specific criteria defined by Differential Therapeutics based on outcome studies (Frances, Clarken, & Perry, 1984). Although differential therapeutics is purported to be incomplete, it is an emerging field that is a systematic attempt to select the appropriate setting and treatment modality based on targeted symptoms, the severity of the symptoms, and other human response patterns (Frances, Clarkin, & Perry, 1984). Specific criteria have been delineated to guide treatment selection, based on age, targeted symptoms, and the severity and urgency of the problems, level of prior functioning, available support and structure, and response to previous treatments (Frances, Clarkin, & Perry, 1984).
A Design for a Continuum of Care In planning the continuum of care for children, the concepts from the above three models were integrated to delineate levels of care, the appropriate settings, and to determine selection criteria. Goals for providing a continuum of care are listed below. A continuum of care will: 1. Assist patients to become better able to take responsibility for themselves and to invest more energy in their treatment. 2. Allow patients and families to follow a ‘‘normal schedule” within the limits of their abilities (for example, some children are able to be at home with their families). 3. Promote self-care and self-responsibility. 4. Forestall regression. 5. Provide a practical transition within each level of care to the end goal of fully functioning in the community, school and home. 6. Lower chances of rehospitalization, especially for hospitalized children returning to home, school, peers and family. 7 . Provide treatment in the least restrictive environment. 8. Provide support and accountability for patients to follow through with treatment goals within each level of care. 9. Provide continuity of care as the patient progresses at each level. 10. Decrease fragmentation of services among different levels along the continuum of care.
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Until now, outpatient and inpatient services were the only alternatives. Partial hospitalization or day treatment “can best be conceptualized as a bridge which facilitates its traveler’s movement to a meaningful and productive place in the community” (Swearingen, 1987, p. 110). Outcome research has shown that partial hospitalization has proven therapeutic and economic benefits (Frances, Clarkin, & Peny. 1984; Parker & Knoll, 1990). The problem with the development of partial hospitalization programs is poor third-party reimbursement in spite of the knowledge that children should remain in their own homes if possible, the cost is lower than acute care, and the outcomes are superior. Therefore, partial hospitalization will probably be the future setting for the psychiatric care of children and adolescents. Figure 2 illustrates the flow of the referral process from one setting to another along the continuum of care so that a child may move along the continuum without disruption of the continuity of care. The goals, selection criteria, and the expected outcomes for each level of care are outlines and described in Tables 1-3. These are based on the integration of concepts from the three models previously discussed. Outcome criteria are related to the goals. Selection criteria are based on the needs of patients for structure, protection, and support.
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coordination of services along the health illness continuum is recommended. Case management ensures continuity along the continuum and provides for the coordination of services. Coordination of care through a system of case management is a necessity to deliver mental health services adequately, using an array of treatment settings (Lamb, 1980). The case manager acts as an advocate, facilitating the interface among the delivery systems (Baier, 1987; Slavinsky, 1984; Young, 1990), so that needed resources are available to meet the goal of improving the quality of care. “The gatekeeping functions of case management assure that clients receive appropriate and cost-effective care within a system of services” (Fuszard, et al., 1988, p. 1). According to Pittman (1989), case management optimizes the family’s self-care capacity. Nurses in child and adolescent psychiatric services are important in case management. The case coordination assignment is maintained by one person from admission to discharge but may be transferred to another case manager in a different setting if it is deemed appropriate by the assigned coordinator. However, it is the responsibility of the case manager to orchestrate an orderly transition of case coordination activities to another professional in a different setting and to provide follow up to evaluate the outcome of the treatment plan.
Case Management To facilitate the movement of children from one level of care to the next, coordination to facilitate the interface of formal and natural support systems because of the “need to overcome unintended fragmentations of services provided by 2 or more agencies or programs” is needed (Young, 1990, p. 124). Therefore, a system of case management for the
Case Example
The following example of a child and his family along the continuum of care illustrates movement from acute care to partial hospitalization to outpatient services. This illustration occurred in a community mental health center where there was an established continuum of care. The partial hospital-
Outpatient Treatment
I
I
1
1
Inpatient Hospitalization
Partial Hospitalization
I
TI
r-----lResidential Treatment
FIG. 2. Flow of referral process among clinical services.
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TABLE1. Components of ptimory Level of the Coniinuum of Care Goals To teach mental health concepts to service providers and enhance public awareness, in order to reduce the incidence of mental illness. To provide assessments for individuals, families, and communities, as well as to provide information about available services for early intervention to enhance early access to care. Services Provided Education Criteria Identification of high-risk groups (e.g., abused children, Attention Deficit Hyperactive (ADHA) children) for referral to mental health services. Identification of community stressors (humcanes, disasters). Provide knowledge about child mental health to service providers, community leaders and others who work with children. Provide knowledge about child mental health to the family. Provide knowledge about child mental health to the general public. Outcomes Populations with increased risks would receive early intervention services in order to reduce mental illness. Populations at high risk because of disasters affecting large numbers of the community would be provided crisis intervention services to decrease the impact of the disaster. Service providers will have increased knowledge about psychiatric needs of children and the available services. Families will develop self-care knowledge and skills. The public will be knowledgeable about the mental health needs of children. Marketing Criteria To foster community awareness. To advertise services for easy access. Outcomes Referral sources will be aware of programs to meet the needs of the community. Increased public awareness of available services through advertisement and other marketing programs. ConsultationlLiaison Criteria Respond to requests for consultation to identify program needs and for specific needs of high-risk children (e.g., daycare programs, elementary schools). Assist service personnel who serve high risk populations. Outcomes Service providers will receive continuing education in order to enhance children’s mental health and will know where to refer in cases of emergencies. Children will be identified as high risk and referred for early intervention, in order to reduce the incidence of mental illness.
TABLE 2. Secondaty Level of the Continuum ~~
~
Goals To identify the source of the stressors and reduce their impact by providing access to an early intervention or counseling program. To achieve the highest level of family functioning so there is no disruption to the family unit. To prevent hospitalization. To facilitate re-entry to school and community following hospitalization and to integrate the patient (child) into the family to achieve the highest level of family functioning. To decrease the stigma of hospitalization. Services Provided Outpatient services offer the least restrictive environment. Criteria Acuity of symptoms is minimal enabling the school, family and community to provide a safe and healthy environment for the child. The family is committed to involvement in outpatient family therapy and exhibits a willingness to keep appointments regularly. The stressful encounter for the patient is recent, and the symptoms are manageable in the home, school and community. Partial hospitalization offers more intensive treatment in the least restrictive setting. Criteria The need for a structured environment and for the intensity of a combination of treatment modalities in the least restrictive setting in order to effect behavioral changes. There is no evidence of suicidal or homicidal ideation. The family can provide care, but the school cannot meet the behavioral needs of the child. Outpatient treatment had a limited response. Patients with special needs (i.e., eating disorders, school phobias) who require continued treatment in special programs after hospitalization can be moved into partial hospitalization. The patient has a history of rapid response to medications so that longer, 24-hour inpatient supervision is not necessary. Outcomes Patients who have early symptoms receive psychiatric services in the least restrictive setting. Families are supported in caring for their own children. The family’s and child’s level of functioning will increase due to continuing emphasis of self-care and support, in order to prevent hospitalization. Children who have been hospitalized experience structure similar to the hospital for an easy transition into the community. Partial hospitalization acts as a “bridge” from the hospital to the community for children with special needs. The stigma of mental illness will be reduced because hospitalization is avoided by offering the “least restrictive alternative.”
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TABLE3. Tertiary h e 1 of the Continuum Goals To provide multiple treatment modalities within a structured, protective and supportive environment. Reconstitution and stabilization. Personality restructuring and prevention of further deterioration of the personality. Reintegration of patient into the family and/or the community at the time of discharge. Provide a “safe haven” for children living in a severely dysfunctional home whose behavior prohibits foster home placement. Services Provided Acute care inpatient hospitalization provides multiple treatment modalities in a protected environment for a limited period of time to achieve treatment goals. Criteria Poor response to community interventions. The severity of the symptoms has reached crisis proportions with a sufficient degree of dangerousness to self or others, or an acute psychosis is present. Need for supervised diagnostic tests, observations, or supervised administration of medication. Patient requires a structured environment to prevent deterioration. Limited family coping skills to care for the child. Provide the family with time, a “respite” to learn skills for self-care. Residential treatment provides multiple treatment modalities in a protective environment for a greater period of time in order to maintain care, to provide rehabilitation and enhance the highest level of wellness. Criteria Poor response to community care or acute care and further treatment is needed. The symptoms are severe and chronic, requiring supervision as well as combination of treatment interventions in a structured and protective environment to prevent further deterioration and promote the highest level of wellness. A sufficient degree of dangerousness to self or others. Needs further evaluation and observation. Noxious family environment that is resistant to therapeutic interventions. Requires custodial care of “asylum” - a “safe haven” because of a lack of a family support system and thus a social service network is required. Outcomes The patient will be stable enough to return to lesser restrictive environment and is no longer in need of the structure and protection of an inpatient setting. The patient has stabilized to the point that a combination of modalities is no longer necessary. The patient’s personality has changed to the point that interpersonal relationships are no longer a problem and patient can handle family and community stressors. Foster home placement is a viable option. Patient has a stable social support network in a less restrictive setting. The family and patient can cany out self-care activities. Familv has stabilized to the mint that thev can orovide adeuuate suomrt and care.
ization program was a joint venture funded by the state and the local public school district. Parents were charged according to a sliding scale. Don, aged 12, was admitted to the acute care hospital because he was anxious and could not remain in school all day. He frequently wandered from school and home without permission, usually to follow a dog. He was obsessed with dogs. Assignments or chores such as mowing the lawn were frequently left undone because Don stopped to play with a dog that had entered the yard and then followed the dog all over town, ignoring where he was and unable to find his way home. At times he heard the dogs speak to him, suggesting that he run away from home and live with them. The parents and teachers became increasingly frustrated at not being able to supervise him and worried that the behavior might be dangerous because of his inability to distinguish between the demands of parents and school, and the demands of his friends, the dogs. The family was severely dysfunctional due to a series of events. Father, an alcoholic, was drinking heavily after having been laid off from work. He viewed himself as a failure and tried to find solace in drinking. Mother was overwhelmed by trying to meet the needs of six children and particularly Don’s need for constant supervision. She resented the lack of physical and emotional support from her husband. Consequently, she was depressed and exhibited some vegetative signs of depression including sleeplessness, anhedonia, and
chronic fatigue. She did not have the energy to supervise Don appropriately. There were severe marital conflicts that usually centered around Don, with father verbally abusing mother and occasionally physically abusing Don. Limit setting and clear expectations of Don were inconsistent. The school was frustrated by Don’s behaviors, which included his inability to perform in school, his distractibility, his verbal conflicts with peers, and his wandering behavior. Don assumed the role of scapegoat and was a target of aggression for father, siblings and peers.
Don was admitted to an acute care child adolescent psychiatric unit because (a) the severity of the symptoms reached crisis proportions that were distressing to Don, the family, and the school; the behavior was escalating, bizarre, and potentially dangerous; (b) there was a lack of structure, protection, and supervision provided by the family including the potential for abuse by an alcoholic father that pointed to the need for removal from the home; and (c) the school could not provide Don protection by preventing the wandering behavior. The admitting nurse was the family’s case manager. Don did not remain in the inpatient setting long, because after further observation, it appeared that Don’s wandering behavior was the result of an obsession with dogs rather than
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command hallucinations that were dangerous in terms of suicidal or homicidal ideations. The parents were willing participants in the family therapy program, and the father was willing to attend Alcoholics Anonymous. Within a period of 14 days, Don was transferred to partial hospitalization, based on the following criteria: (a) partial hospitalization was the least restrictive setting that could provide for a combination of treatment modalities, provide the structure and limit setting for inappropriate behaviors and the supervision needed to intervene in the obsessive behaviors; (b) the crisis of hospitalization caused the father to confront his problem drinking that interfered with family functioning and contributed to the potential for child abuse (once the father joined Alcoholics Anonymous and stopped drinking, the family was capable of dealing with Don’s behaviors with support and guidance from the staff); (c) the parents were willing participants in family therapy and parenting groups; (d) the severity of the symptoms required consistent daily interventionsprovided by the structured milieu that could not have occurred in an outpatient setting with weekly family therapy; and (e) Don remained highly distractible and could not remain in school all day. Because the day treatment program was housed in the same facility as the inpatient program, the case manager remained the same person. Once Don was able to tolerate a full day of school and his behaviors were more acceptable in a school setting, he was transferred to outpatient/aftercare services. The outpatient therapist supported the parents in their use of behavioral techniques and consistent limit setting. She provided emotional support for the parents and child as they examined their dysfunctional communication patterns that reinforced blaming behaviors. The mother and child’s passive aggressive behaviors that invited aggression were also examined, as well as the child’s symptoms that provided a focus away from the dysfunctional marital dyad. They remained in outpatient therapy for the remainder of the year until Don entered high school. The primary nurse who admitted Don met with the child and family periodically for repeated assessment and monitoring. She provided the exit interview at the time of discharge to evaluate Don’s progress and the ability of the family to provide the necessary support to one another in a healthy way. By then, father was working again. The mother was no longer depressed and was actively involved in church affairs. The parents had established a system of rewards for Don in response to his requests to leave the premises and chores successfully completed. Don now had his own dog and a new friend who was a girl and not a dog, a healthy sign of normal growth and development. He was discharged from the facility.
care. A step-by-step examination of the following is required to determine an adequate plan of care: (a) the magnitude and source of the stressors and the severity of the response, as well as the organ system involved, (b) the behaviors targeted for change, (c) the level of care required, and lastly (d) interventions selected to effect behavior changes. Specific criteria for the selection of a treatment setting and interventions along a continuum provides goal directed planning to enhance the continuity of care. The focus remains on the least restrictive setting based on concepts of prevention. Case management can provide coordination among delivery systems along the continuum. Goals that were once achievable because of the ability to provide long-term care can also be obtained by providing a continuum of care facilitated by a case manager. It requires careful planning and coordination. Nurses as part of a health care team are expected to participate in planning for a continuum to ensure accountability to the patient while maintaining cost containment. Brief hospitalization does not necessarily mean poorer care (Nurcombe, 1989). If a continuum of care is available and there is appropriate planning, brief hospitalization may provide an opportunity to attain a better quality of care, because of the required involvement of families with the treatment team, and the fact that the child remains at home. Long-term treatment provided families with time to stabilize without the identified child-patient. Now, families have the opportunity for a respite and a brief time to remobilize their resources. The family system has the opportunity for longterm stabilization with the identified child-patient remaining as an integral member of the family. Cost containment may be perceived as an opportunity rather than a crises. Nurses may use the current crisis in the delivery of mental health care to demonstrate their holistic perspective. A continuum of care to include partial hospitalization as a “bridge” between inpatient and outpatient care is the wave of the future. Case management may facilitate movement along the continuum. The health care delivery system must provide a continuum to ensure high quality of care for children and their families while maintaining cost containment. Perhaps too, third-party payors will also see the wave of the future. Case management may facilitate movement along the continuum. The health care delivery system must provide a continuum to ensure high quality of care for children and their families while maintaining cost containment. Children need to be treated within the family system, when possible, to promote the mental health of all. Self-care and self-responsibility are goals of child and family psychiatric nursing.
Summary
Baier, M. (1987). Case management with the chronically mentally ill. Journal of Psychosocial Nursing. 25 (6). 17-21. Bettelheim, B . (1955). Love is not enough: The treatment of erno~ionally disturbed children. New York: Free Press.
Contemporary economic pressures to shorten hospitalization have produced questions as to how to provide quality
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Caplan, G. (1961). Prevention of mental disorders in children. New York: Basic Books. Cross, J.R. (1985). Betty Neuman. In J.G. George. Nursing theories: The base for professional nursing (2nd ed.) (pp. 258-286). Englewood Cliffs, NJ: Prentice Hall. Frances, A,. Clarkin, J., & Peny, S. (1984). Diflerential therapeutics in psychiatry. New York: Brunner/Mazel. Fuszard, B., Bowman. R., Howell. H.T., Malinoski, A., Morrison, C., & Wahlstedt, B. (1988).Nursingcasemanagement. KansasCity, MO: The American Nurses’ Association. Jemerin, J . M . , & Phillips, I. (1988). Changes in inpatient child psychiatry: Consequences and recommendations. Journal of the American Academy of Child and Adolescent Psychiatn, 27 (4), 397-404. Lamb. H.R. (1980). Therapist-Case managers: More than brokers of services. Hospital and Community Psychiatv, 31 ( I I ) , 762-764. Neuman, B. (1982). The Neuman systems model: Application to nursing education and practice. Norwalk, CT: Appleton-Century-Crofts. Nurcombe, B, (1989). Goal-directed treatment planning and the principles
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of brief hospitalization. Journal of the American Academy of Child and Adolescent Psychiatry, 28 (l), 26-30. Parker, S., & Knoll, J. (1990). Partial hospitalization: An update. The American Journal of Psychiatry, 147 (21, 156-159. Pittman, D.D.(1989). Nursing case management: Holistic care for the deinstitutionalized chronically mentally ill. Journal of Psychosocial Nursing, 27 (1 I ) , 23-27. Slavinsky, A.T. (1984). Psychiatric nursing: Nursing in the year 2000, from a non-system of care to a caring system. Image, 26 (I), 17-20. Stedman, A.T. (1982). Stedman’smedicaldicrionary(24thed.). Baltimore: Williams & Wilkins. Swearingen, L. (1987). Transitional day treatment: An individualized goal-oriented approach. Archives of Psychiatric Nursing, I (2), 104-1 10. Szurek,S.A., Berlin, I.N., &Boatman,M.J. (1971).Inpatientcareforthe psychotic child. Palo Alto, CA: Science & Behavior Books. Young, T.M. (1990). Therapeutic case advocacy: A model for interagency collaboration in serving disturbed children and their families. American Journal of Orthopsychiatry, 60 (I), 118-124.
