The main focus of state and federal policies lies on the provision of support and long-term care services to the individuals with significant disabilities or those who are very old. These individuals, almost one and a half million, are taken care of in the nursing homes and Medicaid covers almost half of the total cost charged by nursing homes for their institutionalization (Tallon, 2007).
While the total population of this special group of individuals only accounted for only 7 percent of the total population supported by Medicaid, it became expensive for Medicaid to support them as they accounted for almost half of the total expenditure of Medicaid. Policy makers therefore focus on changing the predominant service locus to community and home based from nursing homes (Diamond, 2009). Deinstitutionalization of individuals suffering from chronically mentally ill differs depending on the objectives and policies adopted from time to time.
However, the interventions used to deinstitutionalize chronically mentally ill patients tend to share some lessons and parallels. History of chronically mentally ill population As state objectives and policies change over time, the history of the chronically mentally ill population in the United States has experienced significant transitions. Initial interventions, as from 1955 to 1980, policies and objectives were aimed at moving the chronically mentally ill individuals from the public mental hospitals owned by the state (Tallon, 2007).
As a result of these efforts, the population of individuals residing in public mental health facilities reduced to 154,000 from 159,000 (Tallon, 2007). Later, there were approaches aimed at expanding and improving an array of services as well as supportive measures for chronically mentally ill in the community. There was massive closure of whole institutions which resulted to an increased emphasis on the rights which secured integration of the community. The rights that were emphasized included the right to have equitable access to housing (Bailey, 1999).
States could fund small pilot programs since the community for those individuals who positively responded to antipsychotic agents which begun to be available. Thereafter, the national deinstitutionalization movement officially got launched through the programs for community mental health centers in 1965 (Tallon, 2009). Concerns over institutional conditions and the rights of citizens propelled further the need for the movement. The courts then limited the number of involuntary institutions and set minimum standards that were critical for institutional care (Diamond, 2009).
The shift by states between sites of institutional care was fuelled by federal policy. The Commission on Mental Health Centers Construction (CMHC) program was intensively expanded in 1970s (Tallon, 2009). The coverage for Medicare and Medicaid was wide and it included mental healthcare services. Income support was mainly provided by the SSI (Supplement Security Income) program as well as the Social Security Disability Insurance (SSDI) (Tallon, 2009). The psychiatrist beds in community care increased in number after federal Medicaid provided sufficient funds as incentives.
This saw the state moving individuals to the nursing home thus capturing the reimbursement from Medicaid which was not easy to find in mental hospitals of the states. In general, the overall progress of institutionalizing became immensely slow as the resources that were critical for community care. Until 1993, there were relatively fewer mental health dollars controlled by the state which served to assist in community care programs other than other state institution (Tallon, 2009).
Although promising models of successful community care were provided and experimented, these models were rarely evaluated with rigor. They were also rarely integrated into the standard models (Tallon, 2009). The Nature of Chronically Mentally Ill Chronically mentally ill individuals suffer from bipolar disorder, schizophrenia, recurrent and sever depression as well as other several conditions which worsen their quality of living. A number of mental illnesses exist where some of them include schizophrenia, depression, dementia and bi-polar disorder (Szwabo, 2007).
Individuals suffering from chronically mentally illnesses may present signs such as mental disturbances but these presentations vary depending on the type of disorder and age. Chronic mental illness produces major impairments in human functioning for a long period of time which normally covers the entire life span of an individual. For the chronically mentally ill individuals to get attention from the society, they require to negotiate with policy makers about a bureaucratic maze (Szwabo, 2007).
A very ugly history about the chronically mentally ill patients exists where individuals used to be locked up and then forgotten. Today, there has been an emergence of state of the art hospitals, thanks to the historical forces (Bailey, 1999). The chronically mentally ill however, have been reported to face serious problems including incarcerations in the system of the criminal justice. This indicates how history is repeating itself and moving back to the pre-asylum ages when chronically mentally used to be locked in almshouses (Szwabo, 2007).
However, the shift in the locus and pattern of mental healthcare that arise from the deinstitutionalization forces have all resulted in the missing link between the problem definition and modern efforts used to address the problem (Diamond, 2009). There also seems to be a lack of consensus on the clear mark lines which best define the chronically mentally ill individuals. There are no clear boundaries which can serve as a scientific guideline for national policy making process.
Today’s approaches of treatment of the chronically mentally ill have incorporated trans-institutionalization, increased support from the family and the shunting into the system of criminal system (Szwabo, 2007). It is apparent that this special population seriously requires socialization, in-patient care and shelter. Common Clinical Issues and Interventions in the management of chronically mentally ill individuals Care provision to the chronically mentally ill needs adequate planning, trained and committed healthcare providers from both clinical and social capacities and financing programming.
There are many issues which need to be resolved in order to tackle challenges facing effective management of chronically mentally ill patients. Some of these issues are parity for mental healthcare services, availability of mental healthcare provider, care planning and broader case management coverage, education and training in mental health, and warehousing of the patients (Szwabo, 2007). Lack of parity continues to be an issue in the provision of healthcare among mental healthcare providers.
This is due to the low amount of reimbursement made to social and nursing work. There is an intense lobby for social workers and advanced nurses to be reimbursed differently. There is also an inadequacy for the provision mental healthcare services. For instance, the reimbursement for the psychotropic which is an essential part of chronically medically ill is still inadequate (Szwabo, 2007). There is need to provide medical treatments apart from the psychiatric treatment interventions.
However, major problems such as lack of adequate geriatrics to address the rising population of the aged have always been a weakness to the management of chronically mentally ill patients. It is also observed that attending to chronically mentally ill patients in nursing homes require access to suitable mental healthcare amenities. Unfortunately in many situations, access to living facilities, programs, trained staff and oversight becomes difficult to afford. Education and training for mental healthcare professions is inadequate as they lack facilities for long-term care (Bailey, 1999).
It then appears that most managed care programs for chronically mentally ill patients are poorly managed, designed and therefore do not offer the required standards. The traditional mental healthcare systems only focus on reducing the costs of operation while failing to address the important element of patient care. In a capitated mental healthcare, the systems prompt physicians and other caregivers to limit medications to the least minimum in an effort to only manage overt symptoms. The practice literally condemns chronically mentally ill patient to medical starvation doses (Bailey, 1999).
Summary and Future Considerations While the incidences of chronically mentally illnesses have increased and their prevalence well documented, there are still problems related to the use and access of general medical care. For effective management of chronically mentally illness in the future, there should be proper education for the healthcare providers about the condition. Service planning, outreach and assessment are also important elements in improving the way the condition is being managed.
Mental healthcare providers should perform good service delivery monitoring and advocacy. In case of limitations of healthcare providers, psychiatric nurses can take the roles of consultation and supervision. The nurse can also execute roles as a nurse practitioner and deliver services in primary care. In the society, members of the family having an individual suffering from the condition should not neglect him or her. Instead, they should care for and encourage the patients.
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