Nursing Care

The nursing services form an important component of care delivery for the residents admitted to the cottages. The services operate 24-hours per day and are delivered by highly qualified staff who support the recovery model and utilise
evidence-based approaches in the care of the residents. The services are aligned with the human rights principles to ensure that the rights and dignity of the residents are supported.

Referral Process

Admission

Although a referral is required, admission to PRC is not mandatory. Based on the residential status of PRC and services that will be provided, PRC will not be able to accommodate all persons who are diagnosed with a mental health disorder. The facility is not a hospital and its primary focus is on rehabilitation and will function as a continuation of care.

Admission Criteria

Inclusion criteria:

1. Must be at least eighteen (18) years old.
2. Must be willing and motivated to participate in the treatment program offered by the facility. (Ideally, participation should be voluntary).
3. Ideally should be able to meet their ADL with minimal assistance.
4. Should not require acute medical care.
5. Have had previous psychiatric treatment and in need of further maintenance and stabilization.
6. Requires structured therapeutic rehabilitative support.

Exclusion criteria:

1. Individual who is at immediate high risk for violence and/or suicide.
2. Individual who requires acute medical care and are highly dependent.
3. Individual who is a substance user that needs to go through a withdrawal/detoxification program.

Types of Admission

1. Voluntary/Self Admission – an individual recognizes the need for treatment and seeks admission on his/her own.  A referral would however be needed.
2. Involuntary Admission – treatment that is mandated/initiated by a mental health professional, law enforcement/court order.
3. Continuity of Care – individual who is discharged from a hospital and is a part of an outpatient treatment Program but requires additional support to facilitate the recovery process.

Assessment and Treatment Process

Assessment will be an ongoing process. Conducting a full assessment for the incoming residents are necessary even though they will be coming from another treatment program. This is necessary to ensure the accuracy of the admitting diagnosis or to conceptualize new and or additional diagnoses and to formulate treatment plan for the best possible outcome. The clinical team will employ keen observation, interview, examination and critical thinking skills to formulate a diagnosis and treatment plan utilizing the Biopsychosocial Model and Case Formulation.

The treatment plan will incorporate the holistic approach and will include the necessary referrals for psychosocial interventions and nutritional interventions.

Review of Residents

All residents will be reviewed by the psychiatrist as necessary weekly after the initial assessment. Reviews will also be done in cases of emergency or as the need arises. Reviews and updated treatment plans should be documented in the resident’s Electronic Health Record. Reviews by the physician and nutritionist will be done as needed.

Diagnostics Investigations

Medication used to treat psychiatric conditions can have an impact of the physical health of individuals. It is of importance for all residents to have diagnostic investigations performed as a baseline to determine their physical status upon admission as well as to monitor underlying health conditions.

Psychotherapeutic Interventions

Psychotherapy will be done primarily by the psychologist. Each resident will be individually assessed and a treatment plan tailored to meet the identified need/s. Interventions may be in the form of individual, family and group sessions and include any of the following amongst others:

1. Cognitive behavioral therapy (CBT)
2. Dialectical Behavior Therapy (DBT)
3. Solution-Focused Brief Therapy (SFBT)
4. Mindfulness-Based Therapy
5. Interpersonal Therapy (IPT)
6. Acceptance and Commitment Therapy (ACT)
7. Eclectic therapy.

Social Interventions

Social interventions are necessary to provide social benefits and help to build human capital and providing socioeconomic benefits for vulnerable groups. Programs will be designed to help to raise the standard of living and earning capacity for the residents at PRC. The Programs will include helping residents getting financial assistance, housing assistance, family and community investigations and resources necessary to facilitate their reintegration and to help them to live independently. Social workers will be responsible for conducting the initial assessment for each resident to determine their needs and the level of support needed. They will also be responsible for doing follow-up visits following discharge, to ensure that residents are effectively reintegrated.

Discharge

Collaborated discharge planning will commence upon admission and will be completed prior to the discharge of each resident. This will include any social investigations and networking that are necessary to help residents re-integrate with families and communities. It will also include the necessary education on medication management and the importance of keeping appointment for follow-up care.

Follow-up

Follow-up reviews may be facilitated through PRC’s Community Intervention Model Program and collaboration with the HSA Behavioral Health Unit, Community Treatment Team. Members of the clinical team will be responsible to ensure that residents receive follow-up care interventions as necessary when discharge. A detailed follow-up plan outlining the current diagnosis, medications and other needed intervention/s, will be provided by the treatment provider or caregiver.

Medication and Pharmacy Supplies

All prescriptions for the residents will be filled, packaged and collected from the HSA. These will then be distributed through the internal dispensary by the Registered Psychiatric Nurse/Pharmacy Technician.

Stock medications such as over the counter analgesics, anti-allergic medications, and first aid medications as well as other medical supplies such as bandages, needles, syringes, will be stocked in the dispensary. These will be dispensed upon request to the relevant cottages.

Telehealth Services

This is the delivery of distance mental health care through telecommunications technology using videoconferencing, telephone audio or recorded messages. Services include assessment and interventions such as therapy (individual, group, family), resident and caregiver education and medication management. The aim is to provide additional access to care. Telehealth will follow similar format as the face to face care and will involve various members of the multidisciplinary team.