Abstract
This 11440 word manuscript relates a case study derived from field experiences. The format is unique. By describing the fictional character, the manuscript integrates a narrative story line. This is a case study portraying a fictional patient who is determined to take her life. Self distruction is overtly characterized. Holistic Nursing Practice emphasis is upon positive reinforcement.
Author Contributions
Academic Editor: Shahid Ullah, South Australian Health and Medical Research Institute,Email : [email protected]
Checked for plagiarism: Yes
Review by: Single-blind
Copyright © 2018 Joan M Fenske, et al.
This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Competing interests
The authors have declared that no competing interests exist.
Citation:
Introduction
This material illustrates Holistic Nursing modalities as practiced with individuals who are mentally ill. Holistic Nursing attends to the individual as an integrated person, caring for their mind, body and spirit. Modalities practiced elicit an individual’s intrinsic healing potential. Holistic Nursing defines health as a state of inter-relatedness of one’s values to the expression of such values. In the absence of such inter-relatedness, comes suffering. Multiple healing modalities are performed.
Material and Methods
Frisch, Dossey, Guzzetta, Quinn (2000)1identify multiple modalities currently practiced including
a) finding meaning outside oneself (spiritual guidance)
b) establishing a trust relationship (cognitive therapy)
c) modeling appropriate behavior (behavior modification)
d) daily diary entries (journaling)
e) maintaining exercise regime (exercise and movement)
f) planning meals (weight management)
g) establishing relaxation skills (meditation) and
h) encounter-based problem solving (rehearsed diplomacies) These modalities are essential when caring for patients with mental health concerns.
The following case study examines case management evolving into Intensive Case Management (ICM) as an example of a healing modality and a holistic professional nursing practice 1, 2, 3.
The case study chronicles a patient’s struggle to function coherently. Storytelling is a descriptive way to communicate the factual basis of challenging truths. Health professionals use narratives, retrospectively, to depict case studies (Woodside, 2010) 2. Narratives link historical events to create a holistic interpretation of results.
This material establishes Intensive Case Management (ICM) as:
1. A Holistic Nursing modality
2. A Holistic Nursing modality practiced within settings where professional Intensive Case Management (ICM) professional nursing services are delivered2.
A Holistic Nursing modality may be practiced independently under the aegis of an Intensive Case Management (ICM) contract. Licensed, accredited, certified and educated, described in the literature as Advanced Practice Nurses(De Nisco, S., & Barker, A.M., 2013) 3, practice Intensive Case Management (ICM), outside the typical employer-employee relationship, as a Nurse Contractor. (Chart 1)
Chart 1. A Holistic Nursing modality may be practiced independently under the aegis of an Intensive Case Management (ICM) contract.| Licensure | Accreditation | Certification | Function | Education | Referral | Setting | Payment | Care Plan &/or Protocol | |||
| Holistic Nursing | RN | American Holistic Nurses Assoc.(AHNA) | American Holistic Nurses Certification Corp. | ClinicalCare | B.S.&/orM.S.(Plus experience) | MD | Medical OfficeClinicHospital | Employee -Employer | Yes | ||
| Intensive Case Manager | RN | CaseManagement | B.S.&/orM.S.(Plus experience) | MD | Community | Employee -Employer (Independent Practice Option) | Yes | ||||
| Advanced Practice Nurse (APRN) | RN | Accreditation Midwifery Education (ACME) Council on Accreditation of Nurse Anesthesia Educational Programs (COA)American Association of Nurse Practitioners (AANP) | American Midwifery Certification Board (AMCB)Certified RN Anesthetists (CRNA)American Nurses Credentialing (ANCC) | Midwife,Anesthetist,Consultant,Educator,Researcher,Practitioner. | M.S.&/orPhD (Plus experience) | MD MD MDAssignedAssignedProposedMD | ClinicOfficeHospitalGov. Agency UniversityUniversityClinicOffice | Employee -Employer | YesYesYesYes YesYesYesYesYesYes | ||
| Nurse Consultant | RN | Assessment,Consultation,Program Development,Evaluation | M.S.&/orPhD.(Plus experience) | Employee -Employer (Independent Practice Option) | |||||||
| Nurse Contractor | RN | B.S.(Plus experience) | Gov’t/AgencyContract | ||||||||
Background
Intensive Case Managers have not adopted Holistic Nursing strategies. Although Holistic Nursing strategies are suitable for mentally ill patients, literature lack studies of Public Health Nurses, by Clinical Social Workers, or those insurance companies tracking service usage. In the Canadian Journal of Nursing Administration identifies nursing goals using case management to coordinate health and social service systems. Skilled and experienced case managers understand and coordinate multiple agency resources. American researchers have
1) Defined Intensive Case Management: (Schaedle, Richard W. (December 1999) 4. Critical Ingredients of Intensive Case Management: Judgments of Researchers/Administrators, Program Managers and Case Managers Dissertation.com; 1st Edition.)
2) Defined Intensive Case Management used in mental health nursing: (Videbeck, S., PhD, RN (2014). Psychiatric-Mental Health Nursing. Wolters Kluwer Health, Lippincott Williams & Wilkins, Philadelphia, PA 19103) 5.
Few studies exist comparing and contrasting mental health interventions as practiced by mental health professionals. No consensus exists among mental health professionals about effective interventions or “best practices”. Effective skills are evaluated on patient outcomes and do not focus on the specific process that achieves positive outcomes. Comprehending mental health interventions, provided within programs, is required for effective interventions to be taught to practitioners.
The following material addresses:
1) Patient Response to Intensive Case Management
2) Appropriate Relationship between Patient and Case Manager
3) Agency Coordination and Referral
4) Charting Requirements and Billing Options
Literature Review
Cohan, et al, report the following:
A review of 16 controlled outcome evaluations of housing and support interventions for people with mental illness who have been homeless revealed significant reductions in homelessness and hospitalization and improvements in other outcomes (e.g., well-being) resulting from programs that provided permanent housing and support, assertive community treatment (ACT), and intensive case management (ICM). The best outcomes for housing stability were found for programs that combined housing and support (effect size = .67), followed by ACT alone (effect size = .47), while the weakest outcomes were found for ICM programs alone (effect size = .28). The results of this review were discussed in terms of their implications for policy, practice, and future research.
Intensive Case Management (ICM) is a community-based package of care aiming to rovide long-term care for severely ill people who do not require immediate admission. Intensive Case Management evolved from two original community models of care, Assertive Community Treatment (ACT) and Case Management (CM), where ICM emphasizes the importance of small caseload (fewer than 20) and high-intensity input.
To assess the effects of ICM as a means of caring for severely mentally ill people in the community in comparison with non-ICM (caseload greater than 20) and with standard community are. We did not distinguish between models of ICM. In addition, to assess whether the effect of ICM on hospitalization (mean number of days per month in hospital) is influenced by the intervention's fidelity to the ACT model and by the rate of hospital use in the setting where the trial was conducted (baseline level of hospital use).
When ICM was compared with non-ICM for the outcome service use, there was moderate-quality evidence that ICM probably makes little or no difference in the average number of days in hospital per month (n = 2220, 21 RCTs, MD -0.08, 95% CI -0.37 to 0.21, moderate-quality evidence) or in the average number of admissions (n = 678, 1 RCT, MD -0.18, 95% CI -0.41 to 0.05, moderate-quality evidence) compared to non -ICM. Similarly, the results showed that ICM may reduce the number of participants leaving the intervention early (n = 1970, 7 RCTs, RR 0.70, 95% CI 0.52 to 0.95, low-quality evidence) and that ICM may make little or no difference in reducing death by suicide (n = 1152, 3 RCTs, RR 0.88, 95% CI 0.27 to 2.84, low-quality evidence). Finally, for the outcome social functioning, there was uncertainty about the effect of ICM on unemployment as compared to non-ICM (n = 73, 1 RCT, RR 1.46, 95% CI 0.45 to 4.74, very low-quality evidence).
Cohan, H (Am J Health Syst Pharm. 2006 Oct 1; 63 (19): 1888-92)6.
The findings from this study demonstrate that Intensive Case Management (ICM) alone did not alter homelessness but combining ICM with a housing support program did alter mentally ill patients hospitalization rates. ICM did not alter suicide nor unemployment rates. Patients with ICM stayed longer with ICM programs than the patients without ICM.
Intensive Case Management for Severe Mental Illness
Dieterich, M., Irving, C. B., Bergman, H., Kholhar, M. A. Park,B.Marshall, M. Department of Psychiatry, Livorno, Italy 7and the Cochrane Schizophrenia Group, The University of Nottingham, Nottingham, UK 8 report:
We included 40 trials involving 7524 people. The trials took place in Australia, Canada, China, Europe, and the USA. When ICM was compared to standard care, those in the ICM group were more likely to stay with the service, have improved general functioning, get a job, not be homeless, and have shorter stays in hospital (especially when they had had very long stays in hospital previously). When ICM was compared to non-ICM, the only clear difference was that those in the ICM group were more likely to be kept in care.
None of the evidence for the main outcomes of interest was high quality; at best the evidence was of moderate quality. In addition, the healthcare and social support systems of the countries where the studies took place were quite different, so it was difficult to make valid overall conclusions. Furthermore, we were unable to use much of the data on quality of life and patient and carer satisfaction because the trials used many different scales to measure these outcomes, some of which were not validated. The development of an overall scale and its validation would be very beneficial in producing services that people favour.9
DOI: 10.1002/14651858.CD007906.pub3
Case Study Methodology
No single case represents the multiple factors encompassing those who are mentally ill. To fully illustrate the quandary facing those diagnosed as mentally ill, a fictional character was created. Using expertise from historical case management experiences, a study was derived. The narrative portrays issues and concerns confronted as mentally unstable patients require Intensive Case Management. The intent is to characterize the complexities Intensive Case Managers encounter caring for mentally ill patients.
Intensive Case Managers have not adopted Holistic Nursing strategies. Although Holistic Nursing strategies are suitable for mentally ill patients, literature reviews remain devoid of studies comparing Intensive Case Management, with or without Holistic Nursing interventions, with case management conducted by Public Health Nurses, by Clinical Social Workers, or insurance companies monitoring billed service usage. In the Canadian Journal of Nursing Administration, (1998 May-June; 11 (2): 93-109) Canada identifies nursing goals using case management to coordinate health and social service systems. Skilled and experienced case managers understand and coordinate multiple agency resources.
Researchers Defined Intensive Case Management:
(Schaedle, Richard W. (December 1999). Critical Ingredients of Intensive Case Management: udgments Researchers/Administrators, Program Managers and Case Managers. Dissertation.com; 1st Edition.) 10
And Intensive Case Managers practicing mental health nursing:
(Videbeck, S., PhD, RN (2014). Psychiatric – Mental Health Nursing. Wolters Kluwer Health, Lippincott Williams & Wilkins, Philadelphia, PA 19103) 11.
Few studies exist in literature comparing and contrasting the mental health practiced by mental health professionals. No consensus exists among mental health professionals about effective interventions or “best practices”.
Effective skills are evaluated on patients outcomes and do not focus on the specific process achieving positive outcomes. Comprehending mental health I interventions, provided within effective programs, is essential so model mental health programs may be duplicated. Effective mental health strategies are taught to professionals. Documented patient responses are critical for effective mental health service programs.
This material addresses the following:
1. Patient Response to Intensive Case Management
2. Appropriate Relationship between Patient and Case Manager
3. Agency Coordination and Referral
4. Charting Requirements and Billing Options
Fictional Case Study
To create a fictional Patient, facts were collected using information from multiple patients of record. Mentally ill patients are unpredictable. Their lives are chaotic and unstructured. Following-up on a specific Patient, the Patient’s immediate suicidal behavior was apparent. Earlier, the Patient’s interest focused upon concocting brownies from a newly found dessert recipe. Mentally ill patients are unpredictable. What unknown factor triggered the Patient’s determination to cut her wrists, using a kitchen knife to draw blood?
Case Presentation
The Patient’s psychiatrist communicated the following:
1. Diagnoses: DSM-IV Bipolar II Disorder: Code 296.89
2. Diagnoses: Major Depression Disorder: Code 296
3. Diagnoses: with an additional component of Bipolar II Disorder entitled Atypical Features including weight gain, hypersomnia (excessive sleepiness), and sensitivity to rejection.5
Under Intensive Case Management (ICM) for the past years, the following symptoms were incorporated into the Patient’s diagnoses:
1. Hypomania (disproportionate excitement); exhibiting episodes of anorexia, intensive talking, excessive socialization and out of control spending, and,
2. Refusing bipolar-specific prescriptions due to exceptional weight she was often un-medicated.
In addition, the patient’s history documented the patient was a
1. Discharged patient from multiple medical emergency rooms and psychiatric in-patient hospitalizations
2. Survivor of various suicide attempts
3. A discharged patient from multiple medical emergency rooms and psychiatric in-patient hospitalizations
4. Survivor of various suicide attempts
5. Patient at risk for addiction
6. abusing alcohol and drugs
7. Recent graduate of a 28-day licensed, certified, court ordered residential treatment center for individuals recovering from alcoholism and drug addiction.
Holistic Nursing Standard of Practice:
Therapeutic Environment4.2.3 specifies, “Holistic nurses integrate holistic principles, standards, policies and procedures in relation to environmental safety and emergency preparedness” (AHNA, 2000, pg. 98).
The patient intended to commit suicide.
Under the aegis of Holistic Nursing’s standard of practice, the patient needed admission to a facility that would guarantee “environmental safety”. The patient’s documented history of clinical depression reinforced the need to take immediate action.
Patient Assessment
Holistic Nursing Standard of Practice:
Holistic Caring Process5.1.1: specifies, “Holistic nurses use an assessment process including appropriate and holistic methods to systematically gather information” (AHNA, 2000, pg.122).
Holistic nurses value all types of knowing including intuition when gathering data from a person when appropriate” (AHNA, 2000, pg.122).
Illness does not define the Patient. No matter how much of the Patient’s personhood the illness claimed, the Patient remained attractive, charming, and creative. The Patient graduated, cum laude, from a local community college with two Associate of Arts degrees.
Functionally, the Patient is unemployed, unemployable and homeless, and “just that far” from prostituting for drugs or drink. The Patient is ill, struggling, wanting life back.
Could I, as a Registered Nurse Contractor, practicing independently, apply Holistic Nursing dalities and Intensive Case Management(ICM)interventions other practitioners had not? 6 What unique professional nursing services would make a difference?
Balancing Economic Justice with Compassion
Holistic Nursing Standard of Practice: Implementation 5.5.5 specifies, “Holistic Nurses provide care that is clear about and respectful of the economic parameters of practice, balancing justice with compassion” (AHNA, 2000, pg.155).
Establishing a Positive Sense of Self
Holistic Nursing Standard of Practice:
Holistic Nurse Self-Care 3.1.4 specifies; “Holistic Nurses consciously cultivate awareness and understanding about the deeper meaning, purpose, inner strengths, and connections with self, others, nature, and God/Life Force/Absolute/Transcendent” (AHNA, 2000, pg. 64)
Sustaining a relationship with an individual with mental illness is burdensome. No individual, alone, has the emotional capacity to relate to the angst manifested by someone tormented with anxieties. The Patient is unable to self regulate thus one’s own individual professional nursing responsibility to care for such an unstable individual for a 24 hour, 7 days a week shift, is untenable. Responsibility must be shared, either within an institutional setting or adhering to an organized structured day program.
Scrounging money from friends, the Patient lived alone for years. The Patient got through the day caring for her two cats and a dog. When the Patient’s family moved out of state: all pretenses the Patient could live alone evaporated. Acting out another suicide attempt landed the Patient back amidst providers prescribing Electroconvulsive Therapy (ECT). The Patient’s prescribed Clonazepam™ (Klonopin™) dosage, already excessive, could no longer be increased. All other possible medication regimes had been exhausted. A last ditch effort by a friend provided the Patient temporary housing during the course of the Patient’s latest round of therapies.
Promoting Patient Problem Solving
Holistic Nursing Standard of Practice: Implementation 5.5.2 specifies, “Holistic Nurses support and promote the person’s capacity for the highest level of participation and problem solving in the plan of care and collaborate with other health team members when appropriate” (AHNA, 2000, p.155).
The concept of Intensive Case Management (ICM) emerged as an option. In the literature, ICM models share five attributes:
1. Low client/staff ration
2. In-vivo site for treatment
3. Frequent and intense contact to forge regular and strong ties with clients
4. Open ended lengths of service (Schaedle, 1999)
The purpose of Intensive Case Management (ICM) is to allow diagnosed mentally ill Patients sustain themselves in the community. This means the Patient cooperates with the ICM professional nurse case manager as medical and psychiatric services are arranged. The Patient participates and follows through by keeping appointments and taking prescribed medications. Patients require multiple services since their mental illness renders them disabled, unable to function. Those who are mentally ill are unable to remain employed, ending up homeless. Services require job seeking and training, appropriate housing, transportation, childcare and access to food and clothing.
Programs and agencies define Intensive Case Management (ICM) professional services in ways to meet their own objectives:
“Intensive case management is responsive to consumers’ multiple and changing needs, and plays a pivotal role in coordinating required services from across the mental health system as well as other service systems (i.e., criminal justice, developmental services and programs, addiction services and programs). Case managers fulfill a vital function for consumers by working with them to realize personal recovery goals. Case managers work to build a trusting and productive relationship with the consumer (i.e., patient) and provide the support and resources that the consumer (i.e. patient) needs to achieve goals, stabilize his/her life and improve his/her quality of life” 6.
Federal, state, county and local private agencies use the Intensive Case Management (ICM) Program model. These include:
Federal:
The Veteran’s Administration (VA) uses ICM professional nursing services in approved VA medical centers for veterans meeting the following criteria:
a) Diagnosis of Severe and Persistent Mental Illness
b) Severe Functional Impairment (not capable of stable self-maintenance in a community living situation)
c) Inadequately Served (by conventional clinic-based out-patient services), and
d) High hospital use (over 30 days of annual psychiatric hospitalization or 3 or more episodes of psychiatric hospitalization) 7.
State:
State governmental agencies draw from a variety of models that incorporate strategies of Intensive Case Management (ICM) services.8, 9 State governmental Departments of Aging, Health Services, Mental Health and Corrections use Intensive Case Management(ICM) professional nursing services in the following manner:
1. Oklahoma and Missouri monitor those with schizophrenia and other diagnosed cases of mental illness to assure a patient successfully functions in the community, remains employed and sustains appropriate medical interventions10.
2. California uses unique State classifications and duty statements to employ Registered Nurses as intensive case managers to monitor Medicaid recipients’ inappropriate or over utilization of benefits11.
3. Oregon contracts with RN’s to case management patients’ multiple mental health hospitalizations, homeless seniors, newly released prisoners with addiction issues and provide in-home support for psychotic children12.
County:
County social service programs provide intensive case management services to alleviate and support families’ in imminent danger of losing employment, being evicted from housing, at-risk for becoming destitute and losing custody of their children due to child neglect and/or abuse.
Local private agencies:
Catholic Charities. Identify, assess and intensively case manage clients referred to them:
a) during a local hospitals’ discharge planning process,
b) from the police departments for crisis intervention for abused mothers, and
c) from school health programs of homeless school age children in need of shelter13.
Discussion
Balancing Economic Justice with Compassion
Holistic Nursing Standard of Practice:
Implementation 5.5.5 specifies, Holistic Nurses provide care that is clear about and respectful of the economic parameters of practice, balancing justice with compassion” (AHNA, 2000, pg.155).
It is possible to pay for professional nursing services including Intensive Case Management (ICM) interventions incorporating holistic nursing practices. Yet, why not itemize phone numbers of the appropriate agencies; programs and intake workers then encourage family and friends to assist her? Would the patient follow heir counsel, make and keep necessary appointments, obtain essential services then comply with arrangements made for her? If such arrangements were made uniquely for her, in her best interest, would this work? The answer is no.
Exhausted former husbands, sisters, and friends initiated such strategies again and again. All attempted to keep the patient medicated, housed, solvent, fed and out of jail. The patient had been arrested twice, finally admitted and hospitalized via the emergency room for an overdose of Tylenol ®.
Establishing a Positive Sense of Self
Holistic Nursing Standard of Practice:
Holistic Nurse Self-Care 3.1.4 specifies; “Holistic Nurses consciously cultivate awareness and understanding about the deeper meaning, purpose, inner strengths, and connections with self, others, nature, and God/Life Force/Absolute/Transcendent” (AHNA, 2000, pg. 64)
Sustaining a relationship with an individual with mental illness is burdensome. No individual, alone, has the emotional capacity to relate to the angst manifested by someone tormented with anxieties. The patient is unable to self regulate thus one’s own individual professional nursing responsibility to care for such an unstable individual for a 24 hour, 7 days a week shift, is untenable. Responsibility must be shared, either within an institutional setting or adhering to an organized structured day program. Scrounging money from an ex-husband, the patient lived alone for years. The patient got through the day caring for her two cats and a dog.
When the patient’s family moved the patient out of state; all pretenses the patient could live alone evaporated. Acting out another suicide attempt landed her back amidst her providers proscribing Electroconvulsive Therapy (ECT) since her prescribed Clonazepam™ (Klonopin™) dosage, already excessive, could no longer be increased. All other possible medication regimes had been exhausted. A last ditch effort by a friend provided the patient temporary housing during the course of the patient temporary housing during the course of the patient’s latest round of therapies.
Promoting Patient Problem Solving
Holistic Nursing Standard of Practice:
Implementation 5.5.2 specifies, “Holistic Nurses support and promote the person’s capacity for the highest level of participation and problem solving in the plan of care and collaborate with other health team members when appropriate” (AHNA, 2000, p.155).
Many times we listen to our friends and families bemoaning their kindred’s tragic life trajectories. It is more than any one individual can handle alone. Are there alternatives? Life skills, habilitation and activities of daily living are compromised when individuals age,are developmentally disabled, mentally ill or have been institutionalized for considerable lengths of time.
Our society is complex, cherishing self-sufficiency and self-reliance. Not all individuals have the capability to achieve self-mastery thus attaining our cultures’ multifarious standards.
Many times we listen to our friends and families bemoaning their kindred’s tragic life trajectories. It is more than any one individual can handle alone. Are there alternatives? Life skills, habilitation and activities of daily living are compromised when individuals age,are developmentally disabled, mentally ill or have been institutionalized for considerable lengths of time.
Our society is complex, cherishing self-sufficiency and self-reliance. Not all individuals have he capability to achieve self-mastery thus attaining our cultures’ multifarious standards. De-institutionalizing or delivering at-risk patients to board and care homes has been tried and failed. With resources scarce, public programs eliminated and community programs minimally staffed, a variety of options are now considered. The concept of Intensive Case Management (ICM) emerged as an option. In the literature, functions of ICM include models sharing five attributes:
1. Low client/staff ration
2. In-vivo site for treatment
3. Frequent and intense contact to forge regular and strong ties with clients
4. Open ended lengths of service(Schaedle, 1999)
The purpose of Intensive Case Management (ICM) is to allow diagnosed mentally ill patients sustain themselves in the community. This means the patient cooperates with the ICM professional nurse case manager as medical and psychiatric services are arranged. The patient participates and follows through by keeping appointments and taking prescribed medications. Patients require multiple services since their mental illness renders them disabled, unable to function. Those who are mentally ill are unable to remain employed, ending up homeless. Required services include job seeking and training, appropriate housing, transportation, childcare and access to food and clothing.
When the family recognizes their inability to assist their mentally ill family member in any way, they seek understanding. Educating the family about mental health and symptoms of the mentally ill, the case manager assures the family’s continued involvement. The family functions for the patient as an essential support group. Chronic mentally ill patients lose their family’s involvement as their symptoms progress. The case manager continually assesses the patient determining the multiple factors inhibiting their ability to initiate activities and achieve desired recovery. For example, attending regular Alcoholics Anonymous (AA) meetings assist recovery if a patient’s symptom, addiction, is preventing recovery. Patients have personal goals related to vocation options and their future prospects. Eliciting patient goals and personal expectations requires skilled case management by the ICM professional nurse case manager.
Holistic Standards of Caring and Healing
Holistic Nursing Core Value 2: Holistic Ethics; specifies under Standard of Practice 2.1;“ Holistic nurses hold to a professional ethic of caring and healing that seeks to preserve wholeness and dignity of self, students, colleagues, and the person who is receiving care in all practice settings, be it in health promotion, birthing centers, acute or chronic care facilities, end-of-life centers or homes” (AHNA, 200, p.23).
Professional nursing case managers provide intensive Case Management (ICM). As needed services are identified, holistic nursing modalities are constantly updated, services documented, delivered and tracked. Academia assesses and evaluates innovative interventions determining whether newer strategies achieve ICM’s primary purpose: i.e., aiding the patient to sustain participation as a constructive member of the community 14.
Table 1. Comparing Holistic Nursing & Targeted Case Management in Case Study| Core Values | Standards of Practice | Modality | ICM | Case Study |
| 1 Holistic Philosophy & Education | 1.1.1: support pt. self-healing process,1. 1. 2: practice in diverse clinical & community settings,1.1. 3: practice person centered care,1.1.4: model holistic nursing practice,1.1.5: pt. referrals to community networks.1.1.6: collaborate with holistic & Nsg. organizations. | Healing Presence,Active Listening,Communication Skills,Model Holistic Nursing,Create Referral Networks,Participate in Professional Organizations, Learn New Modalities:Biofeedback Acupressure. | Access to & Coordination of:Financial,Housing, Food,Transportation,Drug Rehab,MD & RX Care/Services,Family Education,Job Training. | Access to Services: Hospital Discharge, Court, Jail,In-situ & Frequent Home visit’sPatient Stabilization,Referral Networks,Community of Care. |
| 2 Holistic Ethics, Theories, & Research | 2.1.1: complete holistic re-licensure/certification education,2.1.2: acquire knowledge & skills in auxiliary care/healing modalities,2.1.3: implement holistic Nsg.. research/standards,2.1.4: practice Pt. education, informed consent & confidentiality. | Cognitive Therapy, Acknowledge Higher Power,Meditation,Guided Imagery,Massage,Nutrition Counseling,Health Promotion,Environmental Activism. | Limit Patients,Lengthy CaseManagement,In-situ & Home Service,Frequent Visits,Confidentiality & Informed Consent,Trust Relationship. | Goal: House, Feed, Care & Sustain in Community Without Psychiatric Incident |
| 3 Holistic Nurse Self-Care | 3.1.1: practice self-care principles,3.1.2: maintain own mind-body-spiritual integration,3.1.3: Identify own at-risk behavior pattern,3.1.4 acknowledge one’s own higher power,3.1.5 assume responsibility for self-care. | Self-CareInterventions,Self-Reflection,Assess At-Risk BehaviorPositive Attitude,Self Validation,Coping Strategies, Use of Support GroupHumor & Laughter. | Peer Review,Professional PsychConsultation,MD Check-up,Referrals,Exercise & Nutrition,Paid Leave &Vacation. | “unstable individual’s care:24 hrs. /7 days”,“unable to self-regulate”,“angst/anxiety”,Case Manager burn-out. |
| 4 Holistic Communication Therapeutic Environment & Cultural Diversity | 4.1.1: knowledge of breakdown in holistic communication,4.1.2: increase listening skills,4.2.3: care provided in safe environment,4.3.5: promote healing in social networks & environments. | Cultural Competence, Therapeutic Communication Skills,Prayer,Establish Healing Environments,Emergency Care Plan,Confidentiality,Informed ConsentHealth Education | Therapeutic Communication Skills,Assessment,Data Collection & Analysis,Referral Network,Psych Consultation,Emergency Protocols, | Healthy & Safe Environment,Emergency Protocols,Conflict Resolution,Therapeutic Communication Skills,Referral Network. |
| 5 Holistic Caring Process | 5.1.1: uses traditional & holistic information gathering including intuition to assess Pt. needs,5.5.2: Pt. & other professionals included in care plan development,5.5.4: respectful honoring Pt. & their unique healing process,5.5.5: respect “economic parameters” of care plan implementation,5.6.1: consult Pt. & health team for evaluation. | Data Collection & AnalysisAssessment,Pt. Self Perception,Mutual Respect & Collaboration,Mutual Decision Process,Clinical JudgmentConflict Resolution,Goal Setting & Contracts,Therapeutic Care Plan,Referrals,Healing PresenceMassage. | Healing Environment,Therapeutic Plan,Pt. Input: Concurrence,Prioritization of Goals,Drug Program Participation,Model & StrategizingEffective Behaviors,Assessment,Evaluation. | DSM-IV CODES:Bipolar II Disorder: Codes 296.89, 296.32.Psychiatric Appts.& Evaluation,RX Oversight & Review,Medicaid, Social Security Disability Application & Review, |
The purpose of Intensive Case Management (ICM) is to allow diagnosed mentally ill patients sustain themselves in the community. This means the patient cooperates with the ICM professional nurse case manager as medical and psychiatric services are arranged. The patient participates and follows through by keeping appointments and taking prescribed medications. Patients require multiple services since their mental illness renders them disabled, unable to function. Those who are mentally ill are unable to remain employed and end up homeless. Services required include job seeking and training, appropriate housing, transportation, childcare and access to food and clothing. When the family recognizes their inability to assist their mentally ill family member in any way, they seek understanding. Educating the family about mental health and symptoms of the mentally ill, the case manager assures the family’s continued involvement. The family functions for the patient as an essential support group. Chronic mentally ill patients lose their family’s involvement as their symptoms progress. The case manager continually assesses the patient determining the multiple factors inhibiting their ability to initiate activities and achieve desired recovery. For example, attending regular Alcoholics Anonymous (AA) meetings assists recovery if a patient’s symptom, addiction, prevents recovery. Patients have personal goals related to vocational options. Eliciting patient goals and personal expectations requires skilled case management by the ICM professional nurse case manager.
Table 2. Comparing Holistic Nursing with Intensive Case Management| Core Values | Standards of Practice | Modality | ICM | Aimée Case Study | ||||
| 1 Holistic Philosophy & Education | 1.1.1: support pt. self-healing process,1. 1. 2: practice in diverse clinical & community settings,1.1. 3: practice person centered care,1.1.4: model holistic nursing practice,1.1.5: pt. referrals to community networks.1.1.6: collaborate with holistic & Nsg. organizations. | Healing Presence,Active Listening,Communication Skills,Model Holistic Nursing,Create Referral Networks,Participate in Professional Organizations,Learn New Modalities:Biofeedback Acupressure | Access to & Coordination of:Financial,Housing, Food,Transportation,Drug Rehab,MD & RX Care/Services,Family Education,Job Training | Access to Services: Hospital Discharge, Court, Jail,In-situ & Frequent Home visit’sPatient Stabilization,Referral Networks,Community of Care. | ||||
| 2 Holistic Ethics, Theories, & Research | 2.1.1: complete holistic re-licensure/certification education,2.1.2: acquire knowledge & skills in auxiliary care/healing modalities,2.1.3: implement holistic Nsg.. research/standards,2.1.4: practice Pt. education, informed consent & confidentiality. | Cognitive Therapy, Acknowledge Higher Power,Meditation,Guided Imagery,MassageNutrition Counseling,Health Promotion,Environmental Activism. | Limit Patients,Lengthy CaseManagement,In-situ & Home Service,Frequent Visits,Confidentiality & Informed Consent,Trust Relationship. | Goal: House, Feed, Care & Sustain in Community Without Psychiatric Incident | ||||
| 3 Holistic Nurse Self-Care | 3.1.1: practice self-care principles,3.1.2: maintain own mind-body-spiritual integration,3.1.3: Identify own at-risk behavior pattern,3.1.4 acknowledge one’s own higher power,3.1.5 assume responsibility for self-care.. | Self-CareInterventions,Self-Reflection,Assess At-Risk BehaviorPositive Attitude,Self Validation,Coping Strategies, Use of Support GroupHumor & Laughter. | Peer Review,Professional PsychConsultation,MD Check-up,Referrals,Exercise & Nutrition,Paid Leave &Vacation | “unstable individual’s care:24 hrs. /7 days”,“unable to self-regulate”,“angst/anxiety”,Case Manager burn-out | ||||
| 4 Holistic Communication Therapeutic Environment & Cultural Diversity | 4.1.1: knowledge of breakdown in holistic communication,4.1.2: increase listening skills,4.2.3: care provided in safe environment,4.3.5: promote healing in social networks & environments. | Cultural Competence,Therapeutic Communication Skills,Prayer,Establish Healing Environments,Emergency Care Plan,Confidentiality,Informed ConsentHealth Education | Therapeutic Communication Skills,Assessment,Data Collection & Analysis,Referral Network,Psych Consultation,Emergency Protocols, | Healthy & Safe Environment,Emergency Protocols,Conflict Resolution,Therapeutic Communication Skills,Referral Network. | ||||
| 5 Holistic Caring Process | 5.1.1: uses traditional & holistic information gathering including intuition to assess Pt. needs,5.5.2: Pt. & other professionals included in care plan development,5.5.4: respectful honoring Pt. & their unique healing process,5.5.5: respect “economic parameters” of care plan implementation,5.6.1: consult Pt. & health team for evaluation. | Data Collection & AnalysisAssessment,Pt. Self Perception,Mutual Respect & Collaboration,Mutual Decision Process,Clinical JudgmentConflict Resolution,Goal Setting & Contracts,Therapeutic Care Plan,Referrals,Healing PresenceMassage. | Healing Environment,Therapeutic Plan,Pt. Input: Concurrence,Prioritization of Goals,Drug Program Participation,Model & StrategizingEffective Behaviors,Assessment,Evaluation. | DSM-IV CODES:Bipolar II Disorder: Codes 296.89, 296.32.Psychiatric Appts.& Evaluation,RX Oversight & Review,Medicaid, Social Security Disability Application & Review, | ||||
When the family recognizes their inability to assist their mentally ill family member in any way, they seek understanding. Educating the family about mental health and symptoms of the mentally ill, the case manager assures the family’s continued involvement. The family functions for the patient as an essential support group. Chronic mentally ill patients lose their family’s involvement as their symptoms progress. The case manager continually assesses the patient to determine factors inhibiting their ability to initiate activities and achieve desired recovery. For example, attending regular Alcoholics Anonymous (AA) meetings assists recovery if a patient’s symptom, addiction, is preventing recovery. Patients have personal goals related to vocational options. Eliciting patient goals and personal expectations requires the skill of an experienced case manager.
Further delineating the professional nurse’s interaction with the patient is necessary to clarify the scope of skills used to coach each patient and “nudge them” along the therapeutic path. Within the trust relationship, the professional engages the patient according to patient’s behavioral or clinical behavior. The professional’s skill set provides ongoing patient assessment to determine the quality of needed therapeutic exchanges. Questioning the patient’s perception of reality is often required. The professional interaction is fluid, blending therapeutic exchanges with coaching strategies yet never verging on manipulative or fraudulent scheming.
Intensive Case Management (ICM) is further defined as the development of essential caring relationship between a professionally licensed nursing case manager and the patient. A trusting and dynamic relationship, when established, yields the patient’s hidden incongruities. As assessed needs become apparent, the ICM professional nurse case manager intervenes, using appropriate holistic nursing modalities on the patient’s behalf, in a supportive and protective manner across a variety of service systems. Holistic nursing modalities as well as ICM professional nursing interventions facilitates the patient’s ability to utilize and gain access to comprehensive and coordinated services comprising of crisis intervention, psychiatric and health care services including:
1. Public Assistance, Food Stamp eligibility
2. Medical Care
3. Alcohol and Drug Treatment
4. Family Education
5. Education and Job Training
6. Housing and Transportation
Early intervention in crisis situations diverts the patient from unnecessary, traumatic, in-patient hospitalization. Cases followed by Intensive Case Management (ICM) professional nurse case managers are usually limited to case loads of ten individuals. The expected length of time assigned to intensively case manage a patient is two years.
Families have a difficult time accessing services on their own behalf. Only when an individual becomes known to the system, either by emergency room admission with mandated discharged planning or arrested then jailed and appearing in judicial settings, do Intensive Case Management (ICM) professional nursing services become available for the patient and their families15.
All the above options assume the Intensive Case Management (ICM) professional nurse is an employee functioning under the authority established by federal and state law and licensing regulations and abiding by the local organization or agencies’ program’s professional protocols.
May a licensed, accredited, credentialed and educated Nurse Consultant, building an Intensive Case Management (ICM) professional nursing services practice, function as a Registered Nurse Contractor and establish one’s self independently?
Establishing Competency in Diverse Community Settings
Holistic Nursing Standard of Practice: Holistic Philosophy and Education1.1.2 specifies, “Holistic nurses support, share, and recognize expertise and competency in holistic nursing practice that is used in many diverse clinical and community setting” (AHNA, 2000, p.4).
A Nurse Consultant, uniquely termed a “Registered Nurse Contractor”, if properly licensed, accredited, credentialed and educated may practice independently, meaning their contractual scope of work functions outside of a typical employer-employee relationship16.
To function independently, outside an employer-employee relationship, requires negotiating a private contract detailing the professional nursing services to be delivered.
Holistic Nursing Standard of Practice: Therapeutic Environment 4.2.5 specifies, “Holistic Nurses promote social networks and social environments where healing can take place” (AHNA, 2000, p.105).
Community of Care
National Institutions of Health (NIH) has grappled with the evolving definition of Community of Care. One article facing this issue squarely is Chacko, R.C., The Chronic Mental Patient in a Community Context. Washington D.C.,American Psychiatric Press, 1985., and the National Health Alliance publication “Think Big, Act Now: creating a community of care”.
The character of a Community of Care represents care that is:
1. Non institutionalized, Provided in homes
2. Provided by familiar and known practitioners
3. Located in the community near the residence
4. Involves the patient themselves
5.Gaining acceptance requires extensive public education
6. Addresses mentally ill patient needs.
Creating, implementing, maintaining and sustaining a “Community of Care” as a patient’s major support group is essential for successful functioning of an “at-risk” patient within the community. Building a “Community of Care” dynamically establishes the substance of a patient’s holistic nursing care and Intensive Case Management (ICM) professional nursing service therapeutic plan.
Rationale for Independent Practice
Not satisfied with public or private case management services for their family member, families seek direct involvement. Frequent communications from licensed professionals regarding the status of their family member is sought. Families exhaust options, such as inducing the family member to live with them or assisting the family member sustain residency in a licensed board and care home. All options unravel. No option succeeds over time nor remains a good fit for the unique situation presented by the individual “at-risk” family member. This is especially true when the “at-risk” family member “acts out”.
As stated by Bemis (2008), “An increasing number of RNs are becoming “wellness coaches” as more insurance plans implement wellness programs for employees. Particularly popular with “Baby Boomers”, this option extends beyond traditional corporate initiatives. Some patients are hiring their own wellness coaches to help them stay “well and active”.
Families are willing to privately negotiate Intensive Case Management (ICM) professional nursing services contracts to pay for ICM professional nursing services. As holistic nursing modalities are discussed, agreed to and incorporated within the patient’s ICM professional nursing plan, distressed family members voice their relief.
Holistic nursing modalities enhance Intensive Case Management (ICM) professional nursing services as families recognize the support provided by Advanced Practiced Nurses so educated and certified. Acknowledging their family member as an integrated whole person with the potential for self-healing gives families hope. Health promotion and health education provides families additional information regarding their family members’ illness and concerns.
Holistic Nursing Standard of Practice: Evaluation 5.6.1 specifies, “Holistic nurses collaborate with other health care team members when appropriate in evaluating holistic outcomes” (AHNA, 2000, p.168).
As demand increases for Intensive Case Management (ICM) professional nursing services, and academic evaluations document the stabilizing effect upon the at-risk patient population, the fact that at-risk patients, are successfully living in the community, not being re-institutionalized, options for “third-party reimbursement” e.g., Medicaid and Medicare, will follow.25 As stated by Bemis (2008), “In certain states, an RN can contract with the state Medicaid system and become an RN provider. Services are provided to Medicaid patients, and the program picks up the fee for the nursing care. The respite families obtain knowing the support their family member receives from ICM professional nursing services will promote such change.” (p. 47).
No longer waiting for family members to come to the attention of governmental organizations and agencies, families seek enhanced holistic nursing modalities uniquely incorporated within Intensive Case Management (ICM) professional nursing services for family members who are:
1. Mentally ill
2. Developmentally Disabled
3. Released from incarceration or prison
4. Elderly and living alone
What is unique about the above listed groups is that:
1. Their condition is chronic, long term, and unlikely to be resolved
2.Their condition is associated with immediate and future unforeseen medical problems
3. They are at risk for becoming lost to follow-up and/or homeless
4. They are at risk of being arrested and/or institutionalized
5. They are at risk of being deceived, swindled or victimized
6. Their financial status is problematic with on-going issues
7. Their existing case management services have failed
8. Their institution, agency or program changed personnel, altered services and programs
Stabilizing the Patient
No longer waiting for family members to come to the attention of governmental organizations and agencies, families seek enhanced holistic nursing modalities uniquely incorporated within Intensive Case Management (ICM) professional nursing services for family members who are:
1. Mentally ill
2. Developmentally Disabled
3. Released from incarceration or prison
4. Elderly and living alone
What is unique about the above listed groups is that:
1. Their condition is chronic, long term, and unlikely to be resolved
2. Their condition is associated with immediate and future unforeseen medical problems
3. They are at risk for becoming lost to follow-up and/or homeless
4. They are at risk of being arrested and/or institutionalized
5. They are at risk of being deceived, swindled or victimized
6. Their financial status is problematic with on-going issues
7. Their existing case management services have failed
8. Their institution, agency or program changed personnel, altered services and programs.
Management and Outcome
Case Study Outcome
The Patient’s Community of Care members were identified. Recently her mother died from breast cancer, leaving the Patient bereaved, unattended and under age. The Patient had a stepmother, sister and brother. In addition, the Patient’s mother had many close friends who cared deeply about the Patient, wanting her care secured. Recovering from her Electroconvulsive Therapy, the Patient stayed with a mother’s friend.
The Patient’s Community of Care included a stepsister, two of her mother’s friends, an ex-husband, the Patient herself, plus her Intensive Case Management (ICM) nursing case manager. Priorities included within her ICM professional nursing services plan included:
1.Housing
2. Finances including governmental benefits and food stamps
3. Psychiatric and medical care
4.Transportation
5. Job training and education
Monthly “phone bridges” allowed the Patient’s Community of Care participants to communicate routinely. In addition, all could ascertain from the group’s collective interaction with the Patient whether or not the Patient was successfully functioning.
With the assistance of the case manager, the Patient applied for a variety of governmental benefits, including Social Security Disability and Supplemental Security Income (SSI). Applying required lengthy appointments and frustrating interviews. To sustain the application process while keeping the Patient focused, it was necessary for the case manager to play a story question and answer game. Humor and patience were essential. The numerous psychiatrists and physicians the Patient had seen obtaining psychiatric interventions, and the Patient’s innumerable institutional admissions, documented her mental illness. Her disability was verified and on-going monthly benefits were granted. Medicaid and Medicare benefits are granted as part of Social Security Disability (SSI) benefits. Nearby psychiatric, mental health and medical clinics accepted the Patient’s Medicaid and Medicare payments. Thanks to oversight provided by an ex-husband, issues related to transportation were solved. The Patient owned an older car, with up to date insurance and license.
The Patient’s Community of Care assumed responsibility to monitor potential parking and moving violations. To assure annual Social Security appointments were scheduled and kept, a member of the Patient’s Community of Care accompanied provide emotional support.
Job training and education remained problematic given the Patient’s inability to sustain commitment to stated ambitions. Attempting to achieve wished-for training goals was frustrating. Social Security benefits are “needs tested”, working, even at minimum wage level, wasn’t an option. As an alternative, volunteer work in an animal shelter was incorporated into the Intensive Case Management (ICM) professional nursing services plan serving as the training option.
Responsibility for maintaining a daily schedule, caring for her pets and plants, is now the Patient’s alone. The Patient initiates conversations and activities with her friends, relatives and Community of Care participants. All remember her birthdays.
That is as much life as the Patient can handle.
The Patient’s Community of Care participants monitors activities of daily living and remain in place if dysfunctional needs re-emerge.
If the Intensive Case Management (ICM) professional nursing services plan goal was to stabilize, house, and feed the Patient while sustaining the Patient within the community without institutionalization, the plan’s goal was achieved.
The possibility for destabilizing incidents lurk. Eligibility for benefits change. Friends and family move away or become ill. Beloved pets die. The only constant is change.
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