tive of etiology, dissociation appears to be a major form of symptornatology for individuals addicted to drugs and alcohol. The frequency of truly cornorbid dissociative disorders in this population must be determined by further study. Our preliminary findings indicate that such study is warranted.

References 1.

Ross

HE,

Glaser

FB,

Germanson

T: The

prevalence of psychiatric disorders in patients with alcohol and other drug problems.

Archives

1023-1031, 2. Regier DA,

of General

45:

DS, et al: disorders with aluse. JAMA 264:

ME,

of mental

Rae

cohol and other drug 2511-2518, 1990 3. Ross CA, Norton GR, Wozney K: MultipIe personality disorder: an analysis of 236 cases. Canadian Journal of Psychiatry 34:413-418,

4. Ross

1989

CA,

Miller

multiple

data

personality

four centers. atry

on 102 cases from of Psychi-

unit, is one of the services provided by the Mental Health Center of Dane County in Madison, Wisconsin. Two unique features of the unit are its use of a nurse-physician collaborative practice model and the provision of limited mental health services.

disorder

AmericanJournal 1990 HeberS, NortonGR,

147:596-601,

5. RossCA,

et al: The

Dissociative

Disorders Interview Schedule: a structured interview. Dissociation 2:169-189,

6. Bernstein ment,

1989 EM, Putnam

reliability,

and

FW: validity

Developof a dis-

sociation scale. Journal of Nervous and Mental Disease 174:727-735, 1986 7. Toland AM, Howard HB: Identification of the alcoholic schizophrenic: use of clinical laboratory tests and the MAST. Journal ofStudies on Alcohol 50:49-53, 1989 8. Skinner HA: The Drug Abuse Screening Test. Addictive Behavior 7:363-371, 1982

1988 Farmer

Comorbidity

Psychiatry

interview

Structured of

SD,

Reagor

P. et al:

9. Ross CA: Epidemiology ofmultiple personality and dissociation. Psychiatric Clinics of North America 14:503-517, 1991

10.

Anderson

G, Yasenik

sociative

experiences

L, Ross CA: Disand disorders who identify themselves

among women as sexual abuse survivors. and Neglect, in press

Child

Abuse

A Collaborative Nurse-Physician Practice Model for Helping Persons With Serious Mental Illness Nadine

Nehls,

Blahnik, Nestler,

Lori

Kim Dorothy

R.N.,

R.N., M.D.,

Richardson,

Ph.D.

M.A. Ph.D. R.N.,

B.S.

Dr. Nehls was formerly a clinical specialist in the medical services unit at the Mental Health Center of Dane County in Madison, Wisconsin. Ms. Blahnik is a clinical specialist at the center, Dr. Nestler is a consulting psychiatrist,

and

Ms.

Richardson

is manager.

Community-based treatment for persons with serious and persistent mental illness has received considerable attention (1-10). Most of the attention has focused on community support programs, psychosocial clubhouses, and assertive case management models. Little discussion of alternative approaches for persons with serious mental illness has taken place, even though some clients do not need on wish to participate in comprehensive or intensive programs, and many community mental health centers cannot provide these services due to limited resources.

53792.

In this paper we describe a program for persons with serious and persistent mental illness who are assessed as not needing intensive or comprehensive services. This program, known as the medical services

842

August

Dr. Nehls is currently assistant professor at the University of Wisconsin-Madison School of Nursing, H6/248, 600 Highland

Avenue,

Madison,

Wisconsin

1992

VoL 43

No.

8

The collaborative practice model Unlike many community mental health center programs, the medical services unit employs only nurses as case managers. This policy ensures that clients receive mental health senvices from professionals who not only value continuity ofcare (6), but who also are knowledgeable and comfortable with medication management. The nurse case managers work with consulting psychiatrists to develop treatment plans tailored to individual client needs. Decisions about the frequency and nature of visits to the physician and nurse, medication orders, and referrals are discussed during a weekly meeting of the nurse case managers and psychiatnists at the agency and by telephone as needed. Clients are instructed to direct their concerns to their nurse case manager, who assesses whether psychiatric consultation is needed. This communication pattern maximizes nursing expertise, promotes efficient use ofpsychiatric consultation time, and encourages clients to view the nurse and physician as a team working on their behalf.

The

medical

services

unit

In June 1991 a total of 332 clients were being served in the medical services unit. The largest percentage of clients met diagnostic criteria for schizophrenia(47 percent). Other diagnoses included bipolardisorder(1 1 percent), major depression (7 pencent), schizoaffective disorder (6 percent), personality disorders (5 percent), anxiety disorders (5 percent), manic disorder (4 percent), and dysthymia (3 percent). Fifty percent of the clients were between the ages of 30 and 44; 53 percent were male. The majority of clients had a high school education (70 percent), were white (92 percent), and earned less than $500 a month (55 percent). The medical services unit is

Hospital

and

Community

Psychiatry

staffed by one program secretary, five full-time nurses, one of whom is the manager of the unit, and psychiatnists who provide a total of 16 hours of consultation a week. The 1991 unit budget, including staff, incidental, and overhead expenses, totaled $420,376. The unit staffprovide the following direct and indirect services. intake andreferralservices. The nurse case managers perform initial screening of persons referred to the mental health center for medication. The nurses direct people in crisis to the agency’s emergency services unit. Persons who have access to other community treatment options or who need services not provided by the medical services unit are referred to the agency’s intake committee. Those who are assessed as needing ongoing medication services but who do not want or would not benefit from intensive on comprehensive community services are registered as medical services unit clients. Medication services. Medication services are an important focus of the unit. Clients are offered medication services after initial interviews with the nurse case manager and the psychiatnist. During the first session, the nurse obtains a detailed psychiatric and medical history, conducts a mini-mental status examination, assesses the potential benefits and risks ofprescnibing medication, and, if indicated, obtains the patient’s written permission to review external records. The client is then scheduled to see a psychiatrist for further assessment, diagnostic clarification, and prescription ofpsychotropic medication. Ongoing medication monitoring for each patient is provided by the same nurse-psychiatrist team. Additional medication services are provided to some unit clients. About 50 clients currently have demonstrated that they cannot manage a supply of medication. These clients pick up medications at the unit on a daily or weekly basis. The nurses also administer depot neuro!eptic medication to approximately 50 people. These additional contacts not only ensure careful monitoring but also provide opportunities for cli-

Hospital

and

Community

Psychiatry

ents to develop relationships various staffmembers, thereby itating a positive transference program.

chosocial

with facilto the

A small number of unit clients participate in a medication group. The group sessions are held once a week and are co-!ed by a unit nurse and a psychiatrist. The purposes of the group sessions are to provide a consistent time and place to renew prescriptions, discuss responses to medication, and engage in social interaction and support. Supportive counseling. Although medication services are a very prominent part ofthe program, the importance of supportive contacts should not be underestimated. For many clients, routine medication checks or telephone conversations help satisfy the need for human contact, affinmation, and guidance. In other cases, visits to a nurse case manager provide opportunities for clients to receive health education, reality orientation, and, in some cases, bnieffocused psychotherapy. The staff also reach out to family members and offer crisis intervention, supportive counseling, and education when indicated. From January to June 1991, the number of contacts with a nurse on psychiatrist for medication services or supportive counseling ranged from one to 120 per client. The majority of clients (N= 1 69, on 5 1 percent) had one to six visits in six months; 38 of these had two visits, and 37 had three. Case management services. In addition to medication monitoring and supportive counseling, the unit provides limited case management services. The nurse case managers serve as advocates and liaisons with other parts of the mental health care system, the legal system, the client’s family, Unlike

and

the

community

a community

1992

Vol.

43

lives

in the

community.

Acknowledgments The Ronald sistance.

authors thank J. Diamond,

Barb Shaw and M.D, for their as-

References JH,

Propst

R, Malamud

TJ: The

of psychiatric Rehabilitation

2. Braun P, Kochansky G, Shapiro Overview: deinstitutionalization chiatric

patients.

Psychiatry

American

1 38:736-749,

ferent

8

community

Journal

4. Davidson

RE, Factor

al: Psychiatric

nursing

nity mental health Mental HealthJournal

clinical

perspective.

6. KraussJB:

A comin dif-

treatment

Mental 1987

ap-

Health

R, Gundlach roles

E, et

in a commu-

center. Community 24:83-86, 1988

5. Harris M, Bergman HC: ment with the chronically Orthopsychiatry

of

1981

support

proaches. Community Journal 23:103-113,

re-

R, et al: of psy-

3. Cutler DL, Tatum E, Shore JH: parison of schizophrenic patients

pro-

No.

filling

Fountain House model habilitation. Psychosocial Journal 5:47-53, 1982

gram, the unit was not designed to provide intensive case management services. For examp!e, job coaching on extensive in vivo teaching of mdcpendent living skills is outside the domain of the medical services unit. Clients who are in need of these senvices are referred to the agency’s community support program or the psy-

August

program.

Conclusions The medical services unit has filled a significant gap in the services provided to persons with serious mental illness at the Mental Health Center of Dane County in Madison, Wisconsin. The efficacy of the program has not been formally evaluated. However, clinical experience suggests that some c!ients with serious mental illness may benefit from a program that facilitates normalization by minimizing contact with the mental health care system. In addition, this mode! maximizes efficient use of professional skills and facilitates job satisfaction through co!legial collaboration. This program could be implemented in other cornmunity mental health centers as a means of he!ping some clients with serious mental illness live more ful-

1. Beard

at large. support

rehabilitation

From January to June 1 99 1 , indirect service contacts by the nurse case managers ranged from 1 to 48 per client. For the majority of clients (56 percent), one to seven case management contacts were provided during the six-month period.

American

57:296-287, New conceptions

managementally ill: a

Case

Journal

of

1987 ofcare,

com-

843

and chronic mental ofPsychiatric Nursing

munity,

chives

illness. Ar3:281-287,

1989

7. McRaeJ, HigginsM,LycanC,etal: What happens to patients after five years of intensive case management stops? Hospital and Community Psychiatry 41 : 175-1 79, 1990

8. Stein

U, Test

hospital

treatment tion.

MA: Alternative

treatment,

program,

Archives

to mental

I: conceptual ofGeneral

and

model,

clinical Psychiatry

evalua-

392-397,

1980 EL: Deinstitutionalization and community-based care for the chronic mentally ill, in Research in Community and Mental Health, vol 6: Mental Disorder in a Social Context. Edited by GreenleyJR. Greenwich, Conn,Jai Press, 1990 10. Witheridge TF: The assertive communiry treatment worker: an emerging role and its implications for professional training. Hospital and Community Psy-

Patients’ hospitalizations were cxamined for a five-year period from 1983 to 1988. Admissions to specialized treatment programs with a predetermined length of stay were excluded. Individuals without a service-connected disability were not involved. The medical records of all patients included in the study were reviewed. Data were recorded about age, diagnosis, disability status, the number ofhospitalizations lasting 20 days or less, the number lasting more than 20 days, and the total number ofhospita!izations. The proportion of hospitalizations ofmonc than 20 days duration was calculated for each patient; the mean proportion was calculated for the subject and control groups.

9. Wegner

37:

chiatry

40:620-624,

1989

Disability Status and Length of Stay at a VA Medical Center

Results From 1983

Raymond Danielle

Pary, M.D. M. Turns, M.D.

Judith Carmelita

J.

Steven

Lippmann,

Stephenson, Tobias,

S.M.

M.D. M.D.

Factors influencing hospital length of stay arc of interest to physicians and hospital administrators. In this study the impact ofaVeterans Affairs compensation system on length of stay at a VA hospital was investigated. The mean proportion of hospitalizations exceeding 20 days was compared for patients who benefited monetarily from longer stays and for patients who did not benefit. The VA provides a financially unique health care system at no cost to veterans. Persons incurring disability while in the armed forces reccive pensions ranging from 10 to 100 percent, paid monthly. Fully disabled individuals (100 percent disability) receive the highest benefits. People with a partial disability

The

authors

are affiliated with the of Louisville School of Medicine in Louisville, Kentucky. Drs. Pary and Tobias are staff psychiatrists and Dr. Turns is chief of psychiatry at the Veterans Affairs Medical Center, 800 Zorn Ayenue, Louisville, Kentucky 40206. University

844

obtain less; however, when these patients are hospitalized for more than 20 days for the disabling condition, they receive 100 percent disability benefits. The rationale is that a condition requiring more than 20 days of hospitalization is totally incapacitating. This increased cornpensation is granted only for the penod of hospitalization. The effect of this financial incentive on length of hospital stay is the focus ofthis paper. Methods Every patient with a service-connected disability admitted to the psychiatric unit at the VA Medical Center in Louisville, Kentucky, in 1986 was included in this study. Patients were assigned to one of two groups according to the degree and type ofdisability. The subject group consisted of 85 psychiatrically disabled veterans with conditions rated at less than 100 percent disability. These patients would receive a financia! gain if they remained in the hospita! for more than 20 days. The control group comprised 1 3 3 persons who

100 percent disabled on who had a nonpsychiatnic service-connected disability (N=22). No patients in the control group would have benefited financial!y from a prolonged inpatient psychiatry stay. (N=

were

1

August

1

1)

1992

Vol.

43

No.

8

to 1988,

the 2 18 patients

in the two groups had 1 ,397 admissions, a mean±SD of 6.42±8. 1 5 admissions per person. The primary psychiatric diagnoses for the subject group were schizophrenia (32.9 percent), posttraumatic stress disorder (27. 1 percent), depression (24.7 percent), bipolar disorder (9.4 percent), and anxiety disorder (5 .9 percent). For the control group, the primary diagnoses were schizophrenia (53.4 percent), posttraumatic stress disorden (18 percent), depression (13.5 percent), bipolar disonden(3 percent), anxiety disorder (3.8 percent), and other disorders (8.3 percent). The mean±SD age of the subjects was 44.5±1 1 .6 years, which did not differ significantly from that ofthc control group (43.9±1 1 .7 years). The mean proportion of hospitalizations longer than 20 days was 35.5 percent for the subject group and 23.9

percent

for

the

control

group

(t=2.67, df=216, p=.008). To ensure that the difference was not a product of psychiatric diagnoses, a two-way analysis of variance was carried out using the diagnostic categories of schizophrenia, posttraumatic stress disorder, depression, bipolar disorden, anxiety disorder, and a misce!laneous group ofall other diagnoses. Analysis showed that the main effect ofmembership in the subject or control group was statistically sig-

Hospital

and

Community

Psychiatry