Deinstitutionalization and NP-Led Mental Health Care in Alabama

Introduction: Deinstitutionalization and Its Community Impact

Deinstitutionalization burdens the community given the lack of sufficient resources and infrastructure to house persons who require permanent care for psychological, neurological, and other behavioral disorders. The complexity of adjusting to community life for people with mental health problems calls for help from social workers and psychiatric rehabilitation professionals, which fosters recovery and hope for patients. Deinstitutionalization also provides prospects for Psychiatric/Mental Health (Psych/MH) Nurse Practitioners to establish their own facilities to care for deinstitutionalized mental health patients. Psych/MH Nurse Practitioners offer primary health care to persons with mental health issues across different settings, and their roles emphasize clinical leadership, research, consultation, and expert clinical practice.

The objective of deinstitutionalization is to enhance the quality of life and treatment of people with mental disorders. In practice, however, deinstitutionalization has become a polarizing concern. While some studies report positive outcomes, others confirm that people living in homes or independent community settings experience significant deficits in crucial aspects of health care. Opponents of deinstitutionalization point out that many patients move from inpatient mental health hospitals to residential or nursing homes that are less equipped or staffed to meet the requirements of the mentally ill.

In several cases, moving patients from mental health institutions shifts the care burden to families. While debate over deinstitutionalization continues, healthcare professionals, advocates for mentally ill persons, and families call for increased accessibility and availability of permanent psychiatric inpatient and intermediate care for persons requiring a more structured care setting. Many experts indicate that by enhancing community-based programs and extending inpatient care to satisfy the requirements of mentally ill people, the state can achieve better treatment outcomes, improved quality of life, and increased access to mental health care.

To achieve the goal of deinstitutionalization, a wellness and recovery center for deinstitutionalized individuals is paramount. Such establishments provide detailed services designed to support people with mental health issues, including skill-building activities and curriculum, community-based peer support, and family education. The expectation is that patients will obtain enhanced overall wellness and health, set and attain personal objectives independently within the community or within their families. Wellness and recovery centers require the services of nurse practitioners, nurse technicians, and social workers to provide psychiatric assessments, medication management, general care, supervision of inpatients and on-site patients, and follow-up care. Nurse technicians monitor the physical wellness of patients. All of these services have the potential to address issues linked to the ongoing deinstitutionalization in Alabama.

Nurse practitioners have the potential to examine their own goals and visions for developing individualized practice models. Factors that affect the healthcare system — including electronic record maintenance, technology, efficient payment systems, high costs, and lack of access to care — have created novel and exciting prospects for nurse practitioners who wish to establish their own practices. In light of issues regarding deinstitutionalization and the closure of state-run psychiatric facilities, Psych/MH Nurse Practitioners can help bridge the growing gap left by state-run psychiatric services through establishing wellness and recovery centers.

Statistics from the National Alliance on Mental Illness indicate that out of the 4.7 million people in Alabama, 187,000 adults live with critical mental health illnesses, and approximately 51,000 children live with serious mental health conditions (NAMI, 2010). In 2006, five hundred Alabamians committed suicide caused by unmanaged or under-treated mental illnesses. Statistics indicate that the state loses one life every fifteen minutes through suicide, making suicide the 11th leading cause of death overall and the 3rd leading cause of death among young adults and youth aged between 15 and 24 years. Between 2006 and 2007, 64% of Alabama students aged over 14 years and living with critical mental health disorders dropped out of high school despite receiving special education services (NAMI, 2010).

The state of Alabama has closed most of its state-run psychiatric facilities, a decision that creates increased demand for psychiatric services following the deinstitutionalization of mental health patients. Closing all but two state mental health facilities leaves the state with few providers of psychiatric services to meet the increased need for mental health facilities and services. The Alabama Department of Mental Health stresses that it is crucial to prepare the community for the return of patients before they are released from mental health hospitals.

Deinstitutionalization has led to the elimination of state mental health hospitals and a ninety percent decrease in psychiatric hospital facilities and resources. It places a great burden on communities that lack the resources and infrastructure to treat people with mental health needs. The state also faces resistance to the placement of transitional homes in residential communities, as these homes can become a source of community tension. However, most communities accept facilities that are well managed and have sufficient resources to cater for the needs of former patients.

Background and Problem Statement

Mental health officials in Alabama planned to dismiss 948 employees and terminate operations of all but two state psychiatric hospitals. One of the hospitals remaining operational handles only forensic patients, while the other handles geriatric patients (Plotnik & Kouyoumdjian, 2010). As a result, mentally ill patients are blocked from accessing psychiatric treatment from state facilities unless they are elderly or have committed crimes. The Alabama Department of Mental Health asserts that this move allows the state to expand community care. The ongoing deinstitutionalization has led to a reduction of state hospital beds by 90% in favor of community services and less-restrictive treatment (Plotnik & Kouyoumdjian, 2010).

Law enforcement facilities are under serious pressure because of problems linked to untreated mental illness. State hospital emergency rooms are full of persons in psychiatric crisis who cannot be accommodated given the scarcity of beds. Alabama communities have experienced tragic incidents instigated by rampage killings perpetrated by people with untreated mental illnesses. Deinstitutionalized persons with chronic mental illness live in the streets, in prisons, or jails, suffer neglect, and commit suicide. The state is challenged with handling deinstitutionalized persons as well as new mental health patients emerging from the community.

Yanos et al. (2001) confirm that there is a critical public health issue for deinstitutionalized people. About 60% of deinstitutionalized people suffer premature deaths from health conditions such as cardiovascular, infectious, and pulmonary diseases that could be managed and treated. Thirty to forty percent of mortality is attributable to accidents, injuries, and suicide. Deinstitutionalized persons suffering from schizophrenia die of cardiovascular diseases promoted by smoking and excessive obesity. According to Yanos et al. (2001), people with critical mental illness lead marginal lives because of stigma, social isolation, and fear, making deinstitutionalized people especially vulnerable to social and health problems.

Deinstitutionalization refers to the release of mental patients from mental hospitals and their return to the community to build more self-sufficient and fulfilling lives. In 1950, there were 550,000 patients in mental hospitals in the United States. Following deinstitutionalization, the number of patients in mental hospitals dropped to approximately 150,000 in 1970 and about 80,000 in 2000 (Yanos et al., 2001). Relocating patients from state-run psychiatric hospitals back to communities began in the 1960s, initiated in part by the establishment of civil rights legislation, resulting in the enormous relocation of mentally ill persons. Although deinstitutionalizing mentally ill people appeared to be a humane act, this decision has left many people in far worse situations compared to those they endured while in psychiatric hospitals. Following deinstitutionalization, people face homelessness, poverty, stigma, inadequate treatment, and social isolation.

The objective of deinstitutionalization is only partly achievable. Some former mental patients do live in well-run halfway houses, but past studies show that halfway houses remain poorly maintained, employ untrained staff, and offer little or no treatment to patients. Major problems include lack of funding and poor supervision. Because of insufficient and inadequate halfway houses, many deinstitutionalized patients end up on the streets and become homeless. Twenty-five to eighty percent of homeless people in the United States have serious mental disorders and receive little or no treatment (Plotnik & Kouyoumdjian, 2009). To offer mental health treatment for the homeless and those released from psychiatric hospitals, community mental health centers facilitate treatment and care for these individuals. According to Plotnik & Kouyoumdjian (2010), there is a need to provide treatment to the homeless, county prisoners, and deinstitutionalized individuals, and one way to do so is through the establishment of wellness and recovery centers.

Deinstitutionalized patients report that while most are being maintained on medication, very few have their medication carefully monitored (Weisbrod & Komesar, 1978). In numerous cases, family members pick up prescription renewals, and many patients are maintained in the community not because of mental health services they receive, but because of the dedication of friends and family members. The constant deinstitutionalization of patients in the state calls for adequate facilities to offer in-home and on-site care for adults. Basic deficiencies in the provision of mental health services are attributable to the lack of proper facilities, resources, leadership skills, and organization of mental health services in the state.

Psychiatric Mental Health nursing was the pioneer specialty-nursing group to emerge within a graduate education context. Clinical nurse professionals in psychiatric mental health nursing materialized towards the end of the 1950s, initially established as nurse therapists who could evaluate mental health problems and provide group, family, and individual therapy. A paradigm shift in understanding psychiatric and mental health disorders — instigating the introduction of a neurobiological foundation for these conditions — changed the practice environment and promoted the development of and need for Psychiatric Mental Health NPs. Psychiatric Mental Health NPs are presently in high demand, using both conventional therapeutic methods and novel pharmacological interventions to address the mental health issues of their clients.

Psychiatric Mental Health Nursing has its roots in the 19th century, following reform movements aimed at reorganizing mental asylums into hospital settings and creating genuine care and treatment for the mentally ill. The organized effort to develop psychiatric nursing started at McLean Asylum in Massachusetts in 1882. Critical leaders in the development of this specialty include Harriet Bailey, Euphemia Jane Taylor, and Lillian Wald, who participated through their support for the Mental Hygiene Movement. In 1913, the first nurse-organized training program for psychiatric nursing within a general nursing education program was established at Phipps Clinic at Johns Hopkins Hospital.

Nursing leadership was essential in the development of psychiatric mental health nursing, shifting the field from a narrow medical model and mind-body dichotomy toward a bio-psychosocial approach to addressing mental illness. Adelaide Nutting, a well-known nursing educator at Teachers College at Columbia University, focused on the role of nursing in the promotion of recovery from mental illness and prevention of mental illness through the educative elements of nursing care.

Psychiatric mental health nursing leaders were essential in identifying and developing relevant, specialized bodies of knowledge, and in securing the didactic and clinical experiences vital for students to achieve competence as mental health nurses. Success has been evident in the promotion of integrated mental health concepts in general nursing educational programs and in facilitating national public awareness of the correlation of mental and physical health toward the achievement of patient outcomes. Psychiatric mental health nursing practice moved beyond the walls of state hospital institutions to meet the mental health needs of the broader community through the efforts of pioneer leaders within this specialty. The specialty's position and visibility became especially crucial following the passage of the Mental Health Act in the 1940s.

Literature Review: Psychiatric NPs, Deinstitutionalization, and Business Ownership

In the late 1950s, specialty nursing at the graduate level began to evolve in response to the passage of the National Mental Health Act of 1946 and the creation of the National Institute of Mental Health in 1949. The act was vital in identifying psychiatric nursing as one of the four core disciplines for the provision of care and treatment for the mentally ill, alongside social work, psychology, and psychiatry. Nurses were essential agents in addressing the growing demand for psychiatric services resulting from increasing awareness of post-war mental health issues.

Psychiatric nurses played an important role in the development of the advanced practice nursing role, thus establishing specialty certification through the American Nurses Association. Currently, specialists in Psychiatric Mental Health Clinical Nurse and Practitioner roles adopt and integrate titles reflecting the language in state practice acts and regulations, sharing similar core competencies in clinical and professional practice.

According to Buppert (2009), nurse practitioners are registered nurses with one or two years of additional education that prepares them to offer many of the same services that doctors provide. Nurse practitioners work with other health care professionals such as doctors, counselors, therapists, and nurses, and they offer health and wellness care to people of all ages. Nurse practitioners are lawfully allowed to diagnose, order X-rays, laboratory services, and prescribe medications; they are prepared through advanced education and clinical training to offer a wide range of acute and preventive health care services to persons of all ages (Buppert, 2009). Most NPs hold master's degrees while others hold doctorates, and they are certified to work in different areas including mental health and psychiatric care.

Before the emergence of advanced practice nurses, the legal scope of nursing practice excluded treatment and diagnosis. Nurses performed physicians' orders, and in the 1970s, some state nurse practice acts were modified to include nursing diagnoses within the nursing practice scope (Buppert, 2009). Following the shortage of physicians that arose in the 1960s, it became evident that the restrictions on nurses making medical diagnoses, combined with the physician shortage, limited access to health care for persons in medically underserved areas. Consequently, some nurses joined forces to form what is now known as the nurse practitioner role. Nurse practitioners are primary care providers who practice in acute, ambulatory, and long-term care settings, and they can offer medical and nursing services to groups, families, and individuals. Nurse practitioners can be employed or start their own private practice, subject to the requirements stipulated by their state laws.

To practice as an employee or in private practice in Alabama, a nurse practitioner must hold an RN license, graduate from an accredited program with clinical experience extending beyond basic educational preparation, hold a master's degree in nursing, and obtain certification from a national certifying agency recognized by the Board of Nursing. The favorable regulatory environment offers nurse practitioners the prospect of opening their own private practices. Psychiatric/Mental Health NPs offer a wide assortment of health care to children, adolescents, and adults in primary care settings, psychiatric emergency services, outpatient mental health services, community health centers, psychiatric hospitals, and private practice (Knudtson, 2000). Psychiatric and mental health NPs are licensed to offer physical assessment, emergency mental health services, physical and psychosocial assessments, diagnosis, treatment plans, and patient care management (Knudtson, 2000), and they can practice independently in different settings.

Deinstitutionalization represents one of the most widespread shifts in mental health policy, instigating the enormous transfer of critically mentally ill individuals from psychiatric institutional care to the community with the aim of favoring community treatment. Structural shifts in the community mental health system are a major factor of deinstitutionalization. These changes concern policy makers and mental health professionals, given that reducing the capacity of state-run psychiatric facilities may put at risk the care of the most destitute and critically ill mental patients (Bachman, 1996). Reducing the number of psychiatric facilities would be effective only if the need for these facilities also reduced. On the contrary, the demand for mental health facilities and services remains high and calls for the privatization of the inpatient psychiatric market, where Psych/MH Nurse Practitioners can own and operate their own private practices.

According to Salokangas et al. (2002), death rates caused by suicide among patients with mental health illnesses — specifically schizophrenia — increased following deinstitutionalization and reduction of beds in psychiatric hospitals. Osby et al. (2002) confirmed that in Denmark, a significant negative relationship was observed between reduction in public psychiatric facilities and suicide rates. Results from a previous study by Hansen & Arnesen (2001) confirmed a rise in homelessness, suicide rates, and social isolation following reduction of psychiatric facilities. In the U.S., Haugland and associates assessed the death rates of 1,033 deinstitutionalized persons and found that, following a three-and-a-half-year follow-up period, these patients were eight times more likely to commit suicide, become homeless due to stigma and social isolation, or die of accidents compared to people without mental health issues (Haugland, Craig, & Goodman, 1983). In contrast, McGrew et al. (1999) reported improvements in quality of life and functioning among deinstitutionalized persons treated through private mental health facilities following closure of state-run psychiatric facilities.

According to Yoon & Bruckner (2009), the deinstitutionalization process in Alabama has been executed without adequate assessment of possible health dangers to patients, and the situation can only be resolved through privatization of the mental health market. According to Bachman (1996), privatization of mental health services affects multiple goals: it assists states in attaining economic, organizational, and political objectives while avoiding the influence of interest groups and leveraging state facilities. Privatization of mental health services allows mental health patients to obtain services and treatment from community-based providers.

According to Brown (2006), nurse practitioners need to understand their scope of practice, the challenges they may face in offering care to patients, the kinds of job prospects available, advanced practice nursing roles, and the certification requirements needed to establish their career goals. Nurse practitioners make a crucial contribution to increasing access to county, state, national, and community health care services in secondary, tertiary, and primary care settings. The focus of the NP role has been to provide direct care using a family-centered, holistic perspective to underserved, unserved, and economically disadvantaged clients. NP care achieves equal or better outcomes compared with physician-provided care. Nurse practitioners work independently in many primary care settings and collaboratively in hospital, outpatient, and inpatient settings, creating collegial links with physical therapists, physicians, pharmacists, and other health care professionals. Brown (2006) confirms that nurse practitioners are increasingly building their own businesses and becoming well-informed about owning and administering companies.

Nurse practitioners are advocating for access to care and are becoming politically astute in influencing client-focused public policy, promoting NP prescriptive authority, and easing credentialing obstacles in practice (Knudtson, 2000). When making an informed decision about owning a business, NPs evaluate their career trajectory, determine the level of financial resources needed, examine career options, and assess their retirement goals. Once an NP determines that establishing a new business is the best choice, numerous steps must be taken to build a successful business that upholds financial sustainability (Knudtson, 2000). These steps include business planning that calls for analysis and research — collecting data, consulting with business associates, and networking in the community. Nurse practitioners are in a distinctive position to evaluate, assess, and develop independent business prospects and partnerships given their specialized knowledge and skills in nursing and their insights into emerging consumer needs. Deinstitutionalization, for instance, creates prospects for psychiatric-mental health nurse practitioners to establish wellness and recovery centers for deinstitutionalized individuals.

Nurse practitioners wishing to set up their own business must conduct surveillance of health care and business settings to develop awareness of clients' needs, desires, and wants. This process creates opportunities for NPs to fill consumer service or product voids through entrepreneurial and intrapreneurial ventures. Determining business prospects that represent potential growth or shifting health care practices promotes the financial viability of the business. NPs must assess community resources available for establishing the business, which will allow them to connect with significant stakeholders. Beyond assessing resource availability, NPs must create practical business plans that help evaluate market forces and the financial feasibility of the proposed business venture. A business plan maps out the business proposal in a coherent and organized manner, guiding overall operation and expenditure. NPs should seek accounting or legal help once they have a clear idea of the kind of business they want to initiate. Business plans should contain strategic planning that determines how resources will be utilized to achieve the plan's objectives. Nurse practitioners must also conduct market analysis to map out the potential market share for the products and services to be provided.

Nurse practitioner-led care centers have been in existence since 1965 and offer a distinctive perspective on primary care (Brown, 2006). These care centers have historically served disadvantaged populations while limiting the financial burden on patients. To set up a successful care center, adequate business planning, available revenue sources, and prescriptive authority are paramount. These centers focus on providing holistic, client-centered care to families, individuals, and communities. According to Brown (2006), the first step in establishing an NP-led center in a community requires using innovative perspectives and creativity in shaping the practice and determining the model of care. Market analysis is paramount as it helps assess the clients and their needs. Sound business practices and adequate resources — including physical facilities with code compliance and licensure — are necessary, because the profit margin achieved enables business owners to provide clients with valuable services. NPs can obtain grants from local organizations, loans from banks, or funding from investors to establish their own practice, alongside adequate staffing to ensure better patient management (Brown, 2006). NP-led practices must be properly credentialed, and NPs must develop community partnerships to ensure the smooth operation of the care center.

The proposed Wellness and Recovery Center would be established as a Limited Liability Company registered in the state of Alabama, positioned in Bessemer, Alabama. The proposal assesses the project and helps potential management in planning and anticipating capital disbursement priorities. The proposal encompasses four phases: planning, financing, implementation, and monitoring.

Given the substantial capital needed to establish the wellness and recovery center, funds would be sourced from loans and investors, with total capital estimated at $750,000. These funds would cover start-up expenses including physical facilities, staffing, and operational costs. Financial projections are provided for the first three years of operation.

The wellness and recovery center is expected to begin operations in Bessemer, Alabama. Given the ongoing deinstitutionalization in Alabama, the establishment would offer services to persons with behavioral health requirements through inpatient and on-site patient care. Initially, the organization would treat 12 residential patients. The organization would provide professional, conscientious, and compassionate care to adults with behavioral health needs from 6 a.m. to 6 p.m. Services to be provided include counseling and assistance with the transition to community life, maintenance of physical health and well-being, psychiatric assessments, and medication management and follow-up care.