Recovery and Psychiatric Recovery and Psychiatric RehabilitationRehabilitation

Prepared byPrepared byMohamed Z. AishMohamed Z. Aish

Hisham M. El-MudallalHisham M. El-MudallalSupervised bySupervised by

Dr. Ashraf Aljedi Dr. Ashraf Aljedi

Tertiary Prevention In Psychiatric CareTertiary Prevention In Psychiatric Care Goal of tertiary prevention is to limit the amount of disability Goal of tertiary prevention is to limit the amount of disability

and maladaptive functioning resulting from an illness. and maladaptive functioning resulting from an illness.

Concepts of tertiary prevention relevant to patients with Concepts of tertiary prevention relevant to patients with serious mental illness.serious mental illness.

1 in 17 adults in USA have a serious mental illness.1 in 17 adults in USA have a serious mental illness.

Nurses care for these people in a variety of settings:-Nurses care for these people in a variety of settings:-

• Private and public psychiatric hospitals.Private and public psychiatric hospitals.• Psychiatric and medical-surgical units in general hospitals.Psychiatric and medical-surgical units in general hospitals.• Emergency rooms.Emergency rooms.• Community-based treatment and rehabilitation programs.Community-based treatment and rehabilitation programs.• Primary care settings.Primary care settings.• Patients homes.Patients homes.

RehabilitationRehabilitation Tertiary preventionTertiary prevention is carried out through activities identified as is carried out through activities identified as

rehabilitation, which is the process of helping the person return rehabilitation, which is the process of helping the person return to the highest possible level of functioning.to the highest possible level of functioning.

Psychiatric rehabilitationPsychiatric rehabilitation is a combination of services is a combination of services incorporating social, educational, occupational, behavioral, and incorporating social, educational, occupational, behavioral, and cognitive interventions aimed at long-term recovery and cognitive interventions aimed at long-term recovery and maximization of self-sufficiency.maximization of self-sufficiency.

Psychiatric rehabilitationPsychiatric rehabilitation grew out of a need to create grew out of a need to create opportunities for people diagnosed with severe mental illness to opportunities for people diagnosed with severe mental illness to live, learn, and work in their own communities. live, learn, and work in their own communities.

Psychiatric rehabilitationPsychiatric rehabilitation uses a person-centered, people-to- uses a person-centered, people-to-people approach that differs from the traditional medical model people approach that differs from the traditional medical model of care ( Table 14-1 ). of care ( Table 14-1 ).

Although research has reported that certain interventions Although research has reported that certain interventions effectively assist people who have serious mental illnesseseffectively assist people who have serious mental illnesses function productively in their communities.function productively in their communities.

The first group of disseminated evidence-based practices that The first group of disseminated evidence-based practices that support and enhance psychiatric rehabilitation included the support and enhance psychiatric rehabilitation included the following: assertive community treatment, supported following: assertive community treatment, supported employment, illness management and recovery, integrated employment, illness management and recovery, integrated treatment for co-occurring mental illness and substance abuse, treatment for co-occurring mental illness and substance abuse, family psycho-education, and medication management.family psycho-education, and medication management.

Rehabilitative psychiatric nursing takes place in the context of a Rehabilitative psychiatric nursing takes place in the context of a multidisciplinary treatment team.multidisciplinary treatment team.

Other team members may include: psychiatrists, psychologists, Other team members may include: psychiatrists, psychologists, social workers, occupational therapists, rehabilitation social workers, occupational therapists, rehabilitation counselors, case managers, consumer team members, family counselors, case managers, consumer team members, family advocates, employment specialists, or job coaches. advocates, employment specialists, or job coaches.

Rehabilitative psychiatric nursing also must be Rehabilitative psychiatric nursing also must be studied in the contexts of the studied in the contexts of the patientpatient, , familyfamily, and , and social systemsocial system ..

This requires the nurse to focus on This requires the nurse to focus on 3 elements3 elements::

1- The individual.1- The individual.

2- The family.2- The family.

3- The community.3- The community. The nursing care of people with serious mental The nursing care of people with serious mental

illnesses is related to these 3 elements and the illnesses is related to these 3 elements and the activities of assessment, planning and activities of assessment, planning and implementation, and evaluation.implementation, and evaluation.

The psychiatric rehabilitation philosophy is The psychiatric rehabilitation philosophy is consistent with the goal of recovery.consistent with the goal of recovery.

RecoveryRecovery Recovery Recovery is the process in which people are is the process in which people are

able to live, work, learn, and participate fully able to live, work, learn, and participate fully in their communities.in their communities.

RecoveryRecovery is a journey of healing and is a journey of healing and transformation enabling a person with a transformation enabling a person with a mental health problem to live a meaningful mental health problem to live a meaningful life in a community of his or her choice while life in a community of his or her choice while striving to achieve his or her full potential.striving to achieve his or her full potential.

AssessmentAssessment The Individual:The Individual: Assessment of the need for rehabilitation and recovery begins Assessment of the need for rehabilitation and recovery begins

with the initial contact between the nurse and the patient.with the initial contact between the nurse and the patient. A comprehensive psychiatric nursing assessment provides A comprehensive psychiatric nursing assessment provides

information that enables the nurse to help the patient achieve information that enables the nurse to help the patient achieve maximum possible functioning.maximum possible functioning.

Nurses are expected to identify and reinforce strengths as one Nurses are expected to identify and reinforce strengths as one means of helping the patient cope.means of helping the patient cope.

When conducting an initial assessment, the nurse needs to When conducting an initial assessment, the nurse needs to assist the patient to plan for recovery by identifying the assist the patient to plan for recovery by identifying the individuals life goals and strengths and discussing services individuals life goals and strengths and discussing services available from the health care system and the persons social available from the health care system and the persons social support network that will support strengths and assist in goal support network that will support strengths and assist in goal achievement.achievement.

Characteristics of Serious Mental IllnessCharacteristics of Serious Mental Illness People who have SMI are likely to have People who have SMI are likely to have primary primary and and secondary secondary

symptoms.symptoms. Primary symptoms are directly caused by the illness. For example, are directly caused by the illness. For example,

hallucinations and delusions are primary symptoms of schizophrenia, hallucinations and delusions are primary symptoms of schizophrenia, and elation and hyperactivity are primary symptoms of bipolar disorder. and elation and hyperactivity are primary symptoms of bipolar disorder.

Secondary symptomsSecondary symptoms, such as loneliness and social isolation, are caused , such as loneliness and social isolation, are caused by the person response to the illness or its treatment.by the person response to the illness or its treatment.

Behaviors related to primary symptoms may violate social norms and be Behaviors related to primary symptoms may violate social norms and be considered deviant. Society tries to protect itself from the persons norm considered deviant. Society tries to protect itself from the persons norm violation. As behavior problems become more serious, people violation. As behavior problems become more serious, people increasingly identify themselves as mentally ill. They begin to relate to increasingly identify themselves as mentally ill. They begin to relate to society in terms of this identity rather than others, such as wife, mother, society in terms of this identity rather than others, such as wife, mother, husband, father, or worker. The persons acceptance of mentally ill status husband, father, or worker. The persons acceptance of mentally ill status and adjustment to society in terms of this role are accompanied by the and adjustment to society in terms of this role are accompanied by the secondary symptoms of SMI.secondary symptoms of SMI.

Behaviors related to serious mental illnessBehaviors related to serious mental illness

Blocks to recovery of individuals with SMI include poverty, Blocks to recovery of individuals with SMI include poverty, victimization, and stigma.victimization, and stigma.

People with SMI are often unemployed, less likely to be involved People with SMI are often unemployed, less likely to be involved in close relationships, and tend to have fewer financial resources in close relationships, and tend to have fewer financial resources than their peers.than their peers.

Stigma experienced by those who are mentally ill has been linked Stigma experienced by those who are mentally ill has been linked to self-esteem.to self-esteem.

A study of women with mental illness found that when there was A study of women with mental illness found that when there was low perception of discrimination and the women did not believe low perception of discrimination and the women did not believe that discrimination was legitimate, they had higher self-esteem.that discrimination was legitimate, they had higher self-esteem.

Thus the effects of stigma, poverty and victimization should be Thus the effects of stigma, poverty and victimization should be included in patient assessment and treatment planning.included in patient assessment and treatment planning.

Activities of daily living:Activities of daily living: Are skills that are necessary to Are skills that are necessary to live independently, such as housekeeping, shopping, food live independently, such as housekeeping, shopping, food preparation, money management, and hygiene. Apreparation, money management, and hygiene. A major goal of major goal of recovery is to help the person develop independent living skills.recovery is to help the person develop independent living skills.

Interpersonal relations: Interpersonal relations: People who have SMI are People who have SMI are apathetic, withdrawn, and socially isolated. These behaviors apathetic, withdrawn, and socially isolated. These behaviors create serious problems in establishing close relationships. create serious problems in establishing close relationships. Nonetheless, formal and informal networks are needed by the Nonetheless, formal and informal networks are needed by the seriously ill.seriously ill.

Low self-esteem:Low self-esteem: is the feeling of self-worth or regard for is the feeling of self-worth or regard for oneself. Lack of ability to maintain employment, live oneself. Lack of ability to maintain employment, live independently, marry, and have children contributes to low self-independently, marry, and have children contributes to low self-esteem.esteem.

MotivationMotivation ::Fear of failure often results inFear of failure often results in reluctance to try reluctance to try new experiences. Lack of motivation may be caused by low new experiences. Lack of motivation may be caused by low energy related to the biological effect of the illness or to energy related to the biological effect of the illness or to medication.medication.

Strengths:Strengths: An emphasis on strengths provides An emphasis on strengths provides hope that improved functioning is possible. hope that improved functioning is possible. Strengths may be related to recreational and leisure Strengths may be related to recreational and leisure activities, work skills, educational accomplishments, activities, work skills, educational accomplishments, self-care skills, special interests, talents and abilities, self-care skills, special interests, talents and abilities, and positive interpersonal relationships.and positive interpersonal relationships.

Non-adherence:Non-adherence: Failure to take medication is Failure to take medication is a common cause of re-hospitalization. Assess the a common cause of re-hospitalization. Assess the reasons for non-adherencereasons for non-adherence as denial of the illness, as denial of the illness, lack of understanding of the reason for treatment lack of understanding of the reason for treatment regimen, side effects of medication.regimen, side effects of medication.

Living skills assessment:Living skills assessment: The nursing The nursing assessment of a patient with a SMI should include an assessment of a patient with a SMI should include an analysis of the physical, emotional, and intellectual analysis of the physical, emotional, and intellectual components of the skills needed for living, learning, components of the skills needed for living, learning, and working in the community.and working in the community.

The FamilyThe FamilyComponents of family assessmentComponents of family assessment

The nurse who assesses the family as part of a rehabilitation plane The nurse who assesses the family as part of a rehabilitation plane should consider the following aspects of family dynamics:should consider the following aspects of family dynamics:

Family structure, including developmental stage, roles, Family structure, including developmental stage, roles, responsibilities, norms, and values.responsibilities, norms, and values.Family attitudes toward the mentally ill member.Family attitudes toward the mentally ill member.The emotional climate of the family (fearful, angry, depressed, The emotional climate of the family (fearful, angry, depressed, anxious, calm).anxious, calm).The social supports available to the family, including extended The social supports available to the family, including extended family, friends, financial support, religious involvement, and family, friends, financial support, religious involvement, and community contacts.community contacts.Past family experiences with mental health services.Past family experiences with mental health services.The family s understanding of the patient s problem and the plan of The family s understanding of the patient s problem and the plan of care.care.The nurse should plan on regular contacts with family members and The nurse should plan on regular contacts with family members and inclusion of them as part of the treatment team.inclusion of them as part of the treatment team.

Family BurdenFamily Burden The mental illness of a family member affects the entire family.The mental illness of a family member affects the entire family. The most burden was related to worry about the future, poor The most burden was related to worry about the future, poor

concentration, upset household routines, feeling guilty about not concentration, upset household routines, feeling guilty about not doing enough, feeling trapped, and being upset by changes in doing enough, feeling trapped, and being upset by changes in their family member.their family member.

Burden may be objective or subjective.Burden may be objective or subjective. Objective burdenObjective burden is related to the patients behavior, role is related to the patients behavior, role

performance, adverse effects on the family, need for support, performance, adverse effects on the family, need for support, and financial costs of the illness.and financial costs of the illness.

Subjective burdenSubjective burden is the persons own feeling of being is the persons own feeling of being burdened; it is individual and not consistently related to the burdened; it is individual and not consistently related to the elements of objective burden.elements of objective burden.

Several responses are frequently noted in families who have Several responses are frequently noted in families who have members with SMI:members with SMI:

Grief:Grief: Is common and is related to the loss of the person they knew Is common and is related to the loss of the person they knew

before the illness, as well as loss of the future that they before the illness, as well as loss of the future that they expected to share with the ill family member.expected to share with the ill family member.

Guilt:Guilt: Is common for those who are close to a person with SMI to Is common for those who are close to a person with SMI to

wonder whether they could have done something to prevent it.wonder whether they could have done something to prevent it. Parents of a depressed woman may believe that they couldParents of a depressed woman may believe that they could

prevented her depression if they had not shared their own prevented her depression if they had not shared their own worries with her.worries with her.

Anger:Anger: May be directed toward the patient, other family members, May be directed toward the patient, other family members,

mental health care providers, or the entire health care system.mental health care providers, or the entire health care system.

PowerlessnessPowerlessness and and fear:fear: Often result from families realization that they are dealing with a Often result from families realization that they are dealing with a

long-term recurrent illness.long-term recurrent illness.

Social Support NeedsSocial Support Needs Families who are providing care for members who have SMI Families who are providing care for members who have SMI

often feel isolated and alone in dealing with the challenges of often feel isolated and alone in dealing with the challenges of care giving.care giving.

Previous sources of social support may be lost or limited Previous sources of social support may be lost or limited because of the demands of attending to the mentally ill family because of the demands of attending to the mentally ill family member.member.

Caregivers may be embarrassed about the illness or fear that Caregivers may be embarrassed about the illness or fear that the person with mental illness will behave inappropriately in the the person with mental illness will behave inappropriately in the presence of others.presence of others.

Nurses can play an important role in offering family members Nurses can play an important role in offering family members opportunities to discuss their concerns and taking action to meet opportunities to discuss their concerns and taking action to meet their needs whenever possible. Table 14-3 lists support needs their needs whenever possible. Table 14-3 lists support needs expressed by family caregivers.expressed by family caregivers.

The communityThe community

The community greatly influences the rehabilitation The community greatly influences the rehabilitation and recovery of its mentally ill members. Mental health and recovery of its mentally ill members. Mental health professionals have a unique role in the community professionals have a unique role in the community because they are community member and also because they are community member and also advocates for people with mental illness and their advocates for people with mental illness and their families at the same time .families at the same time .

care providers, including nurses , should assume care providers, including nurses , should assume a leadership role in assessing the adequacy and a leadership role in assessing the adequacy and effectiveness of community resources and in effectiveness of community resources and in recommending change to improve access and recommending change to improve access and quality of mental health care .quality of mental health care .

Nurses in all setting must be familiar with the Nurses in all setting must be familiar with the community agencies that provide services to people community agencies that provide services to people with mental illnesses . Most communities have asocial with mental illnesses . Most communities have asocial and medical services directory that can to consult for and medical services directory that can to consult for basic information , such as location , type ,and cost of basic information , such as location , type ,and cost of services provided .services provided .

Most agencies serve people who come from a Most agencies serve people who come from a particular geographic area, such as one part of a city particular geographic area, such as one part of a city or, in a rural area , one or several counties.or, in a rural area , one or several counties.

Nurses should pay attention to patient evaluation of Nurses should pay attention to patient evaluation of the agencies from which they receive services. This the agencies from which they receive services. This information helps to identify agencies that are information helps to identify agencies that are responsive and helpful as opposed to those that are responsive and helpful as opposed to those that are difficult for patients to approach.difficult for patients to approach.

The nurse also can provide emotional support of the The nurse also can provide emotional support of the patient feels insecure in anew situation. Nurse should patient feels insecure in anew situation. Nurse should introduce them selves to the staff of the agency and introduce them selves to the staff of the agency and explain that they. As well as the patient, would like to explain that they. As well as the patient, would like to learn more about the services. Collaboratetive learn more about the services. Collaboratetive relationships between mental health care providers relationships between mental health care providers and community agencies ate essential if rehabilitation and community agencies ate essential if rehabilitation is to succeed.is to succeed.

A wide range of community services must be A wide range of community services must be available to patients. Those that are directed toward available to patients. Those that are directed toward basic needs include provisions for shelter, food and basic needs include provisions for shelter, food and clothing; activities; and mobility and transportation.clothing; activities; and mobility and transportation.

. Other services provide for special needs . Other services provide for special needs that may differ from one person the next, that may differ from one person the next, such as general medical services, mental such as general medical services, mental Health services, habilitation and Health services, habilitation and rehabilitation programs. Vocational service, rehabilitation programs. Vocational service, and social services.and social services.

A third group of services coordinates the A third group of services coordinates the system. These include patient identification system. These include patient identification and outreach, individual assessment and and outreach, individual assessment and service planning, case management, service planning, case management, advocacy and community organization, advocacy and community organization, community information, and support. community information, and support.

Planning and implementationPlanning and implementation

The individualThe individual Treatment planning and intervention in Treatment planning and intervention in

Recovery-focused psychiatric nursing Recovery-focused psychiatric nursing aim to foster independence by maximizing aim to foster independence by maximizing the per-sons strengths. Specially, the nurse the per-sons strengths. Specially, the nurse helps the individual to do the followinghelps the individual to do the following::• Develop strengths and potential. Develop strengths and potential. • Learn living skills. Learn living skills. • Manage one’s illness. Manage one’s illness. • Access environmental supportsAccess environmental supports. .

The nursing treatment plan should be The nursing treatment plan should be organized be organized around very specific organized be organized around very specific behavioral goals that ate bases on a behavioral goals that ate bases on a comprehensive assessment of the person's comprehensive assessment of the person's living skills. These goals should building in living skills. These goals should building in those that are developed during the acute those that are developed during the acute phase of the illness. This part of the nursing phase of the illness. This part of the nursing care plan may be called the discharge be care plan may be called the discharge be developed in community care setting. developed in community care setting. Discharge plans also should be developed in Discharge plans also should be developed in community care setting. This will remind the community care setting. This will remind the nurses and patient that the expected nurses and patient that the expected outcome of nursing care is independent outcome of nursing care is independent functioning. functioning.

The nurse and patient must decide together The nurse and patient must decide together on the desired level of functioning. If the on the desired level of functioning. If the patient is unwilling to take on activities that patient is unwilling to take on activities that the nurses thinks would be helpful. It is the nurses thinks would be helpful. It is important to determined why. Sometimes important to determined why. Sometimes nurses try to push a patient ahead too nurses try to push a patient ahead too rapidly. Behavior that has developed rapidly. Behavior that has developed gradually over time cannot be changed gradually over time cannot be changed quickly. Learning new behavior patterns and quickly. Learning new behavior patterns and giving up old ones are frightening and cause giving up old ones are frightening and cause anxiety. anxiety.

The nurse must be sure that the The nurse must be sure that the patients coping skills are adequate to patients coping skills are adequate to deal with the stress of growth. deal with the stress of growth. Feedback must be requested to be Feedback must be requested to be sure that the rehabilitation plan sure that the rehabilitation plan continues to address the patient’s continues to address the patient’s needs. Its is a problem if the plan needs. Its is a problem if the plan assumes greater important than the assumes greater important than the patient. The nurse must prevent this patient. The nurse must prevent this from happening. from happening.

Developing strengths and Developing strengths and potentialpotential

The development of the patient’s strengths and potential The development of the patient’s strengths and potential is critically important. Nursing interventions that develop is critically important. Nursing interventions that develop strengths and potentials can help patients develop strengths and potentials can help patients develop independent living skills, interpersonal relationships, and independent living skills, interpersonal relationships, and coping resources and thus help meet their special needs.coping resources and thus help meet their special needs.

Ultimately, the expected outcome of such intervention is Ultimately, the expected outcome of such intervention is change in the patient’s self-concept and an increase in change in the patient’s self-concept and an increase in self-esteem. The negative self-concept and low self- self-esteem. The negative self-concept and low self- esteem that characterize people who have serious esteem that characterize people who have serious mental illnesses interfere with their ability to see the mental illnesses interfere with their ability to see the themselves as individuals with strengths and potentials.themselves as individuals with strengths and potentials.

Learning living skillsLearning living skills Learning living skills. Social skills uses cognitive and Learning living skills. Social skills uses cognitive and

behavioral techniques to help people gain the behavioral techniques to help people gain the knowledge and skills they need to live in the knowledge and skills they need to live in the community.community.

Persons participating in social skills training should Persons participating in social skills training should be assisted to express their problems as positive be assisted to express their problems as positive goals. For example, instead o the negative “I’m tires goals. For example, instead o the negative “I’m tires of watching television al the time.” encourage-age of watching television al the time.” encourage-age the positive “I an going to see at least one friend the positive “I an going to see at least one friend every week” social skills training program typically every week” social skills training program typically use videos. Role playing, practice and homework use videos. Role playing, practice and homework assignments centered on practical problems.assignments centered on practical problems.

Another important aspect of Another important aspect of psychiatric rehabilitation and psychiatric rehabilitation and recovery relates to promoting the recovery relates to promoting the physical well-being of those with physical well-being of those with serious mental illness. problems serious mental illness. problems such as high tobacco use, low such as high tobacco use, low exercise level, poor oral health, exercise level, poor oral health, high-risk sexual behavior, and high-risk sexual behavior, and limited contact with physicians and limited contact with physicians and dentists ate common among people dentists ate common among people who have serious mental illnesses. who have serious mental illnesses.

illness managementillness management

. Illness management is an evidence-. Illness management is an evidence-based practice that focus on assisting based practice that focus on assisting the patient to assume control over the the patient to assume control over the illness and function at the highest illness and function at the highest possible level of independent .possible level of independent .

Four intervention that have been Four intervention that have been identified to support illness identified to support illness management in persons recovery from management in persons recovery from psychiatric illness are as follows : psychiatric illness are as follows :

11 - -psychoeducation:psychoeducation: an approach that an approach that support the rehabilitation process by support the rehabilitation process by teaching the patient and family about teaching the patient and family about the mental illness and the coping skills the mental illness and the coping skills that will help with successful community that will help with successful community living .(box 14-6)living .(box 14-6)

22 - -behavior tailoring for medication:behavior tailoring for medication: developing strategies with the patient developing strategies with the patient that integrate medication regimens into that integrate medication regimens into the persons daily routine and Simplifying the persons daily routine and Simplifying the medication schedulethe medication schedule . .

33 - -training in relapse prevention :training in relapse prevention : most people who have serious mental most people who have serious mental illnesses can learn to recognize signs illnesses can learn to recognize signs and symptoms of an approaching and symptoms of an approaching relapserelapse..

44 - -coping skill training :coping skill training : teaching the teaching the person techniques for coping with person techniques for coping with persistent symptoms of mental illness , persistent symptoms of mental illness , person who has auditory hallucination person who has auditory hallucination can be trained to listen to music use can be trained to listen to music use headphoneheadphone . .

Accessing environmental Accessing environmental supportsupport

support people who have mental illness support people who have mental illness in community setting requires the in community setting requires the development of a wide array of development of a wide array of community support programs. Some of community support programs. Some of these are rehabilitation center. Housing these are rehabilitation center. Housing services , employment opportunities , services , employment opportunities , education , crisis intervention and education , crisis intervention and

outreach and case managementoutreach and case management . .

Rehabilitation programsRehabilitation programs

psychiatric rehabilitation programs were psychiatric rehabilitation programs were developed in response to the plight of developed in response to the plight of people who had been discharged from people who had been discharged from state mental hospital lacking the skill and state mental hospital lacking the skill and resources needed to live independently resources needed to live independently several models are presented here as an several models are presented here as an over-view of some of the psychiatric over-view of some of the psychiatric rehabilitation approaches that have rehabilitation approaches that have

evidence supporting their effectivenessevidence supporting their effectiveness . .

Residential servicesResidential services

Housing is consistently identified as a critical Housing is consistently identified as a critical element of successful recovery and element of successful recovery and rehabilitation services .rehabilitation services .

Appropriate housing must be safe , Appropriate housing must be safe , affordable, and acceptable to the consumer affordable, and acceptable to the consumer early housing program tended to focus on early housing program tended to focus on existing supervised living situation , such as existing supervised living situation , such as foster care more recently , an array of foster care more recently , an array of housing option has been developed under the housing option has been developed under the leadership of consumer and psychiatric leadership of consumer and psychiatric rehabilitation professional . rehabilitation professional .

Employment servicesEmployment services

An extensive of the literature has identified a An extensive of the literature has identified a number of barriers to employment for person number of barriers to employment for person with psychiatric disabilities and recommended with psychiatric disabilities and recommended action that would help to overcome the barriers action that would help to overcome the barriers . These are summarized below. These are summarized below ::

Ongoing health insurance for medical Ongoing health insurance for medical care ,mental health care ,and medication care ,mental health care ,and medication regardless of employment status.regardless of employment status.Integration and coordination of clinical and Integration and coordination of clinical and vocational services . vocational services .

Access to educational program .Access to educational program . Benefits planning and assistance with Benefits planning and assistance with

financial management .financial management . Development of assets through special Development of assets through special

saving program for low-income saving program for low-income individuals.individuals.

Safe ,affordable , and stable housing Safe ,affordable , and stable housing that will not be jeopardized by a higher that will not be jeopardized by a higher income .income .

Peer support and self-help.Peer support and self-help.

EvaluationEvaluation

Evaluation of psychiatric rehabilitations Evaluation of psychiatric rehabilitations services usually covers the impact on the services usually covers the impact on the patient and family and the effectiveness of patient and family and the effectiveness of the community service system.the community service system.

Patient evaluation:Patient evaluation: Evaluation of the services provider to patient Evaluation of the services provider to patient

and family member must focus on the and family member must focus on the achievement of the expected outcome of achievement of the expected outcome of the intervention . Most psychiatric the intervention . Most psychiatric rehabilitation evaluation program rely on rehabilitation evaluation program rely on both objective and subjective measure of both objective and subjective measure of outcome. outcome.

Objective measures are general related to the Objective measures are general related to the following question following question ::

Is the person living in the housing of personal choice?Is the person living in the housing of personal choice? Have days of hospitalization in the last years Have days of hospitalization in the last years

decrease ? decrease ? How many emergency room visits has the person How many emergency room visits has the person

made?made? How often does the person have contact with family How often does the person have contact with family

members? Who are they?members? Who are they? Can the person identify people to provide support in Can the person identify people to provide support in

a crisis?a crisis? Is the person involved in a community activities ?Is the person involved in a community activities ? Is the person enrolled in an adult education course? Is the person enrolled in an adult education course?

In an academic education program ? In an academic education program ?

Program evaluationProgram evaluation Program evaluation is conducted to inform Program evaluation is conducted to inform administration about the relevance and cost-administration about the relevance and cost-effectiveness of the services they offer . It is effectiveness of the services they offer . It is often required by funding , regulatory, and often required by funding , regulatory, and licensure agencies to confirm that public licensure agencies to confirm that public mental health dollars are being spent wisely.mental health dollars are being spent wisely.

Outcome measurement is an approach to Outcome measurement is an approach to evaluation that provide information about the evaluation that provide information about the effectiveness of services to individuals with effectiveness of services to individuals with mental illness and can also be used to analyze mental illness and can also be used to analyze the impact of funding initiatives.the impact of funding initiatives.