Delaware Technical Community College

NUR 330 Population and Community Health

Population/Community Health Promotion Project
STUDENT NAME: Melissa Towe
DATE: 11/9/18
SETTING: Meadowwood Behavioral Health
ASSESSMENT
Answer the following questions:
1. Gather data on your specific site location: Meadowwood Behavioral Health

a. Population/community- The population served here consists mostly of patients with mental health illnesses and

substance abuse disorders.

b. Cultures/Ethnicities Served- A wide variety of cultures and ethnicities are served as mental health knows no

boundaries. We have had patients from the middle east backgrounds, we have several Muslim patients, as well as

Spanish, Chinese, African Americans and Caucasian Americans. This is definitely a population where we see ‘a little

bit of everything.’

c. Languages- Most commonly, English is the spoken and written language. However, Spanish and occasionally Chinese

patients are brought to the facility and interpreters are provided for their length of stay. We also take hearing and

impaired members so sign language interpreters are offered as well.

d. Age Range-he age range of this population starts as early as diagnoses begin (typically not before age three), and
 extends throughout life, including the geriatric population as well. Meadowwood specifically accepts patients from age

12 and up. The adolescent unit services those 12-17 and all other units services those 18 years and older. We have a

geriatric unit for the elderly patients and patients who are not independent with ADLs. We also off a partial program

that is intensive outpatient therapy for patients who do not meet criteria for an inpatient admission

2. Use the Windshield survey on p. 87 & 88 of your textbook to identify community resources and barriers to healthcare

for this population/community.

Are there obvious health-related problems? Yes, for substance abusers this may include transmissible diseases most

commonly: HIV/Aids, Hepatitis C, and sexually transmitted diseases. There are also skin integrity risks such as abscess and

cellulitis from intravenous drug use. For the mental illness portion of this population, noncompliance with treatment, and

especially medications, is a common factor that contributes to the exacerbation of both mental and physical health problems.

What is the perspective of the media in relation to the community? This population is often a focus of the media… between

depression & silent mental illness awareness, stigmas, and of course the opioid epidemic this population frequently the news. At times

the media perspective is supportive and sympathetic, but it can also be very scrutinizing of drug addicts and homeless populations.

What does the community look like? This community has a high risk of homelessness. That doesn’t necessarily mean every

homeless person has a mental illness, but the chances are greater. Unfortunately, that means this population is sometimes viewed with

scrutiny and labeled as unkempt, dirty, and lazy. This community is also largely made up of individuals with substance abuse
problems. At times this population is quickly blamed for crimes/violence, and many may indeed have a background with the criminal

justice department.

Community Resources and Barriers to healthcare for this population: Community Resources discussed in detail below.

As for barriers, access to healthcare is huge for this population. Access to health care can be a barrier due to insurance status,

transportation, or even inability to miss work. Most commonly, transportation causes the largest barrier. Patients who are homeless

struggle with transportation to and from appointments, or are unable to get to the pharmacy to pick up their medications. Lack of funds

is commonly a barrier for this population, for when they can get to their appointments or to the pharmacy, they lack the money to

cover their copays.

3. What healthcare policies apply to your population/community?

The Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008 (finalized in 2013) is one of the most important

healthcare policies that applies to this population (Centers for Medicare & Medicaid Services [CMS], n.d.). The MHPAEA basically

made it so that insurance companies had to provide mental health benefits that matched the medical benefits they currently offered,

meaning they could not impose higher copays or increased limitations on mental health benefits (CMS, n.d.). The only place that this

policy fell short is that it did not require insurance companies to offer mental health/substance use benefits at all. It simply stated that

if they offered mental health/substance use benefits, then those benefits could not be more restrictive than those of medical plan

offered (CMS, n.d.). Specifically: if a plan offered out of network benefits for medical coverage, they also had to offer them for

mental health coverage, copays, days covered, and limitations all had to be consistent between medical and mental health coverage
plans (CMS, n.d.). This policy prevented insurance providers from setting less favorable limits on their mental health/substance use

benefits, which allowed for patients with mental health problems to receive fair coverage and improved their access to adequate

treatment.

4. Identify data and statistics and any historical perspective related to this population/community or problem.

In 2014, in the United States alone, 43.6 million people suffered from some form of mental illness (Center for

Behavioral Health Statistics and Quality [CBHSQ], 2015). Unfortunately, most mental illnesses are hard to physically see, and the

signs and symptoms that tend to manifest often yield stigma instead of support from the rest of the community. Stigma however, is not

a new concept for the mental health population, in fact stigma in this era does not hold a candle to some of the treatment mental health

patients received in historic asylums and institutions.

Presently however, the statistics that speak the loudest for this population relate to substance abuse. The opioid epidemic is the

deadliest drug crisis in America’s history, claiming 33,000 lives in just 2015 (Lopez, 2017). The role of prescription painkillers is

important in trying to solve the opioid crisis. Patients are continuously prescribed opioid analgesics despite their limited success in

treating chronic pain conditions (Lopez, 2017). One thing these prescription medications are known for is their addictive properties;

patients who become addicted to their opioid prescriptions are “40 times more likely to be addicted to heroin” (Lopez, 2017, para. 25).

It is no secret that the United States currently has a severe problem with opiates, both in the form of prescription pills and in the form

of heroin. However, this is not the only substance that is being abused in great proportions of the population. In 2014, 21.5 million

Americans had a substance use disorder (SUD), of them: 16.3 million were due to alcohol, 4.3 million were due to abuse of prescribed
analgesics, and 435,000 were related to heroin (CBHSQ, 2015). A patient with a substance use disorder is more likely to also suffer

from some type of mental health illness (Substance Abuse and Mental Health Services Administrations [SAMHSA], 2016).

When both a substance use disorder and a mental health diagnosis coexist in the same patient, it is termed a co-occurring

disorder or a comorbidity (SAMHSA, 2016). Co-occurring disorders affected 7.9 million adults in 2014, becoming quite a contributor

to the burden of disease in the United States (CBHSQ, 2015). Co-occurring disorders lead to missed days at work, increasing inpatient

hospital stays, limited productivity, and can even contribute to crime and safety issues (CBHSQ, 2015). Unfortunately, co-occurring

disorders often go undiagnosed and/or undertreated, many times only one condition is treated and the other is deferred or ignored

completely (SAMHSA, 2016). Furthermore, “undertreated co-occurring disorders can lead to a higher likelihood of experiencing

homelessness, incarceration, medical illnesses, suicide, or even early death” (SAMHSA, 2016, para. 3).

5. What is the role of the nurse at this site?

The role of the nurse in the mental health population is vast. I have worked in this field for nearly five years and have met

nurses who specialized specifically in the care of the homeless community, nurses who focus on health education and infection control

out in the community, and nurses like myself who work on the in-patient side. My practicum for this course gave me the opportunity

to shadow the admissions department and observe the role of the nurse in that department. The admissions department differs from the

in-patient side in several ways. Most notably, the admissions nurse is on the front line, they must make the determination of which

patients receive an in-patient level of care and which patients are referred to outpatient care or community resources. I was able to see

first-hand that this decision is not always black and white, and most certainly not always easy to make. At times, patients that require
in-patient treatment may not be agreeable to it. When this occurs, the admissions nurse must advocate for their patient and do what is

necessary to ensure their safety. Admissions nurses faced with this scenario must call physicians for a backup opinion, which often

results in the initiation of an involuntary commitment (admitting the patient to an in-patient setting against their will). While this

aspect of advocacy tends to be the most commonly observed, it is not the only way that the nurses advocate for their patients. My

preceptor identified several interesting examples of advocacy that he says occur regularly: meeting the religious needs of Muslims by

providing places for them to pray throughout the day and meeting their dietary needs/restrictions, allowing patients constant access to

their religious personnel for their spiritual needs, and ensuring the appropriate translator for patients who have a language barrier (M.

Kolodgie, personal communication, October 9, 2018). I personally feel that advocacy is one of the most important roles that we as

nurses can fulfill. Advocacy as the responsibility of the nurse is to “act as spokespeople for those who have no voice or are unable to

address their own health-care concerns” (Savage, Kub, & Groves, 2016, p. 21). The mental health population is a particularly

vulnerable population that requires an especially high level of advocacy to ensure their safety and to ensure that they truly receive the

appropriate care.

The admissions nurse also plays an important role in infection control and health promotion which includes “strategies to

promote health, prevent disease, and ensure a safe environment” (Savage et al., 2016, p. 21). In my opinion, our admissions nurses do

an above average job with this. My preceptor showed me all of the screeners that patient’s must answer before being admitted to a

unit. These assessments screen for flu symptoms… and offer a flu vaccination during admission if the patient consents (M. Kolodgie,

personal communication, October 9, 2018). They also must complete a tuberculosis questionnaire which can result in a skin test if a
patient has not recently had one, or a STAT chest x-ray for any patients who have previously had a positive result (M. Kolodgie,

personal communication, October 9, 2018). The mental health population tends to have a higher risk for TB as many subpopulations

of this community live in areas where TB flourished (overcrowded, unsanitary conditions such as homeless shelters and jails). The

fact that the admissions nurses take this so seriously and diligently screen each patient is critical in protecting both staff and other

patients.

6. What disease management and preventative measures are being used?

The diseases that are most commonly seen with this population are communicable diseases. The substance abuse population,

specifically IV drug users, are at high risk of contracting blood-borne or sexually transmitted diseases such as: HIV/AIDS, Hepatitis

B, and Hepatitis C, (Badiaga, Raoult, & Brouqui, 2008). Substance abusers make up a large portion of the mental health community,

and thus contribute to a large portion of the spread of diseases through sharing needles and risky sexual behaviors (Badiaga et al.,

2008). Homelessness also plays an important role in the spread of diseases, as an estimated 100 million people experience some

degree of homelessness worldwide (Badiaga et al., 2008). Of them, nearly 35% are living with HIV, 30% with hepatitis B, 30% with

hepatitis C, 6.8% with tuberculosis, and 56% with scabies (Badiaga et al., 2008). Unfortunately, the actual numbers are likely much

higher, as the homeless population can be very difficult to consistently track. The screenings done by the admissions department

contribute to preventative measures as does offering flu shots. Unit nurses do thorough skin assessments upon admissions to look for

rashes that may be consistent with scabies or bed bugs. There are protocols in place for isolating these patients until they are treated

effectively to minimize the risk of contaminating the unit and transmitting things to other patients. Meadowwood also offers STD
testing, and blood work can be drawn for Hepatitis and HIV if the patient requests.

7. What is the predominate health insurance status of this population/community?

Simply from an observation standpoint, this population tends to have a wide variation in health insurance status. In some

scenarios; we see patients with great insurance, we also see patients who have no insurance at all. Many admissions that we accept are

considered “State” paid, as we cannot turn away a suicidal patient due to lack of health insurance. Unfortunately, this can lead to

abuse of the system as patients who are homeless sometimes say that they are suicidal just to utilize the facility as shelter. This tends

to happen most often in the winter time, and while it is certainly understandable, it is still viewed as misuse of the system’s benefits.

Another trend I have observed from the years of working in mental health is that a large portion of our population also tends to be

insured by Medicaid. The insurance status truly varies, but when you examine the reasons behind that, it is easy to understand why.

Mental health conditions effect everyone, they are nondiscriminatory, meaning that a wealthy CEO may need treatment for depression

just as frequently as a chronically homeless man. With such variations in the classes of people within this population, it makes sense

as to why the insurance status varies so dramatically.

8. Identify your priorities of care for this population/community.

The top priority of care for this population is safety. Many patients come in suicidal and the most immediate goal is to ensure

their safety and engage them in treatment groups that target their conditions or their triggers. Substance abuse is also a priority. A

patient cannot properly care for their mental health while battling active addiction. Substance abuse treatment needs to coincide with

behavioral health treatment as these patients often have both conditions (co-occurring/comorbid disorders). Mental health treatment
needs to address both substance abuse and mental health at the same time in order to optimize patient outcomes. Another priority of

care should be housing stability; this area is truly difficult to target. There are certainly some resources available but the demand far

outweighs the supply.

ANALYSIS

Respond to the following:

Review Data: Review all of the data collected from your population, looking for needs/problems, including background,

population/community information and epidemiologic concerns. Identify at least three problems/needs.

After reviewing all of my data, and while focusing on available resources, and reasonable/realistic outcomes; I was able to

choose three problems/needs:

1. Problem: Mental illnesses often goes undiagnosed or under treated. Need: Improved detection of mental illnesses.

2. Problem: High rate of substance use disorders/co-occurring disorders. Need: Dual-diagnosis focused treatment.

3. Problem: Rising rates of communicable diseases in this population. Need: Better education/screening/treatment.

Identify Disparities and/or Barriers: What disparities and/or barriers have you identified within the population/community?

Develop specific recommendations to address these disparities and/or barriers.

 My practicum experience opened my eyes to several barriers that this population faces. In regards to the homeless portion of

the population: lack of shelter and transportation are the biggest barriers. These patients may desire treatment but have limited access

to it. Barriers in access to treatment can include: inability to get to their appointments and lack of funds to pay for their copays, both of

which contribute to noncompliance and poor health outcomes for these patients. Medicaid is taking strides in intervening in this

problem for their members with Logisticare services. Logisticare is a service that is free to Medicaid members and will provide them

with transportation to and from their medical appointments. Medicaid pharmacies will also waive medication copays if the patient is

unable to pay for their prescriptions. This sounds like a good solution and it certainly benefits the patient, but it is an unrealistic

solution for the populations that do not have Medicaid.

In regards to the substance abuse portion of this population, barriers also include lack of dual-diagnosis treatment options.

Dual-diagnosis treatment refers to treatment of both co-occurring disorders: the substance abuse aspect and the mental illness aspect.

Unfortunately, multiple facilities in Delaware that offer detox for substance abusers do not offer mental illness treatment. Some even

prohibit the patients from continuing their prescribed psych medications while they are there. Furthermore, many rehabilitation centers

do not accept members that are on methadone or suboxone maintenance. In my opinion this is a huge disservice to the patients, and a

barrier to them achieving appropriate care. Discussed below are goals/interventions related to improving the treatment of co-occurring

disorders.
Develop SMART Goals: (SMART = Specific, Measurable, Achievable, Realistic & Timely) What are the optimal SMART

goals to address each of these needs/problems? Develop appropriate goals for your population/community. Your goals should

be reflective of the resources available to the population/community.

1. Problem: Mental illnesses often goes undiagnosed or under treated. Need: Improved detection of mental illnesses.

GOAL: Promote mental health awareness by implementing brief mental health screeners in all practices/specialties by the end of

2019. While this goal may not be realistic for one person to achieve, it is already being implemented in some practices. The National

Alliance on Mental Illness (NAMI) endorses mental health screenings and recommends practices begin screening even pediatric

patients (2017). If all health care specialties and practices were required to add just 2-3 questions to their standard patient

assessments/screeners that assessed general mental health status, imagine the impact and the outreach that it might have. Patients

could be suffering from mental health illness and not know where to turn to. Even if only primary care doctors added these types of

questions to their basic/standard assessments, additional patients with concerning symptoms would be identified and thus able to be

referred for further assessment and care.

2. Problem: High rate of substance use disorders/co-occurring disorders. Need: Dual-diagnosis focused treatment.

GOAL: Promote awareness of comorbid conditions beginning by implementing groups that are focused on dual diagnoses:

addressing both substance abuse and mental health treatment, while patients are in an in-patient setting by the end of 2018.

Implementing dual diagnosis focused groups is something that is achievable for me personally. While I would like to see it occur on a
larger scale, across the entire facility, and ideally across all treatment centers nationwide, it is something that just one person can make

an impact on. At Meadowwood, our patients spend the majority of their day in group therapy. If these groups varied in topics between

substance abuse, sobriety, depression management, coping skills, medication education, and treatment compliance… patients who

suffer from co-occurring disorders would benefit more from the time that they spend in treatment.

3. Problem: Rising rates of communicable diseases in this population. Need: Better education/screening/treatment.

GOAL: Promote health and wellness by immediately improving patient access to education on communicable diseases such as

Hepatitis C, HIV, and STDs. This is another goal that can be easily implemented. Health information can be printed freely from the

internet anytime. These paper educational materials (pamphlets/posters) need to be placed in assessment rooms for patients to view.

Admissions nurses and unit nurses should also incorporate education on offering lab testing during in patient stays and referring

patients to infectious disease doctors upon discharge if they test positive.

Identify Available Resources: What resources are available that will assist the population/community with meeting these

goals? What agencies or individuals are available in the nearby community that can serve as a referral/resource for the

population? Examine what is available and accessible to the population as a resource to help address the identified problem.

Please provide the agency/ individual, address, contact information, as well as a rationale supporting the use of this agency.

How will the patient benefit from this community referral, specifically?
NAMI: National Alliance on Mental Illness

Address: 2400 W 4th Street, Wilmington, DE 19805

Phone: 302-427-0787

NAMI is a resource that offers family education classes, food/clothing closets, housing resources and opportunities for patients with

mental illnesses and substance abuse, and a helpline for patients experiencing a crisis (800-950-NAMI) that is 24/7 (NAMI, 2017).

MCIS: Mobile Crisis Intervention Services

Address: Fernhook Building at 14 Central Ave, New Castle, DE 19720

Northern Delaware Hotline: 800-652-2929

Southern Delaware Hotline:800-345-6785

Mobile crisis is a 24/7 hotline that will assist patients in crisis via the phone or by visiting the person face to face. Their goal is to

prevent in-patient hospitalizations by assessing the member in the community and referring them to the most appropriate level of

resources (Delaware Health and Social Services [DHSS], 2018).

BCCS: Brandywine Counseling and Community Services (Specifically the Drop In Center)

Address: 2713 Lancaster Avenue, Wilmington, DE 19805 (Rear Entrance)

Phone: 302-656-2348

BCCS offers a multitude of services: substance abuse counseling, mental health counseling, support groups, and specifically: the Drop

In Center. The Drop in Center is open Monday through Friday from 7am-12pm. It was designed to assist Wilmington’s homeless

population. They have 2 full bathrooms with showers, a computer, a clothing closet, an emergency food bank, complementary coffee,

infectious disease screenings (HIV/Hepatitis C) and pregnancy testing. This is an excellent resource as all “in need” guests are

welcomed to take advantage of the vast benefits that they offer (Brandywine Counseling & Community Center [BCCS], 2018).

Develop Interventions:

With the goals in mind, develop population/community-specific interventions and rationale to assist with goal achievement.

Plan interventions (include population/community resources) for each of your identified needs/problems. All references must

be properly cited using APA formatting.

GOAL: Promote mental health awareness by implementing brief mental health screeners in all practices/specialties by the end of

2019.

Interventions:
Begin to raise awareness to mental health signs and symptoms by displaying and distributing educational posters/pamphlets

when appropriate.

Utilize support of NAMI to educate providers/practices of importance of mental health screening (NAMI,2017).

Encourage providers to add 2-3 basic mental health screening questions to their standard assessments.

GOAL: Promote awareness of comorbid conditions beginning by implementing groups that are focused on dual diagnoses: addressing

both substance abuse and mental health treatment, while patients are in an in-patient setting by the end of 2018.

Interventions:

Advocate for the need for dual-diagnosis focused groups with administration/staff.

Implement expanded group topics while teaching groups (including education for patients on topics that vary between:

depression, anxiety, coping skills, substance use, sobriety, medication education/compliance, after care and more).

Educate patients on utilizing Brandywine Counseling Services for continued mental health and substance abuse resources

upon discharge (BCCS, 2018).

GOAL: Promote health and wellness by immediately improving patient access to education on communicable diseases such as

Hepatitis C, HIV, and STDs

Utilize free resources to print educational material on infectious diseases.

Provide educational materials in assessment rooms for patients to view.

Have admissions nurses and unit nurses educate patients on available laboratory testing for infectious disease during their in-

patient stay.

Have unit nurses follow-up with patient to discuss results and refer patient to an infectious disease provider prior to discharge

if they test positive.

Educate patients on utilizing Drop in Center for infectious disease clinic/testing (BCCS, 2018).

Develop Evaluation Plan: Identify a method or mechanism for future evaluation of proposed interventions.

To assess the implementation of adding mental health screening questions to all practices/specialties will be difficult. It will be

easier to track once the government takes further investment in ensuring that it is a requirement. At that time, the amount of mental

health referrals made from these screeners will be able to be tracked and the number of patients that have been directed towards the

care that they need will be present.

 Assessing the implementation of groups that address co-occurring disorders will not be difficult. Presently at Meadowwood,

we perform monthly audits that detail all groups that are run throughout the day. Going forward with dual-diagnosis group topics will

be easily reflected in this audit. The topics of the groups are listed in the audit, so it will be easy to see the change from all substance

related groups to a mix mental illness education, coping skills, medication compliance, etc.

Assessing the implementation of a new infectious disease protocol will also be simple to observe. Currently, Labcorp runs all

of our lab testing, and they generate a monthly report of infectious disease results, critical results, and STAT results. Each month, the

nursing supervisor reviews the reports and matches them up to each unit’s infection control book. On each unit, there is a binder for

infectious disease occurrences. Every patient that either comes in with a history of, or receives a new diagnosis of an infectious

disease, is documented in the book. Also in the book, is any follow up made for the patient in regards to the infectious disease.

Currently, the book majorly lacks follow up appointments. If nurses followed the above interventions and had to make follow up

appointments for patients with positive results prior to discharge, it would be reflected in the unit’s infection control book.
 References

Badiaga, S., Raoult, D., & Brouqui, P. (2008). Preventing and controlling emerging and reemerging transmissible diseases in the

homeless. Emerging Infectious Diseases, 14(9), 1353-1359.https://dx.doi.org/10.3201/eid1409.080204.

Brandywine Counseling and Community Services. (2018). Drop in center. Retrieved from https://www.brandywinecounseling.com

/drop-in-center/

Center for Behavioral Health Statistics and Quality. (2015). Behavioral health trends in the United States: Results from the 2014

National Survey on Drug Use and Health (HHS Publication No. SMA 15-4927, NSDUH Series H-50). Retrieved from

https://www. samhsa.gov/data/sites/default/files/NSDUH-FRR1-2014/NSDUH-FRR1-2014.pdf

Centers for Medicare & Medicaid Services. (n.d). The center for consumer information & insurance oversight: The mental health

parity and addiction equity act. Retrieved from https://www.cms.gov/cciio/programs-and-initiatives/other-insurance-

protections/mhpaea_factsheet.html

Delaware Health and Social Services. (2018) Crisis intervention. Retrieved from https://www.dhss.delaware.gov/dsamh/crisis

_intervention.html

Lopez, G. (2017). The opioid epidemic may be even deadlier than we think. Retrieved from https://www.vox.com/science-and

health/2017/4/2 6/15425972/opioid-epidemic-overdose-deadlier-study
National Alliance on Mental Illness, (2017) Donor impact report. Retrieved from https://www.namidelaware.org/annualreport

Savage, C. L., Kub, J. E., & Groves, S. L. (2016). Public health science and nursing practice:Caring for populations. Philadelphia,

PA: F.A. Davis. ISBN-13: 978-0-8036-2199-2

Substance Abuse and Mental Health Services Administrations. (2016). Co-occurring disorders. Retrieved from

https://www.samhsa.gov/disorders/co-occurring