A COLLABORATIVE PRACTICE MODEL FOR TREATMENT OF BIPOLAR DISORDER

Chart, Jul/Aug 2004 by Foley, Kathleen R

In 1998 I began treating Bipolar Patients in a Nurse- Accessed Clinic with a collaborating psychiatrist. Bipolar Disorder is a serious mental illness that is chronic and debilitating, resulting in a high incidence of relapse and frequent inpatient hospitalizations. Care of these patients has placed a significant financial burden on society. The aim of this Clinic is to provide improved access to care, psychoeducation, and illness management training for Bipolar Patients. The ultimate goal is to reduce inpatient hospitalizations and the overall cost of care.

The Collaborative Practice Model is an organization of care that emphasizes the development of disease management skills in the Bipolar Patient. Its overall goal is to improve joint decision-making between the provider and the patient (Bauer, 2001). In the NurseAccessed Clinic, this treatment model encompasses a collaborative practice relationship between a clinical nurse specialist (CNS), a Bipolar Patient, and a psychiatrist. The CNS and the psychiatrist evaluate new patients as a team. They collaborate on the diagnoses, the treatment plan, and prescribe appropriate medications. Once patients are stabilized on an effective course of treatment, they are scheduled for follow-up treatment visits with the CNS in the NurseAccessed Clinic.

The CNS's role in the clinic is to evaluate the patient's symptoms, adverse events, and response to treatment. Various symptoms scales including the Young Mania Rating

Scale and the Beck Depression Scale assist the CNS to identify behavioral change. To facilitate improved access to care, patient's telephone calls are answered on the same day. Walk-in visits are encouraged to adjust treatment and reduce the risk of relapse. Team meetings are held weekly to review all patients treated in the past week. If serious symptoms arise or new treatments are indicated, the patient is evaluated by the team.

Patients with a chronic illness, such as Bipolar Disorder, can become better illness managers if they are well educated about their disease and are encouraged to participate in the decision-making process. At each clinic visit, the CNS educates patients about their illness and their treatment. In addition, the CNS conducts a series of group classes to assist patients to identify their personal symptom profile, common life Stressors, and their potential relapse patterns. Patients are taught to perform a Risk Benefit Analysis in order to make better behavioral choices in their daily life (Bauer, 2003). The Collaborative Practice Model offers the CNS a unique opportunity to provide treatment independently for routine patient care. In the event the patient becomes seriously ill or needs hospitalization, the psychiatrist is available for consultation.

About 70 patients with bipolar disorder have been treated in the Nurse-Accessed Clinic over the past six years. At least 80 % of these Bipolar Patients have not experienced an acute exacerbation of their illness. Many patients have been able to return to work or to continue their education. They enjoy a much improved quality of life. When patients have experienced increased stress they have been able to recognize their symptoms triggers and have sought treatment in a timely manner.

Substance dependence is the most debilitating co-morbid disease experienced by bipolar patients. Most patients who relapse, have been actively dependent on alcohol and /or illicit drugs. Many patients do not recognize the chronicity of their illness and have been non-compliant with their medications. It is the continued goal of this Nurse-Accessed Bipolar Clinic to provide timely medical interventions and education, in a collaborative practice framework that facilitates the Bipolar Patients active participation in managing their illness.

References:

Bauer, M. S.(2003) The collaborative practice model for bipolar disorder. Design and implementation in a multi-site randomized controlled trial. Bipolar Disorders, 233-244.

Bauer, M. S. Structured group psychotherapy for bipolar disorder, the life goals program, 2nd ed, 115-132, New York: Springer, 2003.

Kathleen R. Foley, MS, APRN, BC