Holistic Nurse Self-Care 3.1.4 specifies; Holistic Nurses consciously cultivate awareness and understanding about the deeper meaning, purpose, inner strengths, and connections with self, others, nature, and God/Life Force/Absolute/Transcendent (AHNA, 2000, pg. 64)

Sustaining a relationship with an individual with mental illness is burdensome. No individual, alone, has the emotional capacity to relate to the angst manifested by someone tormented with anxieties. The patient is unable to self regulate thus one s own individual professional nursing responsibility to care for such an unstable individual for a 24 hour, 7 days a week shift, is untenable. Responsibility must be shared, either within an institutional setting or adhering to an organized structured day program. Scrounging money from an ex-husband, the patient lived alone for years. The patient got through the day caring for her two cats and a dog.

When the patient s family moved the patient out of state; all pretenses the patient could live alone evaporated. Acting out another suicide attempt landed her back amidst her providers proscribing Electroconvulsive Therapy (ECT) since her prescribed Clonazepam™ (Klonopin™) dosage, already excessive, could no longer be increased. All other possible medication regimes had been exhausted. A last ditch effort by a friend provided the patient temporary housing during the course of the patient temporary housing during the course of the patient s latest round of therapies.

Implementation 5.5.2 specifies, Holistic Nurses support and promote the person s capacity for the highest level of participation and problem solving in the plan of care and collaborate with other health team members when appropriate (AHNA, 2000, p.155).

Many times we listen to our friends and families bemoaning their kindred s tragic life trajectories. It is more than any one individual can handle alone. Are there alternatives? Life skills, habilitation and activities of daily living are compromised when individuals age,are developmentally disabled, mentally ill or have been institutionalized for considerable lengths of time.

Our society is complex, cherishing self-sufficiency and self-reliance. Not all individuals have the capability to achieve self-mastery thus attaining our cultures multifarious standards.

Many times we listen to our friends and families bemoaning their kindred s tragic life trajectories. It is more than any one individual can handle alone. Are there alternatives? Life skills, habilitation and activities of daily living are compromised when individuals age,are developmentally disabled, mentally ill or have been institutionalized for considerable lengths of time.

Our society is complex, cherishing self-sufficiency and self-reliance. Not all individuals have he capability to achieve self-mastery thus attaining our cultures multifarious standards. De-institutionalizing or delivering at-risk patients to board and care homes has been tried and failed. With resources scarce, public programs eliminated and community programs minimally staffed, a variety of options are now considered. The concept of Intensive Case Management (ICM) emerged as an option. In the literature, functions of ICM include models sharing five attributes:

1. Low client/staff ration

2. In-vivo site for treatment

3. Frequent and intense contact to forge regular and strong ties with clients

4. Open ended lengths of service(Schaedle, 1999)

The purpose of Intensive Case Management (ICM) is to allow diagnosed mentally ill patients sustain themselves in the community. This means the patient cooperates with the ICM professional nurse case manager as medical and psychiatric services are arranged. The patient participates and follows through by keeping appointments and taking prescribed medications. Patients require multiple services since their mental illness renders them disabled, unable to function. Those who are mentally ill are unable to remain employed, ending up homeless. Required services include job seeking and training, appropriate housing, transportation, childcare and access to food and clothing.

When the family recognizes their inability to assist their mentally ill family member in any way, they seek understanding. Educating the family about mental health and symptoms of the mentally ill, the case manager assures the family s continued involvement. The family functions for the patient as an essential support group. Chronic mentally ill patients lose their family s involvement as their symptoms progress. The case manager continually assesses the patient determining the multiple factors inhibiting their ability to initiate activities and achieve desired recovery. For example, attending regular Alcoholics Anonymous (AA) meetings assist recovery if a patient s symptom, addiction, is preventing recovery. Patients have personal goals related to vocation options and their future prospects. Eliciting patient goals and personal expectations requires skilled case management by the ICM professional nurse case manager.

Holistic Nursing Core Value 2: Holistic Ethics; specifies under Standard of Practice 2.1; Holistic nurses hold to a professional ethic of caring and healing that seeks to preserve wholeness and dignity of self, students, colleagues, and the person who is receiving care in all practice settings, be it in health promotion, birthing centers, acute or chronic care facilities, end-of-life centers or homes (AHNA, 200, p.23).

Professional nursing case managers provide intensive Case Management (ICM). As needed services are identified, holistic nursing modalities are constantly updated, services documented, delivered and tracked. Academia assesses and evaluates innovative interventions determining whether newer strategies achieve ICM s primary purpose: i.e., aiding the patient to sustain participation as a constructive member of the community 14.

The purpose of Intensive Case Management (ICM) is to allow diagnosed mentally ill patients sustain themselves in the community. This means the patient cooperates with the ICM professional nurse case manager as medical and psychiatric services are arranged. The patient participates and follows through by keeping appointments and taking prescribed medications. Patients require multiple services since their mental illness renders them disabled, unable to function. Those who are mentally ill are unable to remain employed and end up homeless. Services required include job seeking and training, appropriate housing, transportation, childcare and access to food and clothing. When the family recognizes their inability to assist their mentally ill family member in any way, they seek understanding. Educating the family about mental health and symptoms of the mentally ill, the case manager assures the family s continued involvement. The family functions for the patient as an essential support group. Chronic mentally ill patients lose their family s involvement as their symptoms progress. The case manager continually assesses the patient determining the multiple factors inhibiting their ability to initiate activities and achieve desired recovery. For example, attending regular Alcoholics Anonymous (AA) meetings assists recovery if a patient s symptom, addiction, prevents recovery. Patients have personal goals related to vocational options. Eliciting patient goals and personal expectations requires skilled case management by the ICM professional nurse case manager.

When the family recognizes their inability to assist their mentally ill family member in any way, they seek understanding. Educating the family about mental health and symptoms of the mentally ill, the case manager assures the family s continued involvement. The family functions for the patient as an essential support group. Chronic mentally ill patients lose their family s involvement as their symptoms progress. The case manager continually assesses the patient to determine factors inhibiting their ability to initiate activities and achieve desired recovery. For example, attending regular Alcoholics Anonymous (AA) meetings assists recovery if a patient s symptom, addiction, is preventing recovery. Patients have personal goals related to vocational options. Eliciting patient goals and personal expectations requires the skill of an experienced case manager.

Further delineating the professional nurse s interaction with the patient is necessary to clarify the scope of skills used to coach each patient and nudge them along the therapeutic path. Within the trust relationship, the professional engages the patient according to patient s behavioral or clinical behavior. The professional s skill set provides ongoing patient assessment to determine the quality of needed therapeutic exchanges. Questioning the patient s perception of reality is often required. The professional interaction is fluid, blending therapeutic exchanges with coaching strategies yet never verging on manipulative or fraudulent scheming.

Intensive Case Management (ICM) is further defined as the development of essential caring relationship between a professionally licensed nursing case manager and the patient. A trusting and dynamic relationship, when established, yields the patient s hidden incongruities. As assessed needs become apparent, the ICM professional nurse case manager intervenes, using appropriate holistic nursing modalities on the patient s behalf, in a supportive and protective manner across a variety of service systems. Holistic nursing modalities as well as ICM professional nursing interventions facilitates the patient s ability to utilize and gain access to comprehensive and coordinated services comprising of crisis intervention, psychiatric and health care services including:

1. Public Assistance, Food Stamp eligibility

2. Medical Care

3. Alcohol and Drug Treatment

4. Family Education

5. Education and Job Training

6. Housing and Transportation

Early intervention in crisis situations diverts the patient from unnecessary, traumatic, in-patient hospitalization. Cases followed by Intensive Case Management (ICM) professional nurse case managers are usually limited to case loads of ten individuals. The expected length of time assigned to intensively case manage a patient is two years.

Families have a difficult time accessing services on their own behalf. Only when an individual becomes known to the system, either by emergency room admission with mandated discharged planning or arrested then jailed and appearing in judicial settings, do Intensive Case Management (ICM) professional nursing services become available for the patient and their families15.

All the above options assume the Intensive Case Management (ICM) professional nurse is an employee functioning under the authority established by federal and state law and licensing regulations and abiding by the local organization or agencies program s professional protocols.

May a licensed, accredited, credentialed and educated Nurse Consultant, building an Intensive Case Management (ICM) professional nursing services practice, function as a Registered Nurse Contractor and establish one s self independently?