When most people think of home healthcare, they think of wound care, educating patients and family on how to administer insulin, setting up total parental nutrition and educating the patient on a new pump, and of course, countless hours of charting. Less known is psychiatric nursing services, which was my specialty and expertise for years, before transitioning into academia and consulting. As a psychiatric home healthcare nurse, providing counseling, administering antipsychotic monthly injections, monitoring mood and ability of patients to care for self, educating families, and teaching administration and side effects of medications were some of my duties. Very quickly, however, I began to find myself in situations where patients were in crisis. Many were discharged home after only 3 days in a psychiatric inpatient setting and were still in extremely acute conditions. Collaborating with various psychiatrists, I learned about mental health petitions and before I knew it, was completing them quite often in the field.

Home healthcare nurses are often the first clinician to see a patient in crisis who needs intervention. In my experience as a psychiatric home healthcare nurse, I completed numerous petitions in the state of Illinois. I was either called by the family or had a scheduled visit that occurred when the patient was in crisis. Each state has variations in rules on mental health petitions and provisions. The document needs to be filled out with detailed attention to the patient's current behavior that suggests harm to self or others. Documentation includes both verbal comments made by the patient and observed behavior, and may also include a history of similar behavior and hospitalizations. Witnesses such as caregivers or family may be listed to support the documented unsafe behavior. It should be noted that harm to self may include inability to meet basic needs such as providing food, shelter, or medical care without intervention from caregivers. Family and caregivers can be very helpful in providing the nurse with statements and behaviors exhibited by the patient. If inadequate evidence is provided, the patient may not be admitted for treatment. I have had the experience of patients presenting in a certain way during my home visit, making threats to kill others or themselves, and by the time of arrival at the emergency department, they have changed their story. Solid documentation that describes the patient's recent behavior and verbal statements are necessary to prevent discharge from the emergency department.

By the time the petition has been completed by the home healthcare nurse, emergency services have been called and have arrived at the patient's home. The nurse then calls report to the emergency department and notifies the agency, psychiatrist, and other providers involved in the patient's care. A second petition is completed by the emergency department provider. Two certificates are completed, one by a provider or psychologist, and the second by a psychiatrist within 72 hours prior to admission. A patient can then be admitted to an inpatient psychiatric facility involuntary, if they refuse to be admitted under voluntary status. Due to privacy laws, the home healthcare nurse is no longer able to receive information and updates from the psychiatric inpatient unit at this point. The family or caregiver may update the nurse or home care agency however. Usually upon discharge, the hospital refers the patient back to the home healthcare nurse with discharge and follow-up instructions. It is always gratifying to see a patient who I have seen in crisis, return home in a more stable condition. After inpatient hospitalization and resumption of care, the patient is assessed for safety in the home environment and educated to move forward with stabilization. I witnessed many patients who were successful with the support of family, caregiver, and home healthcare.