whole life whole system in mh, the trieste experience roberto mezzina director who cc, mhdept...
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Whole life whole system in mh, the trieste experience
Roberto MezzinaDirector WHO CC, MHDept
Trieste
European policy documents EU Union Green paper (2006) on social inclusion European Pact for MH and Wellbeing, 2008• Combating stigma and social exclusion• Develop mental health services which are well integrated in the society, put the individual
at the centre and operate in a way which avoids stigmatisation and exclusionWHO, 2009• Psychiatric hospitals (PHs) have a history of serious human rights violations, poor clinical
outcomes, and inadequate rehabilitation programmes. They also are costly and consume a disproportionate proportion of mental health expenditures.
• WHO recommends that psychiatric hospitals be closed and replaced by services in general hospitals, community mental health services, and services integrated into primary health care
WHO Zero draft – Global Action Plan. • Reduction of 20% of long term beds within 2020. • MH laws updated within 2016 in 80% of countries. • All large institutions with neglect must be closed.
Italy
• 100.000 inpatients in 1971 in PHs• 48.000 inpatients in 1978• All PHs closed in 20001978 reform law:-no Phs admission, no new PHs-community based care-human rights focus / involuntary treatment duration
reduced (1 week +) – 2 pych. to mayor-No police / justice involved – just health protection
Mental Health Departments
• They are rooted in areas of about 300.000 inhabitants and encompasses a number of components:
• -Small general hospital acute units (15 beds), 1/10.000• -Community Mental Health Centers (up to 12hr,
sometimes 24hr) 1/80.000• -Group-homes 2/10.000 with a wide range of support
up to 24hr (17.000 beds in Italy, mostly NGOs)• -Day Centre (also with NGOs)
Changing public attitude and family burden
• Social acceptance of the law and a general decrease of stigma attached to psychiatry mark a series of fundamental changes in public attitu des (DEMOskopea).
• Cross-cultural researches demostrate this change in comparsion with other countries (Vicente et al 1995; Roelandt et al, 2007).
• Other transnational researches demostrated less family burden in the new community scenario (Fadden et al, 2002).
• It is generally accepted that the Mental Hospitals belongs to the past and cannot be accepted any more. Carers associations as UNASAM, as well as professional ones (e.g. the Society of Italian Psychiatrists), for many years claim for better community services rather than for a new law.
Deinstitutionalization vs. dehospitalization
‘Dehospitalisation’ is a reduction of the number of beds, while ‘deinstitutionalisation’ in Italy was a complex process resulting in:
• a gradual relocation of the economic and human resources from a profoundly modified MH (open wards, open to community) and the subsequent creation of CMH Services; then closing PHs.
• a profound change in the living conditions of the former in-patients, giving them a chance of being placed in alternative accommodations, possibly outside the MH.
Deinstitutionalization, another way
• a critical attitude towards the hierarchical social organisation as an oppressive system even for the staff, which is being replaced by a more flexible organisation.
• a transfer to the nursing staff of increased autonomy related to their increased abilities and new skills.
• a critical attitude towards the traditional psychiatric treatment, and a profound change in the operative philosophy in order to support the basic needs of the patients.
Key lessons from Italy • A clear policy with investments• working directly within total institutions – not a simple
adminstrative closure• Total reconversion of staff and resources of PH into community
MH Depts (no parallel systems “hospital-community”, no double spending);
• creating alternative networks of coherent services that work in synergy within the community, thereby
• avoiding useless and often harmful fragmentation and specialisations
• Avoiding implementation of general hospital services only instead of comprehenevive community mh centres and services.
Lessons from Italy (2)
• Coordination of services in a given area of the community (MH Department)
• A strong community service / Centre (up to 24 hrs) for delivering care in an integrated and comprehensive way. Then the components and contents of care can have a framework (not separate techniques)
• Citizen’s input through participation (usres, carers, community)
• Health care and general health integration
Toward a value-driven service
• Focus on a citizen with rights• Helping the person and not treating an illness• Understand events of life, overcome crisis• Explain and discuss experience• Not losing value as a person (invalidation, neglect,
violence)• Keep social roles and maintaining social networks / systems• Help social support networks e.g. family• Develop growth potential (recovery)• Have opportunities – real empowerment• Change living conditions using material resources (work,
money, practical help)
ASS n.1 TS• The Healthcare Agency is organised as follows:• 4 Healthcare Districts (each responsible for approx. 60,000 inhabitants),
operating according to area (primary care and home care, the elderly, specialised medicine, Rehabilitation, Children and adolescents, Family counselling, District diabetes centre)
• 3 Departments (Mental Health, Dependency, Prevention)• 2 Specialised Centres (Cardiovascular and Oncological). • 118 Service for health emergencies• 1215 employees. • Budget: cash balance € 29,327,155.82
The MHD and the Local Health Company
• The MHD ( Mental Health Department) is part of the Local Health Company ( LHC).
• The LHC is the organisation which co-ordinates all public health services in a specific and limited territory. The term “ Company” had been created since 1992 with the aim of underlining some similarities in management style with the private trust.
• Specifically, the MHD is the operational structure of LHC which has the following goals : prevention, care and rehabilitation in the field of psychiatry and in the organisation of all interventions aiming to enhance the mental health of the citizens.
The Mission of MHD
• The MHD shall operate for the elimination of any form of stigmatisation, discrimination and exclusion concerning the mentally ill persons.
• The MHD is engaged to actively improve full rights of citizenship for the mentally ill persons.
• The MHD shall ensure that the community mental health services of the LHC have a coherent and unique organisation as a whole, through a strict co-ordination of actions and links with the other services of LHC, particularly with general health districts and emphasizing the relationships with the Community and its institutions.
Today’s features in Trieste (WHO CC lead for service development) are:
Services:• 4 Community Mental Health Centres
(equipped with 6-8 beds each and open around the clock) incl. the University Clinic
• 1 small Unit in the General Hospital with 6 emergency beds;
• Service for Rehabilitation and Residential Support (12 group-homes with a total of 60 beds, provided by staff at different levels;
• 2 Day Centres including training programs and workshops;
• 13 accredited Social Co-operatives);• Families and users associations, clubs and
recovery homes.Staff: • 215 people - 1/1.000 (26 psychiatrists, 9
psychologists, 130 nurses, 10 social workers, 6 psychosocial rehabilitation workers).
Criteria of intervention in Community Based comprehensive Services (Trieste, started 1971, PH closed 1980)
• Responsibility• Proactive, mobile service• Accessible service (walk in, no formal referrals)• Continuity of care• Responding to crisis in community / using MH beds
for people in crisis)• Comprehensive care (social-clinical)
• WHOLE LIFE, WHOLE SYSTEM
Overarching criteria / principles of community practice in the MH Dept.
• Responsibility (accountability) for the mental health of the community = single point of entry and reference, public health perspective
• Active presence and mobility towards the demand = low threshold accessibility, proactive and assertive care
• Therapeutic continuity = no transitions in care• Responding to crisis in the community = no acute inpatient
care in hospital beds • Comprehensiveness = social and clinical care, integrated
resources• Team work = multidisciplinarity and creativity in a whole
team approach
Whole life approach = recovery and citizenship, person at the centre
Whole team approach
• Fully multidisciplinary working is a central goal, including integration of social care and partnerships in care with other community services and non-professional and volunteer inputs.
• The aim is to formulate collective understandings of service users’ situations and shared therapeutic plans.
• Frequent on-site multidisciplinary training and other joint activities underpin this comprehensive team working.
The 24 hrs Community Mental Health
Centre • The 24-hours community mental health centre is a non-
hospital residential facility, not conceived just as a crisis centre.
• It is in fact multi-purpose, multi-functional: also a day centre, an outpatient service, a base for community teams.
• The quality of the environment (home-like) and of the atmosphere (friendly) is based on staff attitudes mainly focused on flexibility and reasonable negotiation with the user’s concerns and needs.
• Its main duty is to be responsible and try to provide a comprehensive response.
• A single multidisciplinary team acts rotating inside and outside, for those who are “guests” on a 24 hours scheme and for the users attending daily or reached at home.
• Knowledge and trust are the main tools for building up therapeutic relations.
• Users’ participation and contribution in the centre ordinary life is seen as crucial.
• Hence crisis is addressed by ‘indirect’ strategies of management using these peculiarities.
Pre-requirements
• Walk-in
• No waiting list
• Intake for problems / not for diagnosis
• concept of “hospitality / guests”
Specialised vs. integrated and holistic models
• A systematic comparison of the various aspects of the care process in an integrated and “comprehensive” approach, based in a single location (the MHC), as opposed to a specialised approach (so-called ‘functional’) in the organisation of services, which is instead based on different teams, would be extremely useful.
• Implications of deinstitutionalisation in terms of costs and strategy.
Community services must be….
• Single access, unified and integrated strategic-organisational moment whose vision must be directed towards the centrality of the user’s needs and desires, with the ‘user’ understood as an active subject
• horizontal organisations which are internally open and participatory
• Flexible • Responsive to change• NGOs included, for a more democratic and diverse
development model in mental health.
Do’s and Don’t’s of Psychiatric Crisis Intervention incl. Residential Care
Do’s• Being with, staying with, doing together among workers and with users• Negotiate and be accountable for everything • Minimise barriers between operators/users• Do normal things in a normal environment • Involve users in running the Centre (telephones, maintenance of the
facilities, cooking, accompaniment and support to others in crisis)
Don’t’s• Reduce the compartmentalisation and ’turf’ issues connected with
individual locations / facilities (no to roles/spaces)• Don’t separate persons receiving hospitality from other users
(‘dissolve’ the crisis in normal, everyday living) • No systems of restraint
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Some relevant outcomes• In 2010, only 16 persons under
involuntary treatments (7 / 100.000 inhabitants), the lowest in Italy (national ratio: 30 / 100.000); 2 / 3 are done within the 24 hrs. CMHC;
• • Open doors, no restraint, no ECT in
every place including hospital Unit;
• No psychiatric users are homeless;
• Social cooperatives employ 600 disadvantaged persons, of which 30% suffered from a psychosis;
• Every year 240 trainees in Social Coops and open employment, of which 20-30 became employees;
• The suicide prevention programme lowered suicide ratio 50% in the last 20 years (average measures);
• No patients in Forensic Hospitals.
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How much does it cost?• 1971: • Psychiatric Hospital 5 billions of Lire (today: 28 million €)
• 2011: • Mental Health Department Network 18,0 millions €
• 79 € pro capita• 94% of expenditures in community services, 6% in hospital acute beds
Social capital and mental health
• Social capital refers to relational resources owned by individuals: social networks and interactions, participation and civic commitment, and institutions enhancing cooperation among individuals.
• It can be measured by trust, reciprocity and civic participation, and positively correlated with health conditions.
• The importance of the “social issue” (participation, rights, power, inclusion) and the role of community mental health services in supporting personal changes - functioning as a sort of mediator, an agency for integration. Again, the concept of social capital.
• The deinstitutionalization experience in Trieste shows that turning points in recovery experiences often coincide with interventions by the Service, but that this is closely linked to the opportunities offered and the resources activated (e.g. working in coop, social activities, outings, mutual help, sports, joy, a social role, community experiences, sense of belonging , new identities, etc.).
Clinical and social• A worldwide trend is the administrative separation between
institutional and clinical services, usually hospital-centred, and community services run by municipalities as a part of welfare services. Often they are run by NGOs using public finances (see Denmark, Iceland etc).
• In other countries such as Sweden all the “social” component of care (e.g. housing, job placement, etc) is completely detached from the sphere of action of Community mental health services and is run by local welfare.
• These policies create another set of complications to the issue of transition from hospital to community based care at least in term of reconversion of resources, but also in term of models of care who are sectorised and fragmented in their premises.
Risk and control• In Italy, following the closing down of asylums, and especially over the last
decade, new forms of harm and abandonment have reappeared in hospitals, private clinics and residences for chronic patients, as well as forensic hospitals, but also in community services.
• These institutions reproduce, albeit in different forms, the dehumanisation of psychiatric hospitals.
• Instead, there has been an increase of institutions for specific forms of reclusion, in a logic of the control of behaviours within psychiatric forensic ‐or ‘special’ containers (or prisons tout court), with psychiatry once again providing guarantees through technical scientific justifications. ‐
• The old notion of danger has been updated to that of ‘risk’, and as such reappears in the new social community, or ‘neo clinical’ psychiatry, ‐ ‐where the concept of illness remains essentially unchanged.
Users and Community PARTICIPATION AND EMPOWERMENT
• plurality of the individuals (the emergence of the subjects)
• real interactions and alliances promoted by deinstitutionalization
• To optimize both exchanges and relationships, within the range of action of the services
• the casting of active roles, the activation and the productivity of those values which are used in relationships
• participation as a contribution to further modifications of a mental health service
WORKERS' EMPOWERMENT IN CMHS
• Developing a shared therapeutic culture. • Not only a multi-disciplinary approach but
optimization of human resources• overcoming of the rigidities of professional roles • different subjectivities • different points of view • power: decisional spaces and initiatives
Rehabilitation in Trieste• Rehabilitation in Trieste is conceived
as a program of restitution and (re)construction of full rights (political, civil, social) and citizenship for individuals disabled by mental illness, and the material construction of these rights. This implies:
• a) the legal recognition of civil and social rights
• b) acquiring resources (houses, jobs, goods, services, relationships) primarily through a
• deinstitutionalization process which reconverts total institutions to community services
Rehabilitation in Trieste• c) improving access to resources,
mainly by • developing user capabilities through• - training (living and vocational skills,
education);• - information (psycho-education, social
awareness). • The creation of social support
networks, which are managed by comprehensive community services totally alternative to the mental hospital, facilitates the delivery of resources.
Rehabilitation in Trieste• In order to achieve these goals, it is
essential to: • - empower primary consumers;• - provide support for family members;• - re-skill and re-orient professionals; • - provide health education and bring about a
cultural change in attitudes, especially in those directly involved in providing services.
All these actions must minimize the limitations and social barriers which contribute to produce handicap and stigma, and which reinforce ill behaviour (long-term institutionalization, forensic hospitals).
The coops: rules• Democratic and participative structure: every member has a vote in the
assembly, that makes any decision and elects the directive committee. • Individual tax exemptions for any employed disadvantagee member.• Overall tax reduction for the coop to 1/4.• Members are paid by normal wages;revenues must be re-invested. • Service staff working either as managers or as mental health specialists;
teaching experts and collaborators for each specific sector (members of the "Intelligentsia" open to the enterprise); ordinary members.
The coops: activities cleaning and building
maintenance (diverse agencies) Canteens and catering, incl.
Home service for elderly people
Porterage and transport Laundry tailoring Informatic archives for councils,
etc furniture and design cafeteria and restaurant
services Hotel Front-office amd call-center of
public agencies
Museums’staff agricultural production and
gardening handicraft carpentry photo, video and radio
production computer service, publishing
trade, CD-Rom serigraphics theatre administrative services Group-homes (type A) Parking
Work places of people with work grants
Profit f irms19%
Associations (accredited)13%
Courses & w orkshops6%
Public agencies3%
Other associations4%
Other social coops8%
Health agency 4%
Social Coops (accredited)43%
National data from work and recovery - PIL
• 2007/2010 – Role of MH services in vocational rehab and job placement • 80% of MH Dept have Social Cooperatives type B as main partners• CMHT have dedicated staff for job placement they do all actions (less on-the-job support, mainly
provided by external partners).• Train on the job and acting as coordinator of team is the main strategy, while inividual support is
offered by the business partners. People with relational skills are required more than experts.• Main criteria for choosing a person are a comprehensive care plan (70%) and opportunities
offered (40%), then motivation (23) and vocational skills (23).• It’s a wide network intervention• Use of economic incentives like work-grants provided by the service (47%), municipality (26).
Employment agencies mediate (66%).• Outcomes: QoL (65) , user satisfaction (59), clinical Improvement (57).• To be employed is the main outcome : 1.448 / 14.403 (10%) • Gender (male), age 35-44, psychosis (49%). • Main determinant of job training programme is the presence of social coops, main determinant
of good outcome is economical and local context (Regional) • FVG 50 /100.000, Marche 52. Calabria 1,55 /100.00.
The women’s group for mutual welcome and support
• A women’s group that meets daily and organizes activities and support (since 1997)
• An association develops from it• 90 women involved (aged 25 to 70)• Cultural initiatives for women: films,
museums, a journey through ethnicity
The recovery home
• A small recovery house with 3 places for a transitional period of time (last year)
• 8 women residents last year (3-6 months) • 20 personalized projects, also with home support • Main aims are emancipation and empowerment• Peer support and real work as service providers within the
residence (contract between the association and the MHD).
Human development or “THE PERMANENT WORKSHOP FOR CITIZENSHIP”
• SOCIAL-CULTURAL REHABILITATION FOR COMMUNITY ACCESS THROUGH EMANCIPATION
• defined as the (re)learning and (re)utilisation of tools for decoding and interpreting (reading) reality;
• (re)learning and gaining access to strategies of communication;
• developing the capacity to care for oneself, and for self awareness and self expression.
“THE PERMANENT WORKSHOP FOR CITIZENSHIP”
• Specific courses, led not specialists in the area of psychiatry but teachers, artists and specialists in other disciplines.
• These course are aimed at strengthening social and cultural abilities, as well as providing user access to individual itineraries of job training and pre-training
• Various aspects of social participation, opposing trajectories of desocialisation and exclusion.
“THE PERMANENT WORKSHOP FOR CITIZENSHIP”
• Themes:• Social and gender identity• the knowledge and discovery of the
community in both natural and cultural terms• the acquisition of linguistic and expressive
abilities• the use of media.
Housing
– Residences (transitional group –homes) sized according to a
“home” model
– Guaranteeing residents a personalized space and subjective time.
– Residences are preferably located in town and integrated in the community
– Residences aim at discharge or the passage to less supported situations.
– Small residences facilitate personalised therapeutic-rehabilitative projects.
Personalised Plan - Personalised Healthcare Budget(PP-PHB)
The personalised plan and related healthcare budget is the main tool for affirming the central role of the person and their needs and guaranteeing care continuity.
This tool stresses the user’s consent and participation in the plan.
Personalised Plan (PP)
identifies: needs/goals expected results interconnection of interventions resources required role/duties of professionals and services verification (when & how)
Personalised Plan (PP)
PP funded by Personalised Healthcare Budget and organised along 3 axes indispensable for full social functioning and empowerment : housing, work, socialisation.
The PP accesses other services (mental health services, healthcare districts, social services) and community resources (volunteers, social coops, associations, families), and works as much as possible within the user’s family, physical and social setting.
The Healthcare Agency must guarantee the quality of the PP.
Personalised Plan - Healthcare Budget
► The PP and related PHB shift resources from the structure to the person
► Easier to see where resources are invested
► Encourage personal living plan by supporting recovery processes
► Quality control of actions through better monitoring of PP’s goals and
outcomes.
Partners
►10 coops ►4 volunteer groups►2 cultural association►3 foster families
total: 19 partners
Villa Carsia: a “real home”
► Right to housing, home ‘ownership’, funds so person can choose coop for services
► Healthcare Services guarantee quality control
► Diversity of actors guarantees quality through a positive competition among partners
and keeps others from ‘taking over’ the space-time of the residence through overly
unified action
► Not just rights, but the awareness of one’s rights
► Not just autonomy, but responsibility and decision-making
Integration
• ‘Integration’ is a key-word widely used to describe a continuum of care and support systems. But integration also means promoting inter-subjective relations within a wider political dimension.
• It means integrating social and healthcare interventions, and recognising the social determinants of illness and healthcare processes based on a ‘whole life’ approach to the person. And mental health is not the only area that must assume this commitment, for ‘there is no health without mental health’.
Mental health and general health in the community
• In parallel with the development of the psychiatric services, the last decade has also seen the significant growth and development of integrated, community health care services (Health Care Districts).
• The Districts are integrated community services which stress the active involvement of the general public and the inter-sectorial offer of the health care services in order to achieve their aims. A single strategy for the community they serve.
• They are located in the sane catchment areas of CMHCs. Inlude elderly, home care, chikd and adolescent health, family coumseling, handicap, specialist medicine, associated GPs.
• Joint plans of care with MH services.
Community health and development
• Non-medical determinants for health – social deprivation and isolation, hence:
• Microarea Habitat Project (global, local, plural) activated in Trieste in collaboration with the City of Trieste and the Public Housing Agency (Ater), and then expanded to include other Regional areas in the context of the Microwin project.
• 10 areas of te city, with an average population of approx. 1000 persons each, for a total of 15,000 inhabitants.
• Interventions for learning about residents, verifying health conditions, guaranteeing good healthcare and social-healthcare practices, reducing inappropriate hospitalisations or stays in nursing homes, verifying the appropriateness of therapies, diagnostics and analyses, promoting self-help, developing collaboration among services and among other actors, such as volunteer groups and/or stakeholders, promote community cohesion.
• Beginning in 2008, 10 additional microareas promoted by other public/private actors (e.g. Enaip, Itis, Caccia Burlo, Salus Spa etc.).
Implications for practice
• The role of community mental health services to support individual change, as agencies for integration that can provide or catalyse resources and opportunities.
• A better use of the skills and the human resources of primary consumers and relatives can lead therefore far beyond a democratization
• accepting their contribution to further modifications of a mental health service in a common action against passive dependence ties, against the overall medicalization of individual and social needs and daily life problems, against the new forms of institutionalization.
• Work on the institutional relationships.
The role of the Services
• risk, openness, involvement, accessibility and flexibility, the possibility of choosing, access to opportunities
• How independent are “recovery” processes from professional help?
• What are the natural support systems for recovery? What are the personal and social factors which encourage and aid it?
outcome research• 75% compliance to antipsichotics (n=587) related to service provision
and SN enhancement. • 27 people - high priority, 5 years f-up:• Highly significant reduction of symptoms severe > 65 p at BPRS from
20% to 4%), increase of social function (50% score), 9 at work, 12 indep living, unmet needs (CAN) from 75% to 25%, 70% reduction of night accomodations. Only 1 drop-out.
• Qualitative research on recovery / social dimension (IRRG, Am J Psy Rehab 2006)
• 24 h services (among 13 centres) better for crisis care and 2-year f-up, trust, continuity, comprehensive health and social care (2005). Reduction of emergency presentations in the GH casualty of 70 % in 20 years.
• 1983-1987, first f-up after reform law showed better outcomes for Trieste and Arezzo among 20 centres due to better organisation and social integration.
• Satisfaction of users is 78% (2008)
1981
1987
1989
1991
1993
1995
1997
1999
2001
2003
2005
2007
2009
2011
5,000
7,500
10,000
12,500
15,000
17,500
20,000
22,500
25,000
0
100
200
300
400
500
600
700
800
Day-night admissions at CMHCs
Day-night admission days at the Mental Health Centre (MHC) Admitted people
Years 1981 - 2011
Day-n
ight
adm
issio
n d
ays
Adm
itte
d p
eople
num
ber
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2,500
5,000
7,500
10,000
12,500
-
300
600
900
1,200
Day-night admissions at CMHCs and admissions at the GHPUDay-night admission days at the MHC
Admission days at the GHPU
Years 1996 - 2011
Day-n
ight
adm
issio
n d
ays a
t th
e M
HC
Adm
issio
n d
ays a
t th
e G
HP
U
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
-
25
50
75
100
125
-
4
8
12
16
20
Compulsory Medical Treatment (CMT) admissions at the General Hospital Psychiatric Unit (GHPU)
CMT days at the GHPU People admitted under CMT at the GHPU
Years 1996 - 2011
People
adm
itted u
nder C
MT a
t the G
HP
U
Adm
issio
n d
ays u
nder
CM
T a
t th
e G
HP
U
Ethics or evidence?• The debate in Europe increasingly revolves around ethical- or values-
based (Fulford) and not just evidence-based practices, grading up to person-centred, and / or recovery oriented systems of care.
• Essentially, moving beyond the deprivation of freedom and coercive treatment, in addition to legislative reforms, requires improving community-based care and strengthening community services in term of centrality of the needs and rights of population served and chiefly users and carers.
• Even cautious views regarding the role of hospitalisation (at variance with the “community” model, Tansella & Thornicrof) are anyway superseded by a vision of services founded on an ethical position of the right to access and an assumption of responsibility by the services which was not based solely on clinical evidence, but also on the risks of discrimination and marginalisation (such as unemployment).
AO in Trieste• Context of broad comprehensive care with low
threshold. 70% of interventions outside cmhc.• Whole team approach with daily discussions.But:• Difficulties of 24h service: driven by crisis• cm not intensive and no definite caseload• Insisting on centre as re-admissions, h.u. or long
term attendance.• The “invisibles” / the routine vs more focused
“projects”
AO in Trieste• From ’94 on: High priority people• 3 axes: severity, service and micro-context• Then more defined criteria = AO• Mapping the service every year. Action-(re)search
on drop-outs.• A small AOT (GRAL) 5 nurses, 1 psych. Then:• Sub-teams focused on continuity with more
consistency and intensity of contacts.• Research on High priority people – heavy burden.
Key elements (Marshall e Lockwood, 2002):comparison with Trieste
• Multidisciplinary team• Targeted user group• Shared responsibility• Health ad social care
managed directly by the team, not delegating to other services
• Care offered in vivo (mostly at home)
• Assertive treatment• Negotiation on programme
Trieste:• Not a dedicated team but a
function of the whole CMHC team
• Part-time service of a limited sub-team for high priority people, while other staff integrate interventions
• Whole team approach with key workers
• Not just individualised programmes but recovery-oriented pathways of care
Recovery and citizenship
• Citizenship should be interpreted as a social process that brings about individual and social transformation
• not a status but a ‘practice’, which is essentially the exercise of social rights (De Leonardis).
• Hence, it involves a re-distribution of power, and the exercise and development of capabilities (Sen).
• Basaglia affirmed that “recoverability” has a price, and is an economic-social fact more than a technical-scientific one.
• As we demonstrated in qualitative cross-cultural researches, a lived citizenship, ‘having a whole life’ can be captured to be at the heart of a recovery process, as stated by individuals themselves in their narratives.
Recovery and social issues
• The importance of the “social issue” (participation, rights, power, inclusion) is linked to the role of community (mental health and welfare) service in supporting personal changes - functioning as a sort of mediator, an agency for integration. Again, the concept of social capital.
• Recovery research shows that turning points in recovery experiences often coincide with interventions of the Service, when this open opportunities and activates resources (e.g. working in coop, social activities, mutual help, sports, joy, a social role, community experiences, sense of belonging , new identities, etc.).
Whole lifePrograms addressed at those who are at risk of social drift as
people with complex needs, incl. SPMI, drug use, medical conditions, high social needs.
Individual plan of care with defined and scheduled aims set up by the MHS with the user, together with Healthcare district teams and welfare services contributions. Economic plan attached (s.c. individual health budget) from high to low intensity. N=160
Implemented through NGOs’ partnerships competing for the best progamme, integrating the persons’network resources.
Pathways of recovery through the service
• Contact into community, in living places• A key-worker but also a team, a place (the CMHC) which is the only
reference• through significant others (full use of SSN, kept involved even if
conflictive)• Understanding toghether• Helping to find mediations and even solutions of conflicts, preserving
autonomy • avoiding emergency by a rapid response• Stay at home or at CMHC, not in hospital • Persistent offer of relationship and care• Avoid involuntary treatments, negotiation and shared decision
making, everything, follow you on the long run
• Immediate offer of rehab and access to opportunities • E.g. a series of programmes developed into community
and with - • Offer of reciprocal relationships, social roles• Participation in the Center’s life, sense of familiiarity• Discuss “what do you want to do with your life” as a basis
for an individual program or “a project”• Helped with money, work or training, education, living
places, acitivity, relations when they’re broken• Creating opportunities for recovery and emancipation
from dependency, social exclusion e.g sports, leisure, culture, wellness etc
Trieste: general indications
• Community health as passage which derives from deinstitutionalisation: systems built around individuals/communities
• Comprehensive, holistic approach which combines medicine with welfare systems for powerful synergies - concept of whole systems, whole life approach (Jenkins, Rix, 2002)
• The focus on individuals and the rights of citizenship raises the issue of values which underpin practices and services (value-based services, Fulford, 2001)
• Creating personalised itineraries as organisational-strategic key, in which the person has an active role and contractual power.
Indications
• Avoid or reduce transitions in care: fragmentation of services system. • Foster the service’s responsibility and accountability towards the
community. The responsibility for care processes should be rooted in the community.
• Recognising the importance of contexts as producers of the meaning of health actions and as bearers of resources - refusing automatic choices which are not differentiated based on the contexts where they are applied.
• Passage from reparative medicine to participatory health (no black box as funnel for specialistic approaches).
• Developing the protagonism of individuals as stake- or shareholders in the healthcare system (concept of leadership linked to the activation of processes of strategic/organisational change, in ‘rushes’ or continuous cycles).
Indications• A shift from healthcare institutions to healthcare
organisations is necessary• Also required is a ‘systemic’ vision based on the person’s life
(whole systems, whole life approach) with a low threshold, single access point (one-stop-shop),
• Developing home care, both network and networked, focussed on the person in their actual living context, and thus on their life story and social capital, and not on the illness.
• A system of possible options which diversifies responses, making them flexible and personalised, should therefore be provided for.
…suggestions• Set up a comprehensive system of care, based on
clear values then procedures as safeguard of deinstitutionalisation
• Integrate it into mainstream health and welfare services
• Improve intensive case management• Consider it as a platform for accessing integrated care
and individual recovery planning• Include components of a whole life offer• Provide exits from 'the circuit'
ConclusionsThe transformation process requires multiple
levels: • Involvement of civil society and of all
stakeholders• Policy level • Legislation• Service models and practices• Involvement• Inter-sectoral change
The person and not the illness at the center of the process of care for recovery and emancipation through users’ active participation in the services
(up close, nobody is normal)
Roberto Mezzina, Director WHO CC for Research and Training,
MH Dept. Trieste