Care in the Community

From Asylum to Recovery.

Cormac WalshAssistant Director of Nursing

Dublin North City Mental Health Service

Themes

• Mental Health Legislation and Policy in Ireland

• Supported Community Residential Services

• The Programme for the Homeless Mentally Ill

• The Future

1850 Lunatic Asylum Act (Ireland)

York Retreat.

Richmond Lunatic AsylumSt Brendan’s Hospital

1814-2013.

1945 Mental Treatment Act

1945 Mental Treatment Act; allowed for the voluntary admission of people in Psychiatric Hospitals, made the first step towards Community care allowing patients to be paroled..

St Brendan’s Hospital 1966

‘Top House’

1966 Commission of Inquiry on Mental IllnessGoffmann’s characteristics of total

institution - asylum• (1)  all aspects of life are conducted in the

same place under the same authority; • (2)  the individual is a member of a large

cohort, all treated alike; • (3)  all daily activities (over a 24-hour

period) are tightly scheduled; • (4) there is a sharp split between

supervisors and lower participants; • (5) information about the member's fate is

withheld. 

Planning for the Future 1984

Planning for the Future (DoH, 1984) provided the strategic framework that enabled the adult mental health services to evolve from an institutional to a community-based service model and approach.

It directed that the psychiatric services should be comprehensive and community-orientated, and aimed at delivering care that was coordinated, integrated, and multidisciplinary (DoH, 1984).

Countrywide, mental hospital services embarked on programmes of ward closure that resulted in a decrease in the number of in-patients in mental hospitals from a total of 19,801 in 1963 to 3,556 at the end of 2004. A significant rise in community-based facilities paralleled this decline in bed usage, giving rise to over 3,100 community residential places under the care of the mental health services in 2004 (O’Regan and Keogh, 2005).

Psychiatric in-patient beds in Ireland

1896 to 2013

1950021000

11906

2838

11000

0

5000

10000

15000

20000

25000

1896 1945 1955 1983 2013

Psy

chia

tric

bed

s in

Irel

and

St Brendan’s Hospital Rehabilitation and Resettlement

Programme’In SBH a formal ‘rehabilitation and resettlement

programme’ was established in 1986. The primary aim of the programme was to decant the mental hospital of long-stay in-patients to more ‘appropriate’ community residential environments in order to facilitate the closure of the hospital.

• In conjunction with this programme, comprehensive and integrated community psychiatric services were planned to provide alternative treatment options to people at home.

• The Programme for the Homeless, ‘NFA Unit’• Sector CMHT, Cabra, Finglas and

Blanchardstown. • Over a nine-year period the number of in-

patients residing in the hospital steadily fell each year from a high of 1200 inpatients in 1986 to 257 in 1994.

Community Residences

• The provision of residential facilities largely depends on two key variables: – (1) the extent of informal family support,

which can substitute and replace the formal support granted by residential facilities;

and – (2) the availability of comprehensive

community resources, including assertive community treatment programmes (Girolamo et al., 2004; Thornicroft, 2003).

Continuum Model• The Continuum model posits that there are different

residential settings, such as ‘group homes’ and hostels, with various levels of support and restrictiveness; the most intensive treatment is offered in the most restrictive environment.

• Residents can move along the continuum, from more restrictive to more open settings, the level of supervision is based on the level of assessed need and level of functioning, thus providing a pathway from institutional care into independent living in the community (Girolamo et al., 2004).

• The ‘continuum’ model has been criticized because it bonds housing and treatment needs, and this may lead to unnecessary dislocations through successive moves as improvement in functioning often requires a move to another setting (Carling 1993).

• Furthermore, housing is frequently not available at precisely the time when the person’s needs change and skills acquired for independent living in an artificial environment, such as residential facility, may not be transferred and used in another setting (Girolamo et al., 2004).

High Supported Community Residences 2005

1013

9

17

11

2515

14

12

26

Avondale

Maysyl Lodge

175 Navan Rd

Cherrymount View

San Remo

Weir Home

Adelphi House

Daneswood

Ard Na Greine

Eliz Court

Diagnoses

• Schizophrenia: 74.9%• Schizoaffective disorder: 5.5%• Bipolar Affective Disorder: 12.3%• Depression: 2.3%• Alcohol Dependence: 0.8%• Other: 1.5%• No Mental Health Diagnosis: 2.3%• Unknown: 0.8%

Mental Health Act 2001

• Involuntary Admission of persons to approved centre

• Independent Review of Detention• Established the Mental Health

Commission“to promote, encourage and foster the

establishment and maintenance of high standards and good practices in the delivery of mental health services”.Inspector of Mental Health Services

Vision for Change 2006

• Vision of Change details a comprehensive model of mental health service provision in Ireland. It proposes a holistic view of mental illness and recommends an integrated multidisciplinary approach to addressing the biological, psychological and social factors that contribute to mental health problems.

• Principles and values underpinning the Vision include Multidisciplinary; community based; comprehensive; active participation and recovery;

Recovery

• The Recovery approach is a shared philosophy which draws upon evidence concerning the importance of values social roles, such as employment while also emphasizing user determination and positive risk-taking. – Personal Responsibility– Hope– Rebuilding programme– Contentment– Roles and relationships.

Leighton (2005)

High Support Community Residences 2011

26

8

1513

20

10

St Eliz Court

Church Ave

Cherrymount

Daneswood

Weir Home

San Remo

Church Ave 2011

Structure:Small 8 ensuite / bedrooms residence

System:Self staffing / NursingMDT input / OT

Skill mix/sleepoverSelf catering

Turnover30 individuals admitted in three years

12 moved back Home 118 episodes of respite2 Individuals at risk of

homelessnesssubstance misuse / anti-

social behaviour / non-payment of charges

14 have moved to lower supported accommodation provided by HSE.

7 have progressed to independent living

Doras 2011 -2013

Genio funded:Collaboration between HSE Dublin

North City Mental Health Services and HAIL

Aim:To build a sustainable model of Community Mental Health Rehabilitation that will deliver a range of recovery focused supports

The challenge

• Housing– Source high quality secure housing– Maintain and support tenancy– Independent living as a realistic goal

• Connections Project– Social Roles Valorization– Meaningful roles

2016 Target High Supported Community

Residential Places.

0

20

40

60

80

100

120

140

160

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

Community Residence

In patients

Supported Community Residential Strategy 2014-

2019

• Reduce the number of residents to between 8-10; individual rooms

• Locate community residences across the catchment area; Cabra, Finglas and Blanchardstown.

Homelessness

Factors contributing to increased homelessness

• Lack of affordable housing • Reduced entitlements• Growing numbers in poverty• Individual vulnerabilities

• Mental Illness• Substance Misuse.

Comparison between Homeless and Homeless

Mentally IllBoth groups share backgrounds marked by:• Poverty• Dependency on welfare• Childhood hunger• Family unemployment .Homeless Mentally Ill had a higher instance• Family violence and abuse• Foster care• Childhood homelessness

Programme for the Homeless

• Established in 1979 comprised– ‘The Willows’– ‘NFA Day Centre’ moved off campus to

Ushers Island in 1997– Three supported Community

Residences– 24 hr self referral assessment unit, SBH– Acute In-patient beds

Changes to the programme

• 2009-2014– Closure of Community Residences– Closure of in-patient unit – Closure of self-referral assessment unit– Assertive Outreach– Acess Team– Outpatient Clinic 2011 Park Gate

Street.– Day Hospital 2012

• Reconfiguration 2014.

Conceptualisation of Needs

• Severe & Complex MH & SC needs+/- Substance Misuse

• Severe MH & SC needs+/- Substance Misuse

• Significant MH & SC needs+/- Substance Misuse

• Minor MH & SC needs

• Social Care (SC) needs

Mission

• The Programme for the Homeless Mental Health Service provides specialist community mental health care and treatment for registered homeless adults with severe mental illness living within Dublin City Centre.

Optimism for the future

• Primary Care Strategy; – strengthening links with MHS

• National Clinical Care Programmes– For episode psychosis– Family education

• Behavioural Family Therapy• Eolas Programme

• Recruitment of full compliment of MDT members.

• National Housing Strategy for People with Disabilities 2011-2016.

DIT Campus,

Students’ first day

Thank you