Visita dei quadri dirigenti del Quebéc in Emilia Romagna

Presentazione del DSM DP di Ravenna

!8 Giugno 2012

Plan of presentation • Law 180/78: main principles• Mental Health Department: the present structure of

mental health services in Italy. • A law isn’t sufficient to change old practices. The

existing weaknesses in the Italian mental health field • The MHDt of Ravenna. The radical transformation of

the services system (vision, policies, strenghts and weaknesses). Main fields of intervention

• Results of the process of change

Law 180/78: main principles

Approved in 1978, the law 180, generally referred to as the “Basaglia law”, marks the “Italian Revolution” in the field of mental health, developing a radical process of change in services delivery: from guardianship to the beginning of the patient’s de-institutionalization. Let we try to summarize the main points of this change.

• First, the law stated that citizens’ mental health had to be promoted by means of three levels of intervention, all deeply interrelated: prevention, treatment and rehabilitation.

• Second, the law affirmed that the people with psychiatric disabilities had the right to receive effective treatments in the environment where they lived, trying both to reduce hospitalizations and desocialization and to maintain the connections with significative others.

Law 180/78: main principles

• Third, the law introduced the concept of social inclusion as result of a range of interventions focused on helping the person with psychiatric disabilities to maintain or achieve valued roles in the community.

• At least, the law forbade further admissions in the mental hospital and established the a wide net of services that should have met the main needs both of people with mental illness and their family members (crisis, enrichment, treatment, rehabilitation, relationships, etc.).

Mental Health Department

• Mental Health Department is the organization that collects the whole array of community based psychiatric services.

• In the Italian Health Reform, the terms “Department” means: Integrated Organization of complementary services ( named Operational Units) each of them pursuing specific objectives, all concurring for a common goal.

• It’s one of the two community based (i.e. extra-hospital) Department (the other is Primary Care Department) and it belongs to Health Local Authority.

Main components of Mental Health Department (Ravenna MHDt too)

• Community Mental Health Centers. Model of care: Community Assertive Treatment, the services are delivered in the environment of life of people with mental illness (outpatient services) with the mission of helping them to obtain and to maintain valid social roles.

• Psychiatric Ward (inpatient service), where people with emotional and behavioural disorganization are helped to re-gain acceptable level of psychosocial balance.

• Psychiatric Rehabilitation Unit, compounded by Residential Facilities and Centers of Psychiatric Rehabilitation, whose function is to develop effective programs for people with severe mental illness that will strengthen their skills and capacities to live independently and meaningfully in the community as more as possible.

• Apartments settled in urban area, where to help people discharged from residential facilities to gain tenant role, according “supported housing” care model.

• Neuropsychiatry Children Services, aimed to deliver treatments and cognitive rehabilitation to people with psychomotor deficit, language troubles and intellective disability under 18 years of age.

• Community Services for drug and alcohol abuse or dependence.

Some data about MHDt of Ravenna MHDt of Ravenna

– 3 Community Mental Health Centers. – 1 Psychiatric Ward (inpatient service) with 21 beds.– Psychiatric Rehabilitation Unit, compounded by 3 Residential Facilities and 3 Centers of Psychiatric

Rehabilitation– Fifteen supported houses– 3 Neuropsychiatry Children Services– 3 Community Services for drug and alcohol abuse or dependence.

• Number of citizens in the catchment of Ravenna: approximately 300.000• Number of professional working in all above mentioned Unit: approximately 380• Number of people served: approximately 4200• Type of professional roles: psychiatrists, nurses, social workers, psychologists, occupational

therapists.

A law isn’t sufficient to change old practices  

Despite the existence of the Italian law 180/78, there is a lot of evidence that most of services’ systems are mainly oriented to “stabilize” the symptoms as unique outcome and to “replace” many clients in the psychiatric residential facilities, often reproducing a marginalized way of living instead orienteering towards recovery processes.

Main weaknesses

• Increased awareness of the inadequacy of the stabilization paradigm (interventions only in acute phase of mental illness, desired outcome: symptoms remission).The consequence: many people with mental illness who are stabilized but disabled and isolated .

• Low clients’ families involvement in their relatives’ treatment plan and lack of support to patients’ families.

• Increased number of clients placed into public and private psychiatric residential facilities with increased costs.

• Lack of monitoring of the quality, of the effectiveness and of outcomes of treatments

• Lack of community based professional competence of practitioners

What we learned during these years

• The traditional treatments, medication and crisis interventions, have shown their selves inadequate to met the different needs of people with psychiatric disabilities and insufficient to increase role functioning in the real world.

• It follows that it’s necessary to pay a greater attention to the tools and the methods with which to counteract the disabling effects of the mental illness on the individuals that suffer from it.

Building a rehabilitation and recovery-oriented Mental Health Department

 

Mentioned above considerations have prompted the Local Health Authority of Ravenna to promote a radical services system’s change through a change of the paradigma (from biomedical paradigma to biopsychosocial paradigma).

Holistic approach (biopsychosocial model)

• To adopt a holistic approach means that people with psychiatric disabilities, before being defined as sick, cases or diagnosis, are regarded as unique persons, each of them with three closely connected dimensions: biological, psychological and social.

• The biopsychosocial model counteracts the risk of fragmentation of interventions and, therefore, of the person.

The vision of MHDt of Ravenna

The whole array of services, each for own specific field of action, has the purpose to increase the personal and social functioning and subjective well-being of people with psychiatric disability, in order to be able to perform successfully a valid social role in the enviroment of chose (job, housing, education, meaningful activities in the community) with the least professional support .

Principles and values • Limiting disabily’s impact through psychosocial treatment and

social supports

• Encouraging client’s incolvement in own treatment

• Strenghten successes ; don’t blame person for his/her failures

• Building close relationship with person with mental illness , who is allowed to risk, to mistake and to have the same apsirations all human beings have

• Focusing on strenghts; don’t amplify deficits

Actions we are doing to promote change

• Increasing practitioners’ knowledges, attitudes and skills about psychosocial evidence practices and concept of recovery .

• Orienting daily practices to scientific evidence • Spreading culture of outcomes’ assessement • Identifying measures of recovery-related outcome.

• Reducing the use of psychiatric residential facilities through supported housing and vocational programs .

• Increasing the number of people discharged from the psychiatric residential facilities through supported housing and vocational programs .

Actions we are doing to promote change

• Helping to change the believes of many mental health professionals which think that serious mental illnesses have almost a poor prognosis associated with and that the people who psychiatric disabilities cannot lead a meaningful life rich without the continuous support of psychiatric services;

• Encouraging the introduction of the concept of recovery in the man therapeutic approaches to people with mental illness, with particular reference to individual treatment plans’ outcomes that do not just concern remission of symptoms and of relapses but also the personal and social functioning, quality of life and the subjective perception of a state of well-being

Actions we are doing to promote change

• Favouring the overcoming of prejudices of many families about the concept of recovery , often rejected for fear either of painful hopes or of the implied challenges of the recovery process (increased relapses and hospitalization rates). Helping family members to recognize the outcomes of recovery, even those one minimal.

• Promoting the adoption of programs of supported housing, supported education and supported employement, helping patients to carry out social roles, according to the principle that the people with psychiatric disabilities had the right to receive effective treatments in the environment where they lived, trying both to reduce hospitalizations and desocialization and to maintain the connections with own environment and with others.

• Changing the objectives of the programs implementing psychosocial programs that counteract:– De-socialization (reciprocal detachment between the individual and his enviroment) – Internal stigma (powerlessness, shame, worthlessness, inability to take over own life)– Giving-up hope, purposes and every effort to change

•

Main policies we are carrying on – The training of the workforce: the “core” of the process of change

– Continuous training of workforce (interdisciplinary and involving the whole system) about EBPs and concept of recovery

– Training programs’ coordinators in order to learn leadership skills – Carrying on a process of de-institutionalization from residential facilities

– Strenghtening partership with families and with Associations of families

– Encouraging the birth of Associations of Users and their participation in

services’ quality assessment – Implementing person -centered programs for specific targets of

population

The training of the workforce: the “core” of the process of change

• In the process of change of the mental health services system of Ravenna, great importance is been attributed to the personnel training.

• Need to increase professional competence of the workers stems from the lack of adequate tools to cope with psychiatric disability and to make the workers competent to help the disabled people to achieve personal goals and to develop processes of recovery.

• To adopt evidence based practices and to measure the outcomes, it’s necessary to supply the personnel with effective tools, through a continuous learning process (intensive training in the workplace and regular supervisions).

• The importance of recruiting skilled and motivated practitioners , has also often been highlighted. It is well-known how the negative attitudes of the professionals influence the consumers’ outcomes.

Effects of lack of workforce competency

The lack of appropriate knowledges, abilities and attitudes to assist users in their processes of rehabilitation and recovery reduces personnel effectiveness and gives rise to : – Repeated failures and intense emotional reactions, that  may  put  into  some  negative  attitudes  and behaviors  

Negative workforce reactions to programs’ (and users’) failure

• Avoiding relationship with user.• Using diagnostic labels to explain failures• Considering disfunctional behaviors an expression of

seriousness of mental illness and of progressive deterioration.

• Repeating every day the same intervention, even if clearly ineffective.

• Taking up role of entertainer, baby-sitter, guardian or substitute of familiars.

• Devaluing own professional role .

The training of the workforce: the “core” of the process of change

• On account of this, we plan annual training programs (18 seminars every year) for the all teams working in Mental Health Department (approximately 300 practitioners) , aimed to teach personnel:– the knowledges and the abilities needed to help people with

mental illness to have a meaningful life in their community, i. e. to re-learn and to practice the daily living activities.

• We promote a continuous training in the workplace• We support practitioners monthly with supervision and work-

team in order to convert theory in practice • The whole personnel is involved in the training programs,

(including psychiatrists).

Two levels of training

The training has been organized in two levels:

–Training for people working day to day with patients

–Training to develop new competences for the leadership.

First level (Psychiatrists, Psychologists Nurses, Social Workers, Occupationa Therapists )

Goal: Development of Staff Professional Competence

Abilities

• Building a relationship of support and partnership with clients and their families .• Using motivational techniques.• Adopting care planning oriented to the patients’ objectives.• Delivering group treatments of social skill training • Supporting patients in the community through practicing social roles• Relating with social referees supporting user’s social role (employers, teachers,

neighbours, etc.) • Listening, understanding, supporting, involving and orienteering clients’ families,

helping them to cope with dysfunctional behaviours of relative.

Second level (Leadership Competence )

Goal: to increase the leadership’s competence

• Orienting staff to change.• Motivating staff, helping it to overcome resistance

to change• Supporting and supervising staff.• Checking patients’ care planning and assessing

outcomes.• Promotin peer support.

Three level of competence

• Exposure

• Experience

• Expertise

Carrying on a process of de-institutionalization from residential facilities

Increasing number of persons discharged from the public and private psychiatricresidential facilities, through:

• developing effective programs in the public and private residential facilities through them people with severe mental illness may enhance their skills and choice

• drawing up a rehabilitation treatment individual plan for each patient living in public and private residential facilities, highlighting personal objective and the desired outcome

• using the supported housing and vocational programs to promote discharge.

• planning a re-entry in their places of origin of patients placed in extra-provincial residential facilities

• improving the quality of the long-term treatment for patients with serious disability and progressive deterioration (so-called “patient without hope) .

• opening the MHDt to the community

Opening the mental health services to the community

The Mental Health Services System is not self-sufficient, but must develop and implement integration strategies with all the stakeholders, with the aim.

– to reduce the dependence of the service users on the mental health system

– to acquire the appropriate resources (jobs, houses, leisure facilities, educational opportunities) that are essential for the social inclusion in the ordinary community environments

Actions taken in the community

• Raising awareness with City Officials to gain housing (a model of supported housing).

• Creating awareness in Employment Agencies to increase opportunities.

• Involving no-profit organizations to support patients practicing social roles.

Tasks of case-manager

• Taking responsibility for the treatment plan and assessing the psychosocial outcomes

• Liaison with all practitioners and stakeholders involved in the treatment plan

• Support to users’ everyday lives. Contextual issues are explicitly present on the practitioners agenda

• Taking responsibility for users during hospitalizations too.

Strenghtening partnership with families and with Associations of families

The need of building a partnership between families and professionals stems from: 1. an high percentage of people with psychiatric disabilities

lives in family (more than 60%) and the most of patients dwelling independently or in the residential facilities has frequent contacts with the parents

2. the family both strongly influences the outcomes of treatments and plays a crucial role in the recovery of his relative.

Strenghtening partnership with families and with Associations of families

Some of the most important task of the mental health community practitioners toward families are: • to listen, understand, support, involve and orient

clients’ families, helping them to:– to cope with dysfunctional behaviours of relative,– to understand their meanings– To grasp the relative’s progresses and

• to maintain hope also when there are steps backward and relapses

How we support parenting role

• Psychoeducation (single and group sessions) • Mutual support groups of family members of

people who are experiencing onset of mental illness

• Mutual support groups of family members of people with mental illness in chronic phase

• Mutual support groups of families with relatives living in the residential facilities.

Promoting the assessment of quality of mental health services by Association of Families

• Periodical meetings (every three months) with the main Association of Families of people with psychaitric disability .

• Periodical meetings (every three months) with the main Association of Families of people with cognitive disability

• Periodical meetings (every three months) with the main Association of Families of people with alcohol or drug dependence or abuse.

Encouraging the birth of Associations of Users and their participation in services’ quality assessment

• MHDt of Ravenna fosters the growth of Users’

Association. At present there are two Association of Users that are seriously committed to educate the community about recovery and mental illness and to counteract the social stigma.

• Users’ Association or single users in recovery are involved as teachers in training programs of our Department

• Users’ Association or single users in recovery are involved in the planning of services and in the assessement of their quality.

User -centered programs: overcoming fragmentation between the differente component of MHDt and between mental health services and other health

services and social agencies

• In the last decades number of people with mental illnes that need integrated multifimensional interprofessional treatments is increased drammatically.

• There is need of going beyond services that works each on their own (failure of parallel model as well as sequential model)

• In this context, the «core» is person and his /her treatment plan and not services or professionists. Different competences are involved on the basis of the different needs of people. and not because practitioners belong to specific Unit or Service.

• This model implies to build an interprofessional team (practioners come from different Unit and service) and to plan perodical meetings between all practioners involved with the aim to rewiev the treatment plan

What targets of population are suitable for person-centered programs?

– People with Dual Diagnosis (practitioners «lended» from: Community Mental Health Centers , Psychiatric Rehabilitation Unit, Community Services for drug and alcohol abuse or dependence, Social Services)

– People with severe personality disorders (practitioners «lended» from: Community Mental Health Centers , Psychiatric Rehabilitation Unit, Community Services for drug and alcohol abuse or dependence, Social Services)

– Ealry intervention for young people with psychiatric disorders and disadapative behaviours (practitioners «lended» from: Community Mental Health Centers , Psychiatric Rehabilitation Unit, Neuropsychiatry Children Services, Community Services for drug and alcohol abuse or dependence, Social Services, Family Clinic)

– People with autistic spectrum disorder. There is a specitfiv program funded by Region Emilia Romagna

– People with mental illness in phase of remissione that have basic social needs (hpusing, employment, subsidies, economic resources to access meaningful social activities) (practitioners «lended» from: Community Mental Health Centers , Psychiatric Rehabilitation Unit, Social Services)

– People with intellectual disability (practitioners «lended» from: Community Mental Health Centers , Neuropsychiatry Children Services, Primary Care)

– Elderly people with phisical and mental illnees (practitioners «lended» from: Community Mental Health Centers , Primary Care , Social Services)

Person-centered programs: how to increase their effectiveness?

In order to increase effectiveness of person cenetered programs is necessary to define a network manager for each program, with the following task

• To join together the team at least weekly in order to rewiev the treatments’ plans

• To warrant that practitioner share information and all know the objective of interventions delivered by colleagues;

• The whole team is trained according to the most recent acquisitions in the field and it is responsible of expected outcomes.

Early intervention program

• Ealry intervention program takes in charge young people (fourteen years old to twenty years old) with: – signs of byopsychosocial vulnerabilty– prodromal simptoms – Clear pychopathology and/or disadaptative behaviuors, indicative of clear

psychosys.

• The program is carried on by a devoted interprofessional team, ( psychiatrists, psychologists, family therapists, case managers, expert in alchool and drugs dependance and abuse, social workers), coming from the varies services of Department or from other health services (family clinic) and from social services.

Eatly – intervention program

• Each of these practiontioners spends part of due work hours in order to deliver treatments and to participate in team meetings.

Work in progress: • Just in these days we are negotiating one/two devoted practioners , that

are expected to take officially part in the team, with social services as well as we are going to plan a training course, aimed to give the appropriate tools whole team. The course will start in september and will involve all services taking part in the program.

• A Primary Care Departement is expeted to partecipate in the program in the next future and in the way that have to be defined yet.

Program for people with Intellectual disability

• Ri-examination of the whole population of users with intellectual disability (adults and under eighteen years old) living in the public and private residential facilities, with the aim to verify the quality and the effectiveness of care planning and the outcomes.

• Identification of standards of clinical practice, orienting the long-term treatment for patients with intellectual disability and progressive deterioration.

• Implementation of EB Psychosocial Practices in all settings of care (in home as well as in the in residential facilities) , through learning of shared method, aimed to increase personal and social functioning and to decrease dysfunctional behaviours.

• In other words, paying a greater attention to tools and methods that counteract the disabling effects of cognitive disability on the person and his enviroment implementing such knowledge in clinical practice, so that services and treatment must reorient the approaches towards emphasizing resources and strengths and minimizing peoples deficits. .

• In order to realize the last point, we agreed a shared training with Social Services that will build the basis for a integrate model of take in charge.

Some barriers that prevent from implementing persone –centered program and tema work

1. The same clinician has the responsability of specific functions (delivering EB treatment) as well as of generic functions (liaison with general practitioners and general hospital, forensic psychiatry, bureaucratic and adminitrative tasks, night or holiday shifts in psychiatric ward).

2. Often there is a conflict between generalist model and EB prctices model

3. Italian managers and practitioners aren’t used to work in team, to share knowledges, to peer supervision and to life long learning and workplace continuous trainig. Most of us have been leanrnig to work in isolated and fragmented way for years, with the complicity of academic culture.

4. So sometimes new way to approach the complexity breeds strong resistance to change, expecially among those who have been used to intervene on symptoms only and not on the whole person.

Results of process of change (2007 – 2011)

General results: • Increased level of professional competence (knowledges, abilities and attitudes) and motivation

of the workforce. • Increased quality of the delivered services through the development of a competent workforce. • Decreased recourse to psychiatric residential facilities. • Increased number of patient living in the residential facilities who has been able to obtain and

maintain a job or to attend education classes. • Increased number of persons discharged from the psychiatric residential facilities, using the

supported housing and vocational programs.• Increased satisfaction of families, more involved in the treatment plan of their relatives. • Containment of the costs due both to the staying in psychiatric residential facilities indefinitely

and to the increase of hospitalizations owing to lack of rehabilitation: • Increased cooperation between professionals and families.• Increased adequacy of treatments, since the patients are been replaced in residential setting

according their levels of functioning and the desired outcomes. • Some patients gained capacity to support clients with severe dysfunctional issues.• Improved families-relatives relationships.

Results of process of change (2007 – 2011)

Results relating to gained social resources

The continuous action of social awakening that the Psychiatric Rehabilitation Unit carried out has been able to gain some essential resource to make the process of de institutionalization concrete and visible. The most important has been 11 apartments obtained from social services of the main local governments. Another significant result has been the increase of jobs for people with mental illness in the social cooperative.

Results of proecces of de-istitutionalization (2007 – 2011)

Results related to process of de-institutionalization. • 60 Patients discharged from the psychiatric residential facilities . As regard the

achieved outcomes of the supported housing program up to now, they are the following:– All patients discharged were able to live independently in their apartments, showing a

higher level of functioning than that one showed in the residential facility, and to maintain the apartments for more than six months.

– There weren’t turbulent relationships with neighbours.– From beginning of the process of discharging, two patients relapsed but they came back in

their apartments after a brief hospitalization.

• 120 Patients assisted in their housing (reduced use to psychiatric residential facilities).

• 120 Clients have lived in their housing or with family for more than six months, without hospitalization.

Further areas of improvement of MHDt of Ravenna

– Improving the level of integrated cooperation with Social Services and general practioners, especially for people with byopsychosocial needs

– Building focus groups with general practitoners in order to: • Highlighting the main difficulties that general practitioner have to deal

with when they assist a persone with mental illness• Highlighting the main difficulties that general practitioner have to deal

with when they interact with mental health community based services • Defining how to support each other and to share information more

efficiently

– Improving the level of integrated cooperation with our provider accreditate private hospital in order to orient it to EBPs and recovery priciples.