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Monaghan Community Mental Health Team

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1 Monaghan Community Mental Health Team
Modello Monaghan Un servizio di salute mentale comunitaria in una comunità rurale Margaret Fleming Clinical Coordinator Monaghan Community Mental Health Team

POPOLAZIONE TOTAL SQ. KM.3.300 TASSO DEPRIVAZIONE SOCIALE CAVAN 10.7% MONAGHAN 4.7% BUGET EURO PRO CAPITE 165 EURO Cavan and Monaghan seen here in red have a combined population of 109,000 and lie on the border of Northern Ireland and covers an area of 3,300 sq. km. The Small Area Health Research Unit deprivation index shows that In Cavan 10.7% of the population are living in deprived district electoral divisions Compared with 4.7% of the population in Monaghan Dependency ratio is higher than the National average whilst unemployment is slightly lower. Because it is a rural area the main employment areas are argicultural and small indiginous industries such as furniture manfacturing. Our buget is 18.5 million Euro and that translates to approx 165 Euro per capita. There are a total of 55 General Practioners covering the both counties 33 in Co. Cavan and 25 G.P.’s in Co. Monaghan.

3 Monaghan Carrickmacross Cavan Bailieborough
Tyrone Armagh Fermanagh Monaghan Carrickmacross Cavan Leitrim What we have is total population of 109,000 approximately. Total square Km is At the furthest points it is 70 miles from east to west and 60 miles north to south. In Cavan 10.7% of the population in Cavan live in deprived areas compared to 4.7% of the population of Monaghan. The resources available to us prior to the changes were four resource centres and two acute units, one in Cavan and one in Monaghan 7 Assessment Beds Elderly 4 occupied (average) Day Hospital CMX 14 places 12 occupied W beds avg 4 occupied Bailieboro accessing Resource centre SCH 24 Industrial Therapy 15 places avg Bailieborough

POSITIVI Comunità rurale Comunità coesa Famiglia non mononucleare ed estesa Cultura unica Basso indice di tossicodipendenza Basso indice di homelessness Integrazione NEGATIVI Area di competenza molto estesa Isolamento rurale Isolamento sociale Bassa densità demografica Poche infrastrutture Collocazione dei servizi Team di lavoro As you can see from the slide there are positives and negatives to a rural area. More recently we are beginning to see an increase in people from the all over Europe coming to work in Ireland IT USE TO BE THE OTHER WAY ABOUT in particular from the new succession countries such as Lithiuina Lativia etc as well as our refugee and aslyum seekers population which are posing new challenges for us such language barriers and lack of interpreteers our inexperience of cultural differences. However we are great believers in the statement of Socrates “ WISE MAN KNOWS THAT HE KNOWS NOTHING” ANCORA IMPARO I AM STILL LEARNING

5 INDAGINE SUL SERVIZIO Coinvolgimento dei servizi in caso di non adesione al trattamento:quale operatività in un innovativo modello nel campo della salute mentale Analisi del ruolo del medico di medicina generale referente Fenomeno“whirling door” : studio su un gruppo di persone con frequenti riammissioni Soggetti che sfuggono all’attenzione dei servizi psichiatrici Un’analisi sulle persone lungoassistite Cittadini che afferiscono all’ospedale psichiatrico Verso la chiusura dell’ospedale psichiatrico: uno studio sulle persone ancora ospiti Follow-up a lungo termine su persone dimesse con importante patologia psichiatrica Caratteristiche della presa in carico giornaliera a lungo termine in un servizio di salute mentale rurale irlandese Valutazione dei bisogni di persone lungo assistite che vivono nella comunità A service research programme undertaken by the Cavan/ Monaghan Mental Health service showed the following results. We had a high certification rate running between 61.5 and 86.5 per 100,000 of the population. While these rates were equivalent to national rates they were much higher than rates in neighbouring jurisdictions eg The U.K.

59% della popolazione risultava in carico 48% di questi frequentavano i servizi 30% veniva visto entro una settimana 36% veniva visto entro 4 settimane 6% necessitava di cure per 1giorno 40% necessitava di cure per 7 gg 54% necesitava di cure per più di 7 gg 57% aveva avuto almeno un contatto 17% aveva 5 o più contatti Of equal concern were the findings that 59% of certified patients were currently attending either their GP or the mental helath service with 48% of these attending the mental health service. Of those 48% attending 30% HAD BEEN SEEN WITHIN 1 WEEK AND 36% had been seen within 4 weeks of certification. With 40% been unwell for 1 week and 54% unwell for more than a week. 66% of people had dropped out of outpatient care by the 4th visit. Our research also showed that 4.6% of patients accounted for 23.6% of admissions and 18.3% of occupied bed days.

7 Risultati della ricerca
Mancanza di input su utenti dei servizi e sui carers Inadeguata focalizzazione sul paziente Ancora troppi esclusi dalle cure psichiatriche di base Eccessivo ricorso alle terapie farmacologiche Servizi basati sull’ospitalità notturna Concezione insufficente dell’ approccio (cura) comunitario Gruppi multidisciplinari ristretti Problemi nella gestione dei servizi Piano nazionale dei servizi obsoleto Servizio pubblico Carenze della formazione e dello sviluppo professionale Organizzazine clinica in via di sviluppo A picture begins to emerge of a service that Fails to recognise and address individual problems of people involved. A service limited in its ability to respond to acute relapse in ways other than certification. The need to phase out institutional beds and establish appropriate alternative facilities in the community The necessity for ungoing individulalised care programmes The importance of multtidisciplinary approache in assessing and meeting the needs of service users. The need for a much closer relationship between psychiatric and primary care services with protocols govering referral practice The need to proactively manage outpatient activity The need for partnership working with other statutory and non-statutory agencies. It was a task orientated service rather than a people orientated service. The aggregate of the research described a service that continued to base its treatment responses on traditional structures and practicies which were inefficient, ineffective, and not meeting peoples needs. We recognised the breadth and diversity of the needs of service users which required an whole systems approach that would facilitate recovery in all areas of people’s lives. What was operating was a bio medical model which is a closed system approach. Closed systems are very rigid and are based on dualistic thinking for example the right way and the wrong way. In healthcare this dualistic thinking has created the expert (the professional and the pateint.) Closed systems are not collaborative, they do not interact with the wider context. They are set and predetermined and in this system do not take the service users needs into consideration. The Expert determines. What we needed to do was to shift from a closed systems approach which is a medical model to an open systems approach (biopsychosocial model) which is based on collaboration, partnerships and teamworking to build networks of knowledge, people and agencies in order to provide an all inclusive untied mental health system that is person centred, needs led, family supporting, recovery orientated,clinically compented and flexible. and which was founded on the following principles. Centrality of service user / recipients needs and rights Delivery of individual effective treatment packages in the setting of home, family and community Empowerment participation partnership and citizenship Mental health is a community issue. A community resource based model has at its foundation housing, work, education, income, and other basic elements of citizenship. Rights to: Equality of opportunity. Economic security. Justice and respect. Freedom of speech. Freedom of choice. To be an individual. Self-determination. described a service, which continued to base it’s treatment responses on traditional structures and practices that were inefficient, ineffective and not meeting peoples needs. We recognised the breadth and diversity of the needs of service users which required an whole systems approach that would facilitate recovery in all areas of people’s lives. We shifted from a closed systems approach which is a medical model to an open systems approach (biopsychosocial model) which was based on collaboration, partnerships and teamworking to build networks of knowledge, people and agencies in order to provide an all inclusive untied mental health system that was needs led and which was founded on the following principles.

8 Organizzazione precedente al 1998
AGENTI DI RIFERIMENTO PSICHIATRI CONSULENTI TERAPIA OCCUPAZIONALE CONSULENZA PER LE TOSSICODIPENDENZE TERAPIA FAMILIARE TER. COMPORTAMENTALE ASSISTENTI SOCIALI INFERMIERI/CPN This is are referral pathway prior to regorganisation 1998? There were multiple access points into the mental health service where disciplines worked autonomously and in isolation. We can begin to imagine a service that is covering 2 counties 3,300 serving a population of 109,000 with 55 general practioners. Chaos comes to mind. PSICOLOGI AGENTI DI RIFERIMENTO


Carta dei diritti Stile tradizionale Supervisione top down (piramidale) Autonomia decisionale Fiducia nel ruolo, competenza specifica ben definita

11 Il cambiamento Evoluzione Innovazioni creative Miglioramento continuo
Pensare a sistemi aperti Pratiche basate sull’evidenza (scientifica) Management creativo improntato al cambiamento Resistenza Gestione sicura Controllo di qualità Procedura di sistema ben definita Pratiche abituali Amministrazione burocratica Continuous improvement – continually challenging or questionning your standards to ensure that they are meeting changing need. Quality control – meeting a pre determined defined standard. Like any living organism mental health systems either evolve or die. There is always a tension between conserving the status quo and change. To conserve the status quo, there is a reliance on fixed policies, traditional ways of doing things and ideas that have proved successful in the past. On the other side there is a need to adapt to change in conditions, changing needs, new ideas (top down legislation, commission of nursing, informed service users and carers, educated society, evidence based practice). Systems do not endure by rigidly resisting change, but by weaving change into the fabric of the organisation so that the organisation is always adapting and growing. It was important that we questioned our current assumptions and procedures, there was no recipe for developing new mental health systems. Ingredients may be put together differently in different places, according to resources and demography.

NESSUN FINANZIAMENTO EXTRA There was absolutely about it things needed to change we needed a fundamental regorganisation and redesign of service delivery and in the absence of any central planning and without additional funding. We went for a bottom-up approache. This strategic shift in the service was to include Flexibility in responses to service users needs and preferences A more community based service with closer links to primary care Alternatives to hospitalisation

Staff (non gruppi) OPPORTUNITA’ Esperienza passata Evidence based practice Convenzione PUNTI DI DEBOLEZZA Inflessibilità, passività Direzione medica / “lettocentrismo” “Ospedalocentrismo” Conseguenze dei ricoveri / certificazioni Mancanza di Coordinamento / Comunicazione Sottoutilizzo del personale Timori Cambiamento Resistenza Fallimento Professionismo Territorialità We carried out a SWOT anlysis our greatest strength as in any other healthcare system was our staff highly skilled talented and knowledgable. A magician can only pull a rabbit out of a hat if there is already a rabbit in it. Our rabbit was our staff. We had past experience of change We were successful back in the 70,s when we began to move people out of the hospital back to the community. There was a strong research culture and an openess and awarness of new ideas and of evidence based practice such as the work of of Dr. John Hoult, Lein Stein, Allen Rossen to name but a few. Our weaknesses as you can see were that we were structure centred rather than person centred medically tasked and bed orientated, problem focused, concerned with symptomatology, diagnosis with an over emphasis on medication clinical decions were been influenced by bed availability The research had clearly indicated thet we were passive and that people had to fit into existing services rather than the service meeting the individual needs of service users needs. The multiple access points lead to poor coordination and fragmented communication. The majority of staff were hospital based while the majority of service users were in the community this was a gross under utilisation of staff The threats of course are the same threats you will get in any organisation. It is difficult for people to change especially when they have invested years learning how to operate under a traditional system and therefore resistance should be seen normal. One of the major resistance forces to chgange is when people are not prepared to take risks there is fear of failure or disaster. However in healthcare we have the additional threat of professionalism and terroitorilism

14 VISION Fornire un sistema di cura personalizzato integrato, esauriente, di alta qualità, di sostegno e che risponda ai bisogni delle persone It is crucial when implementing change that everybody buys into it and that it is not change for the sake of change. The challenge was a mind set leap. A liberetion from traditional thinking to the creation of a new future. A vision is a dream, a hope for the future and it COMMUNICATES when it is shared and people believe in the importance of cooperation and partnership in creating that future This required a need for structures, systems and a cohesive framework to be put in place in which all disciplines could deliver a safe, effective, efficient quality service.

15 PRINCIPI un Servizio Competente
un Servizio con un unico punto di accesso, facilmente raggiungibile, disponibile e sensibile un Servizio che pone al centro la priorità dei bisogni e dei diritti degli utenti un Servizio che offre un efficace pacchetto individualizzato nell’ambito della casa e della famiglia The buliding blocks to transform a vision into a reality are principles We formed and agreed on 4 principles on which the service should build and they were and still are that it must be - A specialist service A service with a single point of access that is easily accessible, available, and responsive A service which has at its core the primacy of service users needs and rights A service which delivers an individualised effective treatment package in the setting of home and family

GSMC per disturbi acuti e crisi con cura infermieristica a domicilio GSMC per disagio mentale di lunga durata con assistenza infermieristica specializzata prolungata GSMC per persone anziane con disagio psichico di lunga data con assistenza infermieristica domiciliare GSMC = GRUPPO SALUTE MENTALE COMUNITARIA We opted for 3 functional teams each specialised in different areas and coordinated by a clinical coordinator. It was important that these 3 teams were well intergated 1 CMHT the focus on acute mental illness and crisis which is known as the CMHT 2 CMHT the focus on enduring mental distress which is known as the Community Rehabillitation Team 3 CMHT the focus on mental ill health in later life which is known as Psychiatry of Later Life

CHANGE AND STABILITY ARE POLES ON A CONTINUUM NOT OPPOSITES The reorganisation of the service required a balance between change and stability. Neither must not outweigh the other. We needed to maintain a service whilst at the same time creating change. Communication was vital to this process it must flow openly and freely in order to create a balance it is imperative to have close and ongoing relationships with people both within the service and outside. Communication is pivitol to the change process it is not about talking to people it is about talking with people listening to their views, opinios, arguments,and affording respect for all. Regonising that change can be difficult and frustrating Comprosing and negotiating. Instilling a sense of support partnership and cooperation and ownership. Ultimately people needed a stable predictable environment in order to continue to do their work. COMUNICAZIONE

INTERNO COSTRUZIONE DEL GRUPPO INCONTRI GUIDA DEL SERVIZIO POLITICHE OPERATIVE HBTT/ PORTINERIA SINGOLI PUNTI D’ACCESSO GRUPPO MULTIDISCIPLINARE HBTT = health based treatment team ( gruppo per il trattamento della salute di base) ESTERNO CREARE ALLEANZA INCONTRI CON I M.M.G. RASSICURAZIONE AZIONE In order to prevent the perception that HBT was an elitist group all disciplines were invited to a meeting where new ideas were explored, opinions were discussed, concerns were addressed. Each discipline was invited to present a formal presentation on their role and the services they provided. This ensured that each discipline understood, valued and respected each others role. It also helped in clarifying boundaries. This information was collated and presented in a published book form as a directory of services. And through discussion, agreement and consensus rules of operation were re defined and the policies for the future were agreed and we took on the name of the Monaghan Community Mental Health Team meeting the aspiration of a specialist service. A service that focussed entirely on acute mental health problems. A service that had at its core the primacy of service users needs and rights. The reorganisation of the service was founded on the following principles. Centrality of service users needs and rights Delivery of effective treatment package in the setting of home and family Minimum use of inpatient beds Responsiveness empowerment participation partnership citizenship

SVILUPPO DI ALLEANZE NELLA COMUNITA’ INCONTRI RETE TRA AGENZIE COLLABORAZIONI  COALIZIONI The bio-psychosocial model requires a need to develop networks and interagency collaboration to obtain skills in areas that were unfamiliar to mental health professionals. We developed coalitions with external agencies inviting them to meet with the multidisciplinary team in order to outline their area of expertise within the community, building access to community resources such as accommodation, education, employment and income because mental health is not exclusive to mental health services, mental health is a community issue and has at its foundation the basic elements of citizenship i.e.. Housing, income, employment, education and rights to, Equality of opportunity Economic security Justice and respect Freedom of speech Freedom of choice Right to self determination Community mental health is built on partnerships with service users, families, and significant others, it is about participation, collaboration, interagency and it is about interdependence not independence.

2 psichiatri consulenti 1 segretario dirigente 3 amministrativi 1 coordinatore clinico 6 operatori ADI 1 operatore territoriale di supporto 3 infermieri psichiatrici di comunità 1 segretario 1.5 psicoterapista cognitivo comportamentale 2 terapisti familiari 1 terapista occupazionale 1 Psicologo 1 assistente sociale 1 consulente alcologia 2 consulenti dipendenze 1 consulente per lutti 1 Consulente 1 terapista complementare Unità per acuti Day Hospital Centro risorsa “SOLAS” Consulente legale

2 Consulenti 1 responsabile amministarativo 3 amministrativi 1 Coordinatore Clinico 7 Operatori domiciliari 1 Operatore territoriale di supporto 1 Segretario 4 Cousellors sulle dipendenze 4 Infermieri esperti di comunità 1 Assistente Sociale 1 Terapista della Famiglia 1 terapista comportamentale 1 consulente esperto del lutto 1.5 Terapista occupazionale 1 Psicologo Unità per Acuti Day Hospital

1 coordinatore clinico 14 Operatori specializzati 6 operatori territoriali di supporto 1 Consulente psichiatra 1 Segretario dirigente 1 segretario 3 Infermieri psichiatrici di Comunità 3 Infermieri per la continuità terapeutica 0.5 assistente sociale 1 Terapista comportamentale 4 +1 strutture protette (50 posti 45 occupati +16 letti nella nuova sede) 12 Gruppi appartamento 55 Posti 38 occupati 1 Segretario

23 PSICHIATRIA DELLA TERZA ETA’ Catchment pop. 109,188
1Coordinatore 1Consulente psichiatra 1 segretario dirigente 1segretario 8 infermieri domciliari 3 operatori di supporto 1 terapista comportamentale 2 Segretari 1 Assistente Sociale Unità di valutazione 7 posti letto Day Hospital 10 accessi 2 operatori Terapia complementare Research in the British Journal of Psychiatry – 513 idenitifes that there is an astonishing variety of how community mental health teams are implemented at least in the UK They identify 7 types of community mental health team models. For example, generic multidisciplinary mental health teams, generic community mental health teams suplemented by crisis home based treatment teams, etc. Mueser et al 1998 in an overview suggests that regardless of the configuration of community mental health teams most studies show that community mental health teams bring about a reduction in length of stay in hospital. Service users prefer community mental health teams to more traditional services. The British Journal of Psychiatry – 502: The conclusion of this study showed that community mental health team management is superior to standard care in promoting greater acceptance of treatment, may also reduce hospital admission and may avoid death by suicide. This model of care is effective and deserves encouragement.

24 Monaghan Carrickmacross Cavan Bailieborough
GRUPPO RIABILITAZIONE COMUNITARIA (POP. 109,000) PSICHIATRIA DELLA TERZA ETà SERVIZI PER LE DIPENDENZE Community Mental Health Team Monaghan The resources available to us prior to the changes were four resource centres and two acute units, one in Cavan and one in Monaghan 7 Assessment Beds Elderly 4 occupied (average) Day Hospital CMX 14 places 12 occupied W beds avg 4 occupied Bailieboro accessing Resource centre SCH 24 Industrial Therapy 15 places avg Carrickmacross Cavan Community Mental Health Team Bailieborough

Our referral pathway is much more streamlined easily assessible I will now hand you over to Bridie Mc Donald who will outline how this is actually achieved. COMMUNITY REHABILITATION TEAM

26 Community Care Gardaí Acute inpatient Solas Primary care CPN S.W.
Admin CPN S.W. Self Help H.B.T. Advocacy Addiction Medical Secretaries Housing Coordinator Family Therapy Youth Groups Management Medical Team O.T. Where ever a group of people exist a system exists.From a whole systems thinking what we had prior to our strategic shift was a closed system which is a medical model IT IS RIGIT AND BASED ON DUALISTIC THINKING the right way and the wrong way THIS DUALISTIC THINKING HAS CREATED THE EXPERT (PROFFESSIONAL) AND THE PATIENT. Closed systems are not colloborative they do not interact with the wider context. The set pretermined and in this closed system or medical model service users are seen in terms of their diagnosis rather than as individuals and people become passive receipients of care. The biopsychosocial approache is an open system approache which is based on multiple discourse and the equality of each voice it does away with the concept that there is one way of knowinG to the concept that there are multiple ways of knowing. It focuses on the whole person and places greater emphasis on the uniquiness of the individual. It is colloborative and autonomous but remains connected. It promotes independence, personal growth, and achievement of personal potential. Where the service user is the expert and is an active participant. Research by Shepherd et al 1994 suggests that service users place greater emphasis on the social and practical aspects of life in the community. The provision of services to enable recovery requires more than a healthcare system. It requires a coordinated interdependent whole systems approach which includes multi sectoral collaborative alliances. Women’s Groups Behavioural Therapy Employment Education Psychology Voluntary groups Health promotion

27 Tasso per 100,000 abitanti over 16 anni
1997 Cavan/ Monaghan National Amissioni totali 639.5 959.8 Primi accessi 179.1 256.8 Rientri 460.4 703.0 Tasso certificazioni 53.06 105.6

28 Rates per 100,000 of the population over 16 years
2000 Cavan/ Monaghan National Amissioni totali 297.2 901.0 Primi accessi 104.8 270.5 Rientri 192.4 630.5 Tasso certificazioni 41.13 97.0

29 Rates per 100,000 of the population over 16 years
2001 Cavan/ Monaghan National Amissioni totali 270.7 907.1 Primi accessi 95.5 270.9 Rientri 175.2 636.2 Tasso certificazioni 59.7 99.0

30 Rates per 100,000 of the population over 16 years
2002 Cavan/ Monaghan National Amissioni totali 233.8 781.7 Primi accessi 79.9 233.1 Rientri 153.9 548.6 Tasso certificazioni 42.9 89.17

31 Rates per 100,000 of the population over 16 years
2003 Cavan /Monaghan National Amissioni totali 252 760.4 Primi accessi 84.8 219.8 Rientri 167.2 540.62 Tasso certificazioni 60.1 80.4

32 Research by Shepherd et al 1994 suggests that service users place greater emphasis on the social and practical aspects of life in the community. The provision of services to enable recovery requires more than a healthcare system. It requires a coordinated interdependent whole systems approach which includes multi sectoral collaborative alliances.

33 MMG: responso – valutazione grado di soddisfazione
Buon livello di comunicazione e relazione con lo staff Complessivamente valutato come un buon sistema e si auspica l’espansione verso i servizi per i disabili Urgenza / crisi – affrontate con efficacia ed efficenza Servizio di grande aiuto in grado di vedere l’utenza in crisi quando contattato dal mmg Molto piacevole lavorare con il servizio, è sempre di grande supporto e disponibile a rispondere alla crisi o ai bisogni urgenti. Servizio ottimo – Comunicazione eccellente.

34 MMG: responso continua………….
Accesso eccellente - Molto utile e disponibile Buona gestione dei posti letto (a volte molto difficile) – Esempio per altri servizi… Raccordo con una varietà di servizi – psichiatrici, terapia comportamentale, terapia occupazionale, psicologia, terapia familiare etc. La soddisfazione dei pazienti che possono essere seguiti sul territorio nelle loro case, presso le loro famiglie è tenuta molto in considerazione

35 Evaluation using the Verona Satisfaction Scale assess satisfaction with services on a five point scale across seven dimensions.

36 Overall level of satisfaction
G.P. 9% mixed 45% mostly satisfied 45% excellent Carer % mostly satisfied 35% excellent Cleint 12% mixed 48% mostly satisfied 36% excellent

37 The response of the service to crisis or urgent needs
G.P. 14% mixed 45% mostly satisfied 41% excellent Carer 7% mixed 60% mostly satisfied 26% excellent Cleint 3% mixed 60% mostly satisfied 28% excellent

38 The effectiveness of the service in helping patinets deal with their problems
G.P. 4% mixed 73% mostly satisfied 23% excellent Carer 10% mixed 57% mostly satisfied 29% excellent Cleint 3% mixed 56% mostly satisfied 40% excellent

39 Go to the people Live among them Start with what they know Build on what they have Be of the best leaders When their task is accomplished Their work is done The people all remark We have done it ourselves THANK YOU

40 Vai tra la gente Vivi tra di loro Inizia con quello che sanno Costruisci su quello che hanno Sii il migliore tra i leaders, Quando l’obiettivo è raggiunto, L’impresa è compiuta, Fai notare a tutti che lo abbiamo fatto insieme Grazie

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