It’s Possible to prevent social exclusion among mentally

Report
It’s Possible to prevent social exclusion
among mentally ill?: IPSE Project, "
Clinical Case Management " in
Schizophrenic Patients in two catchment
areas in Madrid (Spain)
MARIA FE BRAVO ORTIZ
Psychiatrist, M.D., Ph.D., Head of Psychiatric Department.
Hospital Universitario La Paz (Area 5, Madrid).
Professor, Autonoma University.
Principal Research, Project IPSE
MAIN OBJECTIVE

A reflection about the impact of a clinical
case management program in the clinical
and social outcome of schizophrenic
patients, and its possibilities of prevent
exclusion in these people. In this reflection
I will analyse the results of the IPSE
Project.
PROJECT IPSE



The Project that is presented comes framed inside the
evaluation studies of "Case Management" programs and
its impact in the treatment of people with schizophrenic
disorders.
In our country the incorporation of these programs has
been later and they have not still been carried out
studies of effectiveness.
Results about clinical features, and use of inpatient
(emergencies, admissions and stays) and outpatient
(Psichiatric and Care Coordinator consultationa, and use
of specific rehabilitation centers) services of
schizophrenia patients referred to Case Management
Programs (CMP) from three Madrid Community Mental
Health Centers (corresponding to a population of
552.000 inhabitants ) are shown.
WHAT ARE THE FEATURES OF
CASE MANAGEMENT PROGRAMS?




It organizes and coordinates the whole
attention and care for people with more
admissions and difficulties to use the
community and mental health resources.
Keyworker assignmet
Written individualized plan
Clinical Case Management
IPSE PROJECT OBJECTIVES


To evaluate the effectiveness of Case
Management Programs (CMP) in the
improvement of the outcome of people with
schizophrenic disorders in three Madrid
Community Mental Health Centers of Madrid
after two years of follow-up.
To identify the features that these CMP defines
in each one of the studied Community Services
of Mental Health and that they have a bigger
impact in the results in the clinical, social state
and of use of resources.
SAMPLE:
N= 267
SCHIZOPHRENIA PATIENTS ATTENDED IN 3 COMMUNITY MENTAL HEALTH CENTERS
Psychiatric Case Register data since 1985 (Emergencies, Admissions, Stays, Outpatient
contacts)
SCHIZOPHRENIA PATIENTS ATTENDED IN THESE 3 COMMUNITY
MENTAL HEALTH CENTERS (CMHC) DURING 2002 (N=744)
P.C. Register Data + Psyquiatric Questionnaire
SCHIZOPHRENIA PATIENTS ATTENDED IN THESE 3 CMHC
DURING 2002 AND INCLUDED IN CARE PROGRAMME
(N=267)
P.C. Register data + Psychiatric Questionnaire +
Interview + Keyworker Questionnaire
INSTRUMENTS

Demographic Data:


Clinical Features:





Gender, Age, Marital Status, Way of Living, Educative Level,
Current Employment Situation
Positive and Negative Syndrome Scale (PANSS) (Kay SR, Opler
LA, Lindenmayer JP., 1989);
Disability Assessment Schedule (World Health Organization)
(DAS);
Global Assessment of Functioning Scale (DSM-IV) (GAF)
Schizom Subscales (Fisher, Cuffel, Owen et al., 1996)
Use of Inpatient and outpatient Services

Data of Psychiatric Case Register (PCR) since 1985:
Emergencies, Admissions and Stays, CRPS Register
DEMOGRAPHIC DATA
MARITAL STATUS
GENDER
EDUCATIVE LEVEL
40
80
35
70
30
60
Single
Married
Widowed
Divorced
Separate
50
40
35%
30
20
25
20
15
10
10
Illiterate
Without Studies
Elementary School
School
High School
College
University
5
0
0
65%
Male
Female
WAY OF LIVING
40
40
35
30
25
20
15
10
5
0
CURRENT EMPLOYMENT
SITUATION
Alone
Wife/Husband
Couple
Parents
Father
Mother
Sons
Other relatives
Institution
Other
35
30
25
20
15
10
5
0
Working
Serching first job
Non working with help
Non working without help
Pensioner
Student
Housing work
Non permanent disability
Permanent disability
AGE OF ILLNESS
BEGINNING
YEARS INCLUDED IN
CASE MANAGEMENT
PROGRAMME
35
30
<13 years old
20
15
10
5
0
24%
32%
25
13-18 years old
Between 5 and 10
Years
<5 Years
19-25 years old
>26 years old
>10 Years
44%
SOCIODEMOGRAPHIC
DESCRIPTION :



Single men, with a mean of ages of 42,73 years
that reside with their parents. Their educational
level is Primary or Secondary School. They
receive a a social benefit or permanent disability
pension.
The disorder began between the 19 and 25
years, with an average evolution of the disease
of more than 15 years.
44 % of the studied patients are between 5 and
10 years in the program, and 24 % of them
more than 10 years.
CLINICAL FEATURES
EEFG
PANSS
70
DAS
40
60
35
Absent-Minimal
50
Mild
30
40
Moderate
25
30
ModerateSevere
20
Severe
15
Extreme
10
20
10
5
0
Positive Symptoms
Negative Symptoms
100
90
80
None
Mild
50
Midium
40
Severe
30
20
10
0
En
y
erg
l
y
s
e
air
ce
ion
ing
oid
pp
t ro
in g
n c oice
ha aran Desp fide
on ll-b e feren cast ienat
V
tc
d
n
l
Un
P
Re
oa h t a
gh lf we
Co
r
u
b
o
g
t
Se
Th
gh Thou
ou
Th
1
2
3
4
5
6
7
8
100
90
80
70
60
50
40
30
20
10
0
Spoken suicide last Threatened suicide Tried suicide last
month
last month
month
NO
YES
100
90
80
70
60
50
40
30
20
10
0
60
50
None
Mild help
40
Medium-low help
30
Medium-hight help
9
10
11
20
12
10
Great help
Severe disability
13
14
Mean= 6,39
SCHIZOM:
SUBSTANCE
ABUSE
SCHIZOM:
SUICIDE RISK
SCHIZOM: CURRENT
SYMPTOMS
60
0
0
General Psychopatology
70
70
20
18
16
14
12
10
8
6
4
2
0
1 to 20
21 to 30
31 to 40
41 to 50
51 to 60
61 to 70
71 to 80
81 to 90
91 to 100
DAS
0
15
Personal care
No insight
25
Contradictory insight
20
"Psychotic" Insight
10
5
Drugs
Total Substance
Abuse
No abuse problems High probability of abuse
0
Social
functioning
60
30
15
Familiar
functioning
familiar
TREATMENT
ADHERENCE
ILLNESS
AWARENESS
35
Alcohol
Occupational
functioning
No Psychological
Insight
Psychological Insight
Comprehensive
Insight
50
Low
adherence
40
Medium-low
adherence
30
Mediumhigh
adherence
High
adherence
20
10
0
CLINICAL CURRENT
SITUATION:







They have not presented clinical relevant
symptomatology recently; showing minimal or light
levels of positive, negative and general symptomatology.
In the main, they do not present problems of substance
abuse.
Low levels of risk of suicide.
More than the half of them they have high adherence to
the treatment.
The illness awareness is very poor, in general.
They present major levels of disability, needing more
help, in the occupational functioning and in the social
wide context.
With regard to their global functioning, in the main,
they present difficulties of mild to moderated.
USE OF INPATIENT SERVICES
ADMITTED SUBJECTS
EMERGENCIES
70
60
50
40
30
20
10
0
150
100
50
0
YEAR OF INCLUSION IN CMP
YEAR OF INCLUSION IN CMP
-7 -6 -5 -4 -3 -2 -1 1 2 3 4 5 6 7
ADMISSIONS
YEAR OF
INCLUSION
IN CASE
MANAGEMENT
100
PROGRAM
80
60
40
20
0
-7
-6
-5
-6
-5
-4
-3
-2
-1
1
2
3
4
-3
-2
-1
1
2
3
4
5
6
7
6
7
DAYS OF STAY
3000
2500
2000
1500
1000
500
0
YEAR OF INCLUSION IN CMP
-7
-4
YEAR OF INCLUSION IN CMP
5
6
7
-7
-6
-5
-4
-3
-2
-1
1
2
3
4
5
USE OF OUTPATIENT SERVICES
NUMBER OF
CONSULTATIONS IN 2002
PATIENTS INCLUDED IN
SPECIFIC REHABILITATION
CENTER
25
20
Psychiatrist
48%
15
10
5
0
52%
Care Coordinator
Yes
No
USE OF INPATIENT AND
OUTPATIENT SERVICES:





A significant reduction exists in the use of resources of
hospitalization in those patients who are included in CMP
from the moment of their incorporation.
They diminish both the emergencies, and the admissions
and the stays, as well as the number of subjects that
have been admitted.
This reduction is kept throughout the years
48% of patients are using specific rehabilitation
programs.
The average number of psychiatric consultations is 1
every 2 months, and of care coordinator 1 every 15 days
CONCLUSIONS


Clinical Case Management programme
reduces significantly the use of inpatients
and emergencies services, contributing to
the clinical stabilization of the
schizophrenic patients
CCM contribute also to social stabilization
and prevent exclusion among
schizophrenic patients

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