It’s Possible to prevent social It’s Possible to prevent social exclusion among mentally ill?: IPSE exclusion among mentally ill?: IPSE

Project, " Clinical Case Management Project, " Clinical Case Management " in Schizophrenic Patients in two " in Schizophrenic Patients in two

catchment areas in Madrid (Spain)catchment areas in Madrid (Spain)

MARIA FE BRAVO ORTIZMARIA FE BRAVO ORTIZPsychiatrist, M.D., Ph.D., Head of Psychiatric Psychiatrist, M.D., Ph.D., Head of Psychiatric

Department. Department. Hospital Universitario La Paz (Area 5, Hospital Universitario La Paz (Area 5, Madrid). Madrid).

Professor, Autonoma University. Professor, Autonoma University. Principal Research, Project IPSE Principal Research, Project IPSE

MAIN OBJECTIVEMAIN OBJECTIVE

A reflection about the impact of a A reflection about the impact of a clinical case management program in clinical case management program in the clinical and social outcome of the clinical and social outcome of schizophrenic patients, and its schizophrenic patients, and its possibilities of prevent exclusion in possibilities of prevent exclusion in these people. In this reflection I will these people. In this reflection I will analyse the results of the IPSE analyse the results of the IPSE Project. Project.

PROJECT IPSEPROJECT IPSE

The Project that is presented comes framed inside the The Project that is presented comes framed inside the evaluation studies of "Case Management" programs evaluation studies of "Case Management" programs and its impact in the treatment of people with and its impact in the treatment of people with schizophrenic disorders.schizophrenic disorders.

In our country the incorporation of these programs has In our country the incorporation of these programs has been later and they have not still been carried out been later and they have not still been carried out studies of effectiveness.studies of effectiveness.

Results about clinical features, and use of inpatient Results about clinical features, and use of inpatient (emergencies, admissions and stays) and outpatient (emergencies, admissions and stays) and outpatient (Psichiatric and Care Coordinator consultationa, and (Psichiatric and Care Coordinator consultationa, and use of specific rehabilitation centers) services of use of specific rehabilitation centers) services of schizophrenia patients referred to Case Management schizophrenia patients referred to Case Management Programs (CMP) from three Madrid Community Mental Programs (CMP) from three Madrid Community Mental Health Centers (Health Centers (corresponding to a population of corresponding to a population of 552.000 inhabitants552.000 inhabitants ) are shown. ) are shown.

WHAT ARE THE FEATURES OF WHAT ARE THE FEATURES OF CASE MANAGEMENT CASE MANAGEMENT

PROGRAMS?PROGRAMS? It organizes and coordinates the It organizes and coordinates the

whole attention and care for people whole attention and care for people with more admissions and difficulties with more admissions and difficulties to use the community and mental to use the community and mental health resources. health resources.

Keyworker assignmetKeyworker assignmet Written individualized planWritten individualized plan Clinical Case ManagementClinical Case Management

IPSE PROJECT IPSE PROJECT OBJECTIVESOBJECTIVES

To evaluate the effectiveness of Case To evaluate the effectiveness of Case Management Programs (CMP) in the Management Programs (CMP) in the improvement of the outcome of people improvement of the outcome of people with schizophrenic disorders in three with schizophrenic disorders in three Madrid Community Mental Health Centers Madrid Community Mental Health Centers of Madrid after two years of follow-up.of Madrid after two years of follow-up.

To identify the features that these CMP To identify the features that these CMP defines in each one of the studied defines in each one of the studied Community Services of Mental Health and Community Services of Mental Health and that they have a bigger impact in the that they have a bigger impact in the results in the clinical, social state and of results in the clinical, social state and of use of resources.use of resources.

SAMPLE:SAMPLE:N= 267N= 267

SCHIZOPHRENIA PATIENTS ATTENDED IN 3 COMMUNITY MENTAL HEALTH SCHIZOPHRENIA PATIENTS ATTENDED IN 3 COMMUNITY MENTAL HEALTH CENTERSCENTERS

Psychiatric Case Register data since 1985 (Emergencies, Admissions, Stays, Psychiatric Case Register data since 1985 (Emergencies, Admissions, Stays, Outpatient contacts)Outpatient contacts)

SCHIZOPHRENIA PATIENTS ATTENDED IN THESE 3 SCHIZOPHRENIA PATIENTS ATTENDED IN THESE 3 COMMUNITY MENTAL HEALTH CENTERS (CMHC) DURING COMMUNITY MENTAL HEALTH CENTERS (CMHC) DURING

2002 (N=744)2002 (N=744)

P.C. Register Data + Psyquiatric QuestionnaireP.C. Register Data + Psyquiatric Questionnaire

SCHIZOPHRENIA PATIENTS ATTENDED IN THESE 3 SCHIZOPHRENIA PATIENTS ATTENDED IN THESE 3 CMHC DURING 2002CMHC DURING 2002 AND INCLUDED IN CARE AND INCLUDED IN CARE

PROGRAMME PROGRAMME (N=267)(N=267)

P.C. Register data + Psychiatric Questionnaire + P.C. Register data + Psychiatric Questionnaire + InterviewInterview + Keyworker Questionnaire + Keyworker Questionnaire

INSTRUMENTSINSTRUMENTS Demographic Data: Demographic Data:

Gender, Age, Marital Status, Way of Living, Educative Gender, Age, Marital Status, Way of Living, Educative Level, Current Employment Situation Level, Current Employment Situation

Clinical Features: Clinical Features: Positive and Negative Syndrome Scale (PANSS) (Kay SR, Positive and Negative Syndrome Scale (PANSS) (Kay SR,

Opler LA, Lindenmayer JP., 1989); Opler LA, Lindenmayer JP., 1989); Disability Assessment Schedule (World Health Disability Assessment Schedule (World Health

Organization) (DAS); Organization) (DAS); Global Assessment of Functioning Scale (DSM-IV) (GAF)Global Assessment of Functioning Scale (DSM-IV) (GAF) Schizom Subscales (Fisher, Cuffel, Owen et al., 1996)Schizom Subscales (Fisher, Cuffel, Owen et al., 1996)

Use of Inpatient and outpatient ServicesUse of Inpatient and outpatient Services Data of Psychiatric Case Register (PCR) since 1985: Data of Psychiatric Case Register (PCR) since 1985:

Emergencies, Admissions and Stays, CRPS RegisterEmergencies, Admissions and Stays, CRPS Register

DEMOGRAPHIC DATADEMOGRAPHIC DATA

0

5

10

15

20

25

30

35

40AloneWife/ HusbandCoupleParentsFatherMotherSonsOther relativesInstitutionOther

WAY OF LIVINGWAY OF LIVING

0

10

20

30

40

50

60

70

80

SingleMarriedWidowedDivorcedSeparate

MARITAL MARITAL STATUSSTATUS

0

5

10

15

20

25

30

35

40

IlliterateWithout StudiesElementary SchoolSchoolHigh SchoolCollegeUniversity

EDUCATIVE LEVELEDUCATIVE LEVEL

0

5

10

15

20

25

30

35

40

WorkingSerching first jobNon working with helpNon working without helpPensionerStudentHousing workNon permanent disabilityPermanent disability

CURRENT EMPLOYMENT CURRENT EMPLOYMENT SITUATIONSITUATION

GENDERGENDER

65%

35%

Male Female

24%

44%

32% >10 Years

Between 5 and 10Years<5 Years

YEARS INCLUDED YEARS INCLUDED IN CASE IN CASE MANAGEMENT MANAGEMENT PROGRAMMEPROGRAMME

0

5

10

15

20

25

30

35

<13 years old

13-18 years old

19-25 years old

>26 years old

AGE OF ILLNESS AGE OF ILLNESS BEGINNINGBEGINNING

SOCIODEMOGRAPHIC SOCIODEMOGRAPHIC DESCRIPTIONDESCRIPTION :

Single men, with a mean of ages of 42,73 Single men, with a mean of ages of 42,73 years that reside with their parents. Their years that reside with their parents. Their educational level is Primary or Secondary educational level is Primary or Secondary School. They receive a a social benefit or School. They receive a a social benefit or permanent disability pension.permanent disability pension.

The disorder began between the 19 and The disorder began between the 19 and 25 years, with an average evolution of the 25 years, with an average evolution of the disease of more than 15 years. disease of more than 15 years.

44 % of the studied patients are between 44 % of the studied patients are between 5 and 10 years in the program, and 24 % 5 and 10 years in the program, and 24 % of them more than 10 years.of them more than 10 years.

CLINICAL FEATURESCLINICAL FEATURES

0

10

20

30

40

50

60

70

Personal care Occupationalfunctioning

Familiarfunctioning

familiar

Socialfunctioning

None

Mild help

Medium-low help

Medium-hight help

Great help

Severe disability

010

2030

4050

6070

8090

100

Spoken suicide lastmonth

Threatened suicidelast month

Tried suicide lastmonth

NO YES

SCHIZOM: SCHIZOM: SUICIDE SUICIDE

RISKRISK

DASDAS

ILLNESS ILLNESS AWARENESSAWARENESS

EEFGEEFG

0

10

20

30

40

50

60

Lowadherence

Medium-lowadherence

Medium-highadherenceHighadherence

0

5

10

15

20

25

30

35

No insight

Contradictory insight

"Psychotic" Insight

No PsychologicalInsight Psychological Insight

ComprehensiveInsight

0

5

10

15

20

25

30

35

40

1 to 2021 to 3031 to 4041 to 5051 to 6061 to 7071 to 8081 to 9091 to 100

0102030405060708090

100

Alcohol Drugs Total SubstanceAbuse

No abuse problems High probability of abuse

SCHIZOM: SCHIZOM: SUBSTANCE SUBSTANCE

ABUSEABUSE

0

10

20

30

40

50

60

70

80

90

100

None

Mild

Midium

Severe

SCHIZOM: SCHIZOM: CURRENT CURRENT

SYMPTOMSSYMPTOMS

0

10

20

30

40

50

60

70

Positive Symptoms Negative Symptoms General Psychopatology

Absent-Minimal

Mild

Moderate

Moderate-Severe

Severe

Extreme

PANSSPANSS

TREATMENT TREATMENT ADHERENCEADHERENCE

DASDAS

02468

101214161820

Mean= 6,39

0

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

CLINICAL CURRENT CLINICAL CURRENT SITUATION:SITUATION:

They have not presented clinical relevant They have not presented clinical relevant symptomatology recently; showing minimal or light symptomatology recently; showing minimal or light levels of positive, negative and general symptomatology.levels of positive, negative and general symptomatology.

In the main, they do not present problems of substance In the main, they do not present problems of substance abuse.abuse.

Low levels of risk of suicide.Low levels of risk of suicide. More than the half of them they have high adherence to More than the half of them they have high adherence to

the treatment.the treatment. The illness awareness is very poor, in general.The illness awareness is very poor, in general. They present major levels of disability, needing more They present major levels of disability, needing more

help, in the occupational functioning and in the social help, in the occupational functioning and in the social wide context.wide context.

With regard to their global functioning, in the main, they With regard to their global functioning, in the main, they present difficulties of mild to moderated.present difficulties of mild to moderated.

USE OF INPATIENT USE OF INPATIENT SERVICESSERVICES

010203040506070

YEAR OF INCLUSION IN CMP

ADMITTED SUBJECTS

-7 -6 -5 -4 -3 -2 -1 1 2 3 4 5 6 7

0500

10001500200025003000

YEAR OF INCLUSION IN CMP

DAYS OF STAY

-7 -6 -5 -4 -3 -2 -1 1 2 3 4 5 6 7

0

50

100

150

YEAR OF INCLUSION IN CMP

EMERGENCIES

-7 -6 -5 -4 -3 -2 -1 1 2 3 4 5 6 7

0

20

40

60

80

100

YEAR OF INCLUSION IN CMP

ADMISSIONS

-7 -6 -5 -4 -3 -2 -1 1 2 3 4 5 6 7

YEAR OF YEAR OF INCLUSION INCLUSION

IN CASE IN CASE MANAGEMENMANAGEMENT T

PROGRAMPROGRAM

USE OF OUTPATIENT USE OF OUTPATIENT SERVICESSERVICES

48%

52%

YesNo

PATIENTS INCLUDED IN PATIENTS INCLUDED IN SPECIFIC SPECIFIC REHABILITATION CENTERREHABILITATION CENTER

0

5

10

15

20

25

Psychiatrist

Care Coordinator

NUMBER OF NUMBER OF CONSULTATIONS IN 2002CONSULTATIONS IN 2002

USE OF INPATIENT AND USE OF INPATIENT AND OUTPATIENT SERVICES:OUTPATIENT SERVICES:

A significant reduction exists in the use of resources A significant reduction exists in the use of resources of hospitalization in those patients who are included of hospitalization in those patients who are included in CMP from the moment of their incorporation.in CMP from the moment of their incorporation.

They diminish both the emergencies, and the They diminish both the emergencies, and the admissions and the stays, as well as the number of admissions and the stays, as well as the number of subjects that have been admitted. subjects that have been admitted.

This reduction is kept throughout the yearsThis reduction is kept throughout the years 48% of patients are using specific rehabilitation 48% of patients are using specific rehabilitation

programs.programs. The average number of psychiatric consultations is The average number of psychiatric consultations is

1 every 2 months, and of care coordinator 1 every 1 every 2 months, and of care coordinator 1 every 15 days15 days

CONCLUSIONSCONCLUSIONS

Clinical Case Management programme Clinical Case Management programme reduces significantly the use of reduces significantly the use of inpatients and emergencies services, inpatients and emergencies services, contributing to the clinical stabilization contributing to the clinical stabilization of the schizophrenic patientsof the schizophrenic patients

CCM contribute also to social CCM contribute also to social stabilization and prevent exclusion stabilization and prevent exclusion among schizophrenic patientsamong schizophrenic patients