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