Recovery, Psychiatric Rehabilitation and Recovery, Psychiatric Rehabilitation and Community Integration: Community Integration:

The role of the Rehabilitation The role of the Rehabilitation Case Manager’s ServiceCase Manager’s Service

Max Lachman, PhD. & David Roe, Max Lachman, PhD. & David Roe, PhD. PhD.

The Laszlo Tauber Family Foundation The Laszlo Tauber Family Foundation Mental Health Community Dep’t , Mental Health Community Dep’t ,

Haifa UniversityHaifa UniversityIsraelIsrael

Outline of presentationOutline of presentation

Recovery, Psychiatric Rehabilitation and Community Integration – a theoretical framework

Psychiatric Rehabilitation in Israel

The Rehabilitation Case Manager’s new service

Research

What can we learn from the Israeli experience into the International Psychiatric Rehabilitation Movement

From Recovery to Community From Recovery to Community IntegrationIntegration

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The role of Self The role of Self DeterminationDetermination

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Values of Psychiatric Values of Psychiatric RehabilitationRehabilitation

Self-determination

Dignity and worth of the individual

Optimism or hopefulness for progress of improvement

Belief in the capacity of individuals to improve self, learn, and grow

Sensitivity/understanding to the culture of others

Core Values of PSRCore Values of PSR

Normalized Roles & Relationships

Potential for Growth

Pragmatism

Learn by Doing

Egalitarian Relationships

Holistic Approach

Blurred Professional Roles

Guiding PrinciplesGuiding Principles

Individualize services

Maximize client preference and choice

Ensure normalized, community basis

Focus on strengths

Use situational assessments

Integrate efforts with treatment holistically

Coordinate services, make them accessible

Emerging PrinciplesEmerging Principles

Multicultural Sensitivity

Consumer Empowerment

Family Role

HopeHope

Respect & DignityRespect & Dignity

Eclectic ApproachEclectic Approach

Outcomes Focus

Collaboration

“Recovery”

Prevention of Prevention of Hospitalization Hospitalization

Goal achievementGoal achievement

StrengthsStrengths

PSR Program ElementsPSR Program Elements

Prevention - Case Prevention - Case ManagementManagement

SocialSocial

ResidentialResidential

VocationalVocational

EducationEducation

Activities of Daily LivingActivities of Daily Living

Health & Well BeingHealth & Well Being

Community Integration DefinitionCommunity Integration Definition

Housing

Employment

Education

Health Status

Leisure/Recreation

Spirituality

The opportunity to live in the community and be valued for abilities and unique qualities

like everyone else Citizenship and civic

engagement

Valued Social Roles (e.g., marriage, parenting)

PEER SUPPORT

Self-Determination

Some data’s…Some data’s…

In Israel 7.500.000 citizens.

We evaluate 10 % of the population as having Disabilities.

70.000 – 120.000 Persons have Psychiatric Disabilities.

This is the bigger group from all the Disabilities groups.

People with Psychiatric Disabilities are underprivileged and suffer from discrimination.

Barriers to Recovery and PR implementation in Israel

Stigma

Hegemony of the medical model

Citizenship, war and recovery

No enough basic training in Mental Health policy and practice inside the Universities

Political base practice

Developments of the Israel System of Care

Reforms and deinstitutionalization process

Shift in societal attitudes towards persons with disabilities

Consumers movement (Family members & “Coppers”)

New legislation and government appointed committees reports

New LegislationsNew Legislations

Treatment of Mental Health Patient Act

1991

National Health Insurance Act

1995

Patient’s Rights Act

1996

Equal Opportunity for Disabled Persons Act 1998

Rehabilitation of Mentally Handicapped Persons in the Community Act

2000

Basket Rehabilitation Basket Rehabilitation ServicesServices

Admission Criteria

Types of services (“The Basket itself”)

Individual Choice and Partnership

The Role of the The Role of the District Rehabilitation CoordinatorDistrict Rehabilitation Coordinator

1. Responsible for all rehabilitation actives in their district.

2. Coordinates the committees for “basket of Services”.

3. Responsible for follow up on every client Plan in rehabilitation services in district.

4. Ongoing assessment of the need for new services in district.

Basket Rehabilitation Basket Rehabilitation ServicesServices

Admission Criteria

Types of services (“The Basket itself”)

Individual Choice and Partnership

0

2000

4000

6000

8000

10000

12000

14000

16000

1999 2000 2001 2002 2003 2010

Number of Persons using Psychiatric Rehabilitation

Services

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ChallengesChallenges

No data management at all levels (referrals are No data management at all levels (referrals are very poor in quality and quantity, no data very poor in quality and quantity, no data monitoring, no connection between the clinical monitoring, no connection between the clinical and the rehabilitation data)and the rehabilitation data)

Many clients are referred to rehabilitation Many clients are referred to rehabilitation without readiness to changewithout readiness to change

Many clients use services without connections Many clients use services without connections to their personal goals (self determination, to their personal goals (self determination, abilities development, motivation)abilities development, motivation)

The community service system (Health, Mental The community service system (Health, Mental Health, Welfare and Psychiatric Rehabilitation) Health, Welfare and Psychiatric Rehabilitation) is not coordinated and organizedis not coordinated and organized

(Marianne Farkas, (Marianne Farkas, 2006)2006)

The right according to The right according to the lawthe law

The right according to The right according to the lawthe law

The psychiatric rehabilitation law states that any adult with at least 40% Medical

Psychiatric Disability of has the right to apply to a Regional Rehabilitation Basket

Committee and present “an individual rehabilitation plan”. In a meeting with the committee, the person will be eligible to receive formal resources (services and

rehabilitation interventions) so he/she can reach his personals goals and implement

their individual plan.

Obstacles to the implementation of the law

Obstacles to the implementation of the law

Lack of motivation and involvement of the consumer during the plan creation. (domination of paternalistic attitude and forced elements during the process)

A lack of preparation and guidance in implementing the plan after the committee decisions.

"The client’s choice” throughout all the stages of the implementation of the plan is still limited.

Conflict of interests between the consumer ’ will and ability and the economics interests of services providers.

A lack of use of “Individual Rehabilitation Plan” as practice in the services. No systematic evaluation of micro-outcomes.

The policy and the practice in Psychiatric Rehabilitation is not based enough on evidences of the efficacy of the services to enhance personal goals of the clients. (E.B.P.)

The Service Definition

The “Individual Rehabilitation Plan – Case management Service” is a new

Rehabilitation Service to support persons with Psychiatric Disabilities.

(who applied and receive approbation to their personal programs from the

Regional Psychiatric Basket of Services Committee – Psychiatric Rehabilitation

in the Community Law-2000).

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New ServiceNew ServiceCase ManagersCase Managers

Consumers

Treatment

Family

Evaluation andRelationship

Rehabilitation Readiness

Individual Planning

Access to Services

Follow up

RecommendationsFor ending the process

ResearchResearch

Psychiatric Rehab.

Services

Ministry of HealthBaskets CommitteesRegional Coordinator

Community Services

Welfare, Heath

Rights

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o Strengths ModelStrengths Model- - Rapp C.Rapp C.

o Rehabilitation Readiness, Boston UniversityRehabilitation Readiness, Boston University, , Farkas M. et Farkas M. et al.al.

o Definition ofDefinition ofSetting an Overall Rehabilitation Goal Setting an Overall Rehabilitation Goal ((SORGSORG))

o Collaborative Goal Technology (CGT)Collaborative Goal Technology (CGT)- - Oades L. G. et al.Oades L. G. et al.

Prochaska and DiClemente’s Stages of Change ModelProchaska and DiClemente’s Stages of Change Model

o Recovery Interview – Lachman M.Recovery Interview – Lachman M.

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Values and AttitudesValues and AttitudesValues and AttitudesValues and Attitudes

The case managers will work in respect to the “client’s choice”.

The relationship between the client and the case manager will be base on the principle of self-determination and full partnership.

The main activities and tasks are:

1. Help the person access psychiatric rehabilitation services (defined by the regional committee) and follow the progress in achieving the different goals by the services. (Micro -Outcomes)

2. Assist the client redefine and initiate new plans and change to achieve more community integration and quality of life.

This support will be based on the client’s will, strengths, and This support will be based on the client’s will, strengths, and capacities in cooperation and support from the family and capacities in cooperation and support from the family and

others professionals involved.others professionals involved.

Ministry of Health, Procedure No 88.001

Service components – Tasks and Expectations

Service components – Tasks and Expectations

Mediation and brokerage between the client, the desire to build and advance an individual rehabilitation plan and the formal and informal resources.

Establish a systematic way of monitoring the Rehabilitation service of care.

Support and advocate the client voice in the decision process.

Identify and recruit community resources to strengthening the individual rehabilitation plan .

Make more resources available in the system by helping client use fit services, redefine needs and want and not be stock.

Case manager Activities and Case manager Activities and taskstasks

Case manager Activities and Case manager Activities and taskstasks

Individual support, given attention to the client preferences and will, follow-up and helping the process of change in a way the process of change can continue.

Tailoring the individual rehabilitation plans by listening and knowing the particular expectations and needs of the client.

Create coordination and division of tasks between all the partners (family, services, professionals and significant others).

Assist in the demands of the Law for individual follow-up.

Evaluation of outcomes (efficiency and efficacy of the services)

Give interventions to client for enhancing readiness to change and be able define personal goals.

Direct Professional activities

Direct Professional activities

Getting to know the clients and create a trust relationship.

Evaluate the client’ desire of change.

Define the the individual plan in the most operative level (objectives, tasks, scheduling, …)

Recruiting internal and external resources for the plan realization.

Knowing and being in contacts with the partners involved in the realization of the plan .

Reporting and document the activities to the service and the “Rehabilitation Basket Committee”

The Pilot deployment The Pilot deployment

The service will be available in two “rehabilitation areas:

An office will be established in each area, as a centre for operating the service.

Each service will included: a professional area coordinator, 15 “rehabilitation case-managers”, and administrative staff.

Most of the interventions will be provided close to the rehabilitation activity (mobility)

Main role of the rehabilitation case managers

Main role of the rehabilitation case managers

Accompanying and serve a caseload of 30-42 clients

Routine individual meetings with each clients for implementing and follow-up progress in their individual rehabilitation plan (at least twice a month)

Routine sessions with the rehab service providers' staff for consolidating the plan and gaining detailed information on the advancement towards achieving personal goals that were specifically defined in the plan.

Meetings with the program partners according to the need.

Recruiting essential resources for enhancing the chances of a successful plan.

Ongoing report on the daily activity and implementation of the program

Initiating changes in the plan with the approval of the rehab basket team in the Ministry of health.

Participating in staff meetings, individual counseling and various training programs

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Basic data on the service

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Numbers of referrals to the service by the Rehabilitation Committees

June 2009- Referrals 569 (63%) Active 526 (92%) Dec 2009- Referrals 862 (95%) Active 777

(90%) Feb 2010- Referrals 963 (107%) Active 843 (87%)

*service data-Feb 2010.doc

Gender males 613 (62%) females 363 (38%)

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Individual Rehabilitation coordinated Plan (IRP)

Focused on client’s wants and needs

Integrative rehabilitation plan for each client- plan per service vs. plan per person

Review of the plan every 3 months

The plan is computerized

IRP Template *Format for Individual Rehabilitation Plan-Feb 2010.doc

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Impact of Service on Rehabilitation System in Israel

Enhance Recovery values into the way services are giving to consumers.

Enhancing clients’ rights to choose services and plans.

More Focus on the Person instead of Service

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Study GoalsStudy Goals

Primary:

To assess the effectiveness of the RPCS intervention for individuals suffering from severe mental illness compared to individuals receiving regular rehabilitation services (the control group) and compared to baseline.

Secondary:

To assess different subgroups relative to the efficiency of the service (age, gender, services used etc..).

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Methodology Stratification and randomization: Stratification and randomization: based upon a based upon a

service-use and age stratification procedure.service-use and age stratification procedure.

Wave 1 within the first 2 weeks or 4 meetings of Wave 1 within the first 2 weeks or 4 meetings of service inception. Wave 2 after 20 month.service inception. Wave 2 after 20 month.

Assessment based upon 3 sources: Assessment based upon 3 sources: Structured face to face interviews Structured face to face interviews Clinician ratingsClinician ratingsMinistry of Health databaseMinistry of Health database

Two regions studied (Center North/South).Two regions studied (Center North/South).

Two control groups (Within & outside [Haifa]-of Two control groups (Within & outside [Haifa]-of RPCS region)RPCS region)

Number of Interviews

0

200

400

600

800

1000

1200

Ever In Service Currently In Service

Total

Interviewed83% 86%

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Data collection so far-Data collection so far- Wave 1Wave 1 Experimental & Control Experimental & Control GroupGroup

Total

Center (regions with service)

Haifa(control region)

Groups

South North

805 420 385 Study

713 202 110 401 Control

1518 622 495 401 Total

Service

Weight

Up to 30 years 31-55 years 55 years >

Expected

%

final %

Expected %

final %

Expected %

final %

Heavy 16 13 21 21 8 10

medium 12 11 17 21 6 6

Light 8 5 8 10 4 3

Stratification Results for ‘Veteran’ Users: expected vs. final sample*

*User status was primarily based upon the use of housing services (from intensive to slight use). If no housing facility was used, user status was based upon the use of vocational services (from intensive to slight use). Information for this classification was provided by the Ministry of Health. Results based upon experimental and control ‘Veteran’ sample. ‘New’ users didn’t use any services and were thus not part of the stratification procedure.

Interviews done since study inception:Overall Monthly

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Primary findings: Primary findings: Characteristics of 925 Characteristics of 925 participantsparticipants

43%

18%

39%

חיפה

מרכז צפון

מרכז דרום

Region

63%

37%חדש

ותיק

Status

59% are study participants and 41% control group

*

*Within the ‘New’ category there are between 15-25% veteran ‘Revolving door’ service receivers

Haifa

North

South

New

Veterans

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Characterization of Characterization of study and control study and control groupsgroups

Most participants are single and with only basic or Most participants are single and with only basic or lower educationlower education

Control Group Study Group

60.0% 61.4% Men Gender

Women40.0% 38.6%

42 years (12.6) 37 years (12.3) Mean Age (Sd)

*p<.001

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SCALE DOMAINS

•Goals Number & Kinds AchievementBarriers & Support

•Quality of Life (subjective and objective functioning) Physical Health Leisure Community Integration Residence Interpersonal/Social Employment Financial Education•Satisfaction•Optimism•Psychiatric Symptoms