Modernization of Psychiatric Service to a Community Model

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Modernization of Psychiatric Service to a
Community Model

• Dr. Hung Se-fong
• The President
• Hong Kong College of Psychiatrists
• Conference onPromoting Community Mental Health
  Issues, Achievements and Visioning into the
  Future17 December 2009

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Are we good enough for our Patients?
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Current Psychiatric Service in HK Public-Private
Interface?

• Bulk of in-patient services specialist
  out-patient services (90) are provided by
  Hospital Authority
• Limited service provided by private psychiatrists
  due to high costs limited supply (only 10 of
  specialists are in private practice)
• Medical insurance does not cover mental illnesses
• Primary care paid by patient
• Specialist care paid by government

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Current Psychiatric Service Provisions (08/09)

• Total psychiatric beds
• per 10,000 population 5.71
• Psychiatric beds in standalone
• hospitals per 10,000 4.02
• Psychiatric beds in
• general hospitals per 10,000 2.37
• Number of psychiatrists
• per 100,000 population 3.11
• Number of psychiatric nurses
• per 100,000 population 28.3

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Current GapsManpower
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Current GapsManpower
International benchmarking of population
specialist ratio (as at 2005)
By 2009, the ratio in HK has now improved to
32110
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Current GapsManpower
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Expenditure

• Expenditure shifting from inpatient service to
  ambulatory service

• Financial Highlight
• Total Psy Service
• 1.5 (2,575M to 2,536M)
• Inpatient
• ? 7.8 (1,895M to 1,748M)
• Ambulatory
• 19.2 (547M to 652M)
• Community
• 1.5 (134M to 136M)

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Note The variations in total psychiatric
expenditure between 2003/04 and 2006/07 were
mainly due to annual salary adjustment
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Current GapsGovernment Expenditure
Mental Health funding of selected countries (WHO
Mental Health Atlas 2005)
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HA Psychiatric Beds Occupancy Rate
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No. of Psychiatric Beds/ 1000 people
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Psychiatric OPD attendance from
1992-2006transient phenomenon?

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Are we good enough for our patients?

• YES
• Dedicated, competent, efficient staff
• Cost effective service
• Beds available, bed no. comparable to UK
• Relapse prevention as good
• NO
• Whats missing

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Mental Health Services Reforms - Drivers

• Professionals initiatives
• Development in other countries
• Incidents
• Institutionalization
• Stigmatization
• Advances in medical treatment
• Value based versus
• Evidence based service planning
• Common mental disorder versus
• Severe mental disorder

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Mental Health Services Reforms Drivers (II)
Incidents
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(III) Institutionalization
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(IV) Stigmatization

• 9/10 people with mental illness reported negative
  impact of stigma discrimination
• 1/8 will not want to live next door to someone
  with mental illness
• 6/10 describe a person with mental illness as
  someone to be locked up in mental hospital
• 1/3 believe that people with mental illness
  should not have the same rights to a job as
  everyone else

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(V) Advances in Medical Treatment

• Mental illness is highly treatable nowadays
• Advent of effective pharmacological treatment
• Newer generation drugs have less side effect
• Possible benefits in negative symptoms
• More expansive

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(VI) Value based versus Evidence based
service planning

• New Horizon (UK)
• Equality, Justice and Human Right
• Social inclusion
• Tackling stigma and discrimination
• Reaching our full potential
• Prevention and Early Intervention
• High quality care Clinically effective
  evidence-based, personal, safe
• Being in Control of our lives
• Recovery, personalization, self
  determination
• Valuing Relationships
• Support for families and carers
• Skilled compassionate workforce

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Mental Health Services Reforms Oversea
Reference
Australia
UK
- Closing down of Mental Hospitals
- Rebuilding of new facility
in DGH - ?Beds

• Crisis Home,
• Supervised Lodging
• - Crisis resolution and
• Home Treatment Team (CRHT)
• Community Mental Health Team (CMHT)
• Assertive Outreach and Recovering Team (ASOT)

• - Community beds (CCU)
• - Prevention, Assessment and
• Recovery Centre
• - Crisis assessment and
• Treatment Services (CAT)
• - Mobile support Continuing Care Team

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Community Care Basic Rationale

• Least restrictive environment
• Patients are more effectively treated in a
  familiar environment than in the hospital
• Stigma can be minimized if patient can be
  assessed treated in the community
• Community treatment minimizes the chance of
  patient developing negative symptoms and become
  dependent
• Community treatment, if started early enough, can
  reduce the likelihood of in-patient treatment
• Recovery is more than just symptom control

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Closing Mental Hospital is Possible

• Team for the Assessment of Psychiatric Services
  (TAPS) Projects
• Leff J et al. (TAPS) Project 33 prospective
  follow-up study of long-stay patients discharged
  from 2 psychiatric hospitals. American Journal of
  Psychiatry 1996
• Leff J et al. (TAPS) Project 46 long-stay
  patients discharged from psychiatric hospital
  social and clinical outcomes after 5 years in the
  community. British Journal of Psychiatry 2000
• Improvement in use of community facilities and
  domestic skills
• Appreciation of increased freedom
• Very little change in psychiatric symptoms or
  social behaviour problems

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Community Care in Hong Kong

• Local data
• Cheung HK. A 2-year prospective study of patients
  from Castle Peak Hospital discharged to the first
  long-stay care home in Hong Kong. Hong Kong
  Journal of Psychiatry 2000
• Study on patients discharged to long-stay care
  home
• Significantly improved social and community
  skills
• Remaining behaviourally and symptomatically
  stable
• Chan GWL et al. Impact of deinstitutionalization
  on the quality of life of Chinese patients with
  schizophrenia a longitudinal pilot study. Hong
  Kong Journal of Psychiatry 2003
• Study on patients discharged to halfway house
• Significant improvement in objective quality of
  life indices

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De-institutionalization

• Experiences from overseas showed that poorly
  coordinated de-institutionalization process
  created various problems
• Increased readmission rates
• Homelessness
• Unemployment
• Criminal offences
• Medical non-compliance
• Not cost-saving

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Kwai Chung Hospital

• Kowloon West Cluster
• Cover ¼ population
• Downsized from gt 1600 beds in 1990s to 900 beds
  now
• Various rehabilitative projects

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Distribution of Public Hospitals and Institutions
NT East
NT West
Kln Central
Kwai Chung Hospital
Kln West
HK West
Kln East
HK East
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Kwai Chung Hospital Psychiatric Beds Occupancy
Rate
Hospital Beds 38 (1,622
to 1,000) Occupancy
Rate 14 (81.6 to 67.6)
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Average Length of Stay (1995/96-2007/08)

• ALOS of discharged inpatient 56 (185 days
  to 81 days)

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De-institutionalization Project (D Project)
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• 2001-2004
• Recruited 189 patients, discharged 116 patients
• Randomized Controlled Trial
• Intention to Treat Analysis
• Testing rehab efficacy of 2 interventions
• Case Management
• PREP (psychoeducational package)
• Demonstrated that Case Management is an effective
  means to discharge long stay severely mentally
  ill patients

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EXITERS (??????)

• Service since 2002
• 3 sites CPH, KCH, PYNEH
• Discharge extended-care mentally ill in-patient
  back to community (gt120 days LOS)
• Components
• Rehabilitation programs
• Home-like hostel setting (EXITERS Home)
• Case management model
• Target
• 5 year project (2003-2007)
• Pledge 35, 42, 50, 50, 50 DC from KCH in 5
  consecutive years

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EXITERS Home at KCH
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EXITERS Home at KCH
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EXITERS Home at KCH
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Results
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Gate-keeping Services (Designated Programs)

• AED EMW Support Services (PMH CMC) Nov 07
  gt
• AED EMW Support Services (YCH)
  Feb 09 gt
• Intervention for Frequent Re-admitters (IFR)
  Sep 08 gt
• Recovery Support Outreach Team (RSOT) Apr
  09 gt

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AED EMW support service

• On-site psychiatric consultation service to AEDs
  Emergency Medical Wards (EMWs) in PMH, CMC
  YCH
• Liaison with skill transferal to AED staff
• Staff  3 APNs in each hospital
• Working hours 7am-11pm
• Phone support by psychiatrists from 7am-11pm
• On site supervision by psychiatrists every
  morning from Mon to Sat

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Admissions via AE
No. of Admissions via AE ? 32
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EMW Service
No. of Admission from PMH CMC to KCH
EMW Services launched in PMH CMC from
11/07 No. of Admission from PMH CMC to KCH ?
21
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Readmissions
No. of Readmissions ? 10
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Telecare

• Service to patients on home leave or recently
  discharged (before first OPD attendance)
• Telephone contact by ward nurses
• 3rd day the patient left ward, the night before
  and ward follow up
• Counseling and advice to the patients

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Recovery Support Outreach Team (RSOT)

• Support acute patients in their early stage of
  recovery after discharge from hospital
• Run in 2 divisions (General adult teams)
• Each team 1 APN, 3 RNs, 1 OT
• At least 5 visits covering period after
  discharge 28 days to 3 months
• Weekly meeting, supervision by psychiatrist

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KCH Psy OPD attendance (1994-2008)
Psy OPD Attendances ?? 73 (99,447 to 171,630)
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Out-patient Service

• Backbone of comprehensive psychiatric service
• Linking community care and in-patient service
• Various disciplines stationed and work together
• Triage service
• Day hospital service
• Sub-specialty clinics

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EASY

• Three major components
• Information campaign
• Ready access
• Optimal management

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EASY Information Campaign

• Extensive media publicity to educate the public
  about the condition
• Workshops for frontline professionals such as
  social workers and primary care physicians

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EASY Ready Access

• Direct and responsive referral system
• Networking of the teams with the local primary
  care workers
• Interface with NGO, community agencies and family
  support
• Bridging programmes in NGOs providing a
  structured but stress-free environment helps
  their reintegration at school tremendously

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EASY Optimal Management

• Optimal pharmacological management but
  psychosocial management
• Intensive case management by designated case
  managers provide psycho-educaiton to patients and
  family, crisis intervention and outreach services
  to the clients and their families

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Suicide ratepre- vs post- EASY
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Trend of Community Service
CPT attendances ? 56 PGT attendances ? 88
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Case Management

• Among various models of community care, intensive
  case management (ICM) and assertive community
  treatment (ACT) have proven effectiveness
• A patient-centred approach
• Role of a case manager
• Assess, plan and implement treatment goals and
  care in collaboration with patient, carer and
  other team members
• Coordinate care across services for patient
• Point of contact and accountability for patient
  and family
• Accessible in times of crises

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Evidence

• Marshall M et al. Case management for people with
  severe mental disorders. Cochrane Database of
  systematic reviews. 2009
• RCT, versus standard community care
• Only case management (not ACT)
• Increased no. remaining in contact with services
• 2x admissions
• No significant advantages over standard care on
  any psychiatric or social variable
• Insufficient information for cost data

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Evidence

• Marshall M et al. Assertive community treatment
  for people with severe mental disorders. Cochrane
  Database of systematic reviews. 2009
• Randomized controlled trial
• ACT vs standard community care
• More likely to remain in contact with services
• Less admission and less time in hospital
• Significant and robust differences on
  accommodation, employment and patient
  satisfaction
• No differences on mental state or social
  functioning
• Less cost of hospital care, no clear cut
  advantage when other costs taken into account

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Intervention for Frequent Re-admitters (IFR
Team) ??????

• Establishment of mobile support team to cover
  frequently re-admitted patients in each cluster
• Case management approach
• Pilot programs in 2 clusters (Kowloon West
• New Territories East), run for 2 years and
  review
• Intensive psychiatric treatment and
  rehabilitation for in-patients and community
  support for out-patients
• Case management model
• 5-day week (Mon. to Fri.)
• Round-the-clock mobile-phone support (Mon. to
  Sun.)
• On-site crisis intervention/outreach visit (Mon.
  to Sun.)
• First near ACT model (staff-patient ratio
  lt120) in HK

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• Kwai Chung Hospital IFR Team launched in Sep 08
  (tagged 127 patients)
• Preliminary results (Sep 08-Oct 09)
• No. of admissions decreased by 89.2 (3.7
  admissions/month, baseline 34.2/month)
• Length of stay decreased by 76.7 (328
  days/month, baseline 1405 days/month)
• Maintenance cost to keep these patients in
  community / sustainability of service /
  generalizability to other patient groups

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Community psychiatry in Hong Kong the way forward
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Principles of service for SMI

• Least restrictive environment
• Shifting to a new balance with emphasis on
• community care
• Early detection / Intervention
• Increase accessibility and partnership with NGO
  and other care providers
• Phase-specific intervention with a range of
  in-patient, day-patient, rehabilitation,
  out-patient and community care facilities

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Modernization of Inpatient Service

• Hospitalization when in need
• Gate keeping to avoid unnecessary hospitalization
• Safe, homely, clean, pleasant environment with
  space / privacy
• Clear target of reintegration / recovery and
  early discharge
• Need to change both the hardware and software

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Community teams for SMI

• Early intervention teams? (Craig, 2005)
• Assertive outreach teams? (Burns, 2007)
• Home treatment crisis intervention teams?
• Step-up or step-down beds in hostels
• Crisis beds in hostels

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Just one or many teams?

• Fragmented care
• Value-based or evidence-based?
• Chinese culture?
• Small city

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Community workers add more hands?

• Training of community mental health workers
• Recruiting from graduates of Social Work,
  Psychology, OT and Counseling
• Separate career pathway?
• Re-engineering of roles of community ward
  nurses from routine ward work to providers of
  psychosocial interventions prescribing
  medication under protocols (Nursing Council, 2009)

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Recovery-based rehabilitation for SMI

• Emphasis on personal recovery
• Permanent supervised small group homes vs.
  independent living
• Supported work
• Supported education
• Volunteer service
• Expert user participation

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Community treatment orders?

• Now in form of conditional discharge in HK
• Recapture in face of violations of conditions
• How extensive for effective community care?
• Treatment vs. coercion?
• Reducing length of stay?
• Reducing admissions?
• Acceptability to all?
• Resource implications?

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Common mental disorders can we cope if better
detected?

• Depression / Anxiety disorders13-15
• Highly treatable yet under-recognised by GPs
  general public
• Hurdles of recognition
• - low awareness among people and
  professionals
• - stigma
• - inaccessible unacceptable service
• Increasing demand without exit strategies
• Private psychiatric care is inaccessible to the
  general public due to costs and availability
  (lack of mental health insurance)

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Common mental Disorders shared care

• Shared care liaison teams
• - Close collaboration between specialists
  primary care

Tiered Model for the Management of
High-Prevalence Disorders
Specialist Psychiatrist for Complex problems
Specialist Psychiatrist
Primary Care Doctors
Teachers, social workers, TCM practitioners
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Improving access to psychological treatments

• Empirically validated psychological
  treatments in OPD

Stepped Care Model for Psychological Treatments
Psychotherapy team For complex problems
Clinical psychologists/medical psychotherapists
Nurses/social workers/occupational
therapists/counselors
Primary care doctors TCM practitioners teachers
etc.
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Re-engineering of OPD

• Better environment
• Practitioner-led clinics
• Designated clinics for
• different disorders
• Special centres for highly
• complex disorders
• Psychiatric clinics in
• accessible, acceptable settings

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Community Mental Health Education

• Population level public education experience
  with patients media coverage celebrities as
  role-models
• Targeted group at-risk individuals
• e.g. -at-risk incipient psychosis
• -substance abuse
• -postpartum depression
• -self-harm presenting to casualty
• -prison/forensic population
• -care home population
• - school children with conduct
• -physical illness with pain
• conditions

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Enhancing mental health care

• Expert Group on
• Mental Health Service Development
• HA Mental Health Service Plan
• HKSAR CE policy address

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Evidence-based policy?

• No local epidemiological data in past 20 years
• Such data sheds light on health care needs
• Health care resource allocation
• Testing out specific culture-specific hypotheses
  of mental illness
• Culturally competent relevant interventions

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Conclusions

• Mental health problems are common
• Mental illness are highly treatable
• Rising demand cost for mental health care
• Lack of coherent mental health policy
• Optimal balance of community, in-patient
• outpatient care
• New roles of mental health professionals
• Research

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Mental Health Policyin HK?

• Does HK need one? HK College of Psychiatrists

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Recommendation (1)

• Cost-effective, accessible, equitable and humane
  treatment
• Public health problem
• Involving all stakeholders
• Separate funding
• Coordinate service development and delivery of
  both the medical and social sectors
• Commitment to comprehensive psychiatric care from
  early detection to active rehabilitation and
  aftercare

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Recommendation (2)

• An optimal balance between hospital bed provision
  and community care
• 8. Early detection, timely intervention and rapid
  crisis prevention, as well as on addressing
  issues of accessibility
• 9. Prioritising resource allocation according to
  areas of pressing need namely SMI, common
  mental disorders community mental health
  education.
• 10. Extensive campaigns in combating stigma and
  sustainable public education

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Recommendation (3)

• Clinical evidence robust scientific data
• Epidemiological study
• Research
• A roadmap for training manpower planning of
  mental health professionals.

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Strategy and Priority

• Enhancing service for age-specific severe mental
  illnesses (Level 1)
• Strategies to tackle common mental disorders
  (Level 2)
• Community mental health education (Level 3)

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Thank you!
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