implementing the community mental health care model in a large latin-american urban area

7/30/2019 Implementing the Community Mental Health Care Model in a Large Latin-American Urban Area

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62 INTERNATIONAL JOURNAL OF MENTAL HEALTH

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Raael Seplveda is the head o Psychiatry at the Barros Luco Hospital, proessor o psy-chiatry at Universidad Mayor, and senior lecturer at the School o Public Health, Facultyo Medicine, University o Chile, Santiago, Chile. Jorge Ramrez is a specialist in publichealth at the Mental Health Department, Ministry o Health, Santiago, Chile. Pedro Zitko isan epidemiologist at the Research Unit, Barros Luco General Hospital, Santiago, Chile. AnaMara Ortiz is an occupational therapist at Barros Luco General Hospital, Santiago, Chile.

Pablo Norambuena is a psychologist at the Mental Health Department, Ministry o Health,Santiago, Chile. lvaro Barrera, MRCPsych, M.Sc., Ph.D., is a consultant psychiatrist atOxord Health NHS Foundation Trust, Oxord, England. Cecilia Vera is a psychiatrist andhead o the Outpatient Psychiatry Department, Barros Luco General Hospital, Santiago,Chile. Eduardo Illanes is a psychiatrist and deputy head at Barros Luco General HospitalPsychiatry Services, Santiago, Chile.

International Journal o Mental Health, vol. 41, no. 1, Spring 2012, pp. 6272. 2012 M.E. Sharpe, Inc. All rights reserved. Permissions: www.copyright.com

ISSN 00207411 (print)/ISSN 15579328 (online)DOI: 10.2753/IMH0020-7411410105

Rafael Seplveda, JoRge RamRez, pedRo zitko,ana maRa oRtiz, pablo noRambuena,lvaRo baRReRa, CeCilia veRa,and eduaRdo illaneS

Implementing the Community MentalHealth Care Model in a Large Latin-American Urban Area

The Experience rom Santiago, Chile

ABSTRACT: This article outlines the development o the Barros Luco General Hos-pitals Psychiatry Service since its creation in 1968. Initially, some historical and

political background is provided ollowed by a description o how our service has

endeavored, over the last 10 years, to put the community mental health care model

into practice. Subsequently, we describe the growth o a network o locally based

mental health services. Another process running in parallel has been the acquisi-

tion, by the local primary care teams, o skills that have enabled them to manage,

on an ambulatory basis, patients with severe and enduring mental illness. In this

regard, some data are provided in order to illustrate the eect o the changes that

are taking place, including a reduction in the proportion o emergency psychiatry

consultations at the casualty department. Finally, current and uture challenges are


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discussed, including the need or a mental health law, clinical governance issues,

and the provision or people with developmental disorders and those with highly

complex mental health needs.

Mental and neurological disorders are a signicant public health problem world-wide. It is estimated that they account or 23.2 percent o the burden o illness inChile [1]. In the ace o this epidemiological reality, the patchy and largely insu-cient provision o mental health care led the World Health Organization (WHO) toemphasize the importance o countries to develop consistent mental health services[2]. In order to provide a ramework to undertake such a task, WHO has proposedsome guiding principles that mental health services development should ollow,

specically, the so-called community care model has been advocated because itensures that patients needs are at the center o the service development. The com-munity mental health care model emphasizes the importance o services beinglocated close to where patients live with a range o services available to peoplewith mental and behavioral disorders, including alternatives to hospital admission,such as home treatment and access to acute inpatient care as well as local accom-modation placements or patients that require more prolonged residential care. Themodel also emphasizes the importance o treatments and support being tailored tothe individuals needs as well as clinicians working with and addressing the needs

o caregivers. Similarly, clinical interventions must consider not only symptomaticremission, but also should address any associated disabilities with close collabora-tion between mental health proessionals and community resources. Finally, last butnot least, the provision o mental health care must take place within the context oan eective legal ramework [3]. Services delivered along these lines are consideredby WHO as providing community mental health care [4].

In the case o Chile, with the creation o the National Health Service in 1952,the country saw a gradual and signicant improvement in the health standards oits population, becoming one o three countries in Latin America and the Carib-

bean region with improving health care indicators [5]. However, at the time othe return to democratic rule in 1990 ater 17 years o military dictatorship, thenations mental health service was in a deplorable condition, even more so thanthe other areas o health care [6]. Since then gradual and signicant changes inthe provision o mental health care in Chile have taken place, and these changeshave attempted to ollow the above-mentioned model o community mental healthcare advocated by WHO. Initially, some changes started to occur between 1990and 1996 [7], but their scope increased with the momentous publication o theNational Plan o Mental Health in the year 2000 [8], which provided a route map

or the work and eorts o mental health proessionals over the ollowing decade.The gradual implementation o the National Plan o Mental Health encouragedthe transition rom mental health care revolving around the our large psychiatrichospitals located in the geographical center o the country to a network o regionalmental health services distributed around the country (Figure 1). It goes without


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saying that this change in itsel has led to improvements in peoples access to mentalhealth care [9]. Currently, each one o the main regional hospitals has general psy-chiatry services that are embedded in a network o mental health community servicesas well as primary health care units [10]. Unortunately, these changes in the waymental health care is provided in Chile have not been adequately communicated ordocumented. We believe that more detailed knowledge o these processes may behelpul both or those who are just preparing to embark on such changes as well asor those who are already in the process o change. The present article describes the

development o psychiatric services in the south o Santiago, Chiles capital city,where we have at least tried to ollow the community mental health care model.

The Barros Luco General Hospital in Southern Santiago, Chile:

Some History and Context

The Santiago South Health Service currently provides services or almost 900,000people who live in eleven communes, and it includes thirty-one primary care cen-ters and seven community hospitals with the Barros Luco General Hospital being

the largest hospital providing specialist (secondary and tertiary) medical care. Fordecades, and ollowing the priorities set at the oundation o the National HealthService in 1952, the ocus o the Barros Luco General Hospital centered on the con-trol o inectious diseases as well as improvements in maternal and child health. Inother wards, mental ill health was not at the top o the agenda at the time. Psychiatric

Figure 1

Stages of Developmental Psychiatry Service, Barros Luco General Hospital,19682009


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services centered on alcohol-related disorders as well as on psychotic disorders; thecare and treatment o the latter ocused around large national asylums.

The above situation started to change in 1968 when Proessor Juan Marconi andhis team o academics, clinicians, and residents moved rom the University o Chileto southern Santiago, a move probably not unrelated to the process o radical reormthat the University o Chile itsel was going through at the time. Proessor Marconisteam moved rom northern Santiago, where most o the university and public sectormental health acilities were concentrated, to the southern hal o the city, whichdid not have any resources at all up until that year; the newly arrived team startedtheir work both in the outpatient department o the Barros Luco General Hospitalas well as in a primary care center (the Santa Anselma Centre) [11]. Refecting on

their own practice and experiences o engaging with a local community, highlyorganized and politically aware, this group o academics and proessionals startedto develop what they called the intracommunity psychiatry model (ICPM). TheICPM was built upon and encouraged community health education and peoplesparticipation in the denition o the priorities and the development and implemen-tation o interventions through what was called a pyramid o delegation. Briefy,the pyramid o delegation ensured that the interventions, emphasizing health pro-motion, sel-care, and early detection, reached a very wide audience in the localcommunities. The pyramid consisted o ve levels, starting at the bottom with the

learning community (D5) level and at the top with the individual responsible orthe program (D1) [12]. Remarkably, the psychiatrists trained within the programacquired a clear community mental health ethos, and in act, some o them wouldsubsequently go on to play an important role in the development o Chilean mentalhealth. Proessor Marconis work, his ICPM, as well as the work o his team arestill widely acknowledged in Latin America.

In 1973, a military coup interrupted the countrys democratic tradition andestablished a dictatorship that lasted until 1990. The political conditions thatollowedhuman rights violations, drastic reduction o the size o the state and

public spending, massive unemployment, and social breakdownmade it impos-sible to work on a model that, like the ICPM, emphasized community engage-ment and participation. In that context, Proessor Marconis team had no optionother than to limit their work to what became the Barros Luco General HospitalPsychiatry Service (henceorth, the service). Thus, the service unctioned or 17years basically as an outpatient department in which the opportunities o collabo-ration amongst proessionals o secondary and primary care were very restricted,not the least because o the political environment. One o the rst victims o thisprocess o withdrawal into the walls o the hospital was, o course, continuity o

care. The result o this was that an increasing number o patients became caughtin what could be described as chronic ambulatory psychiatric care, a veritableorm o institutionalization not very dierent rom that inficted on people by largepsychiatric asylums. Because not many patients were discharged rom the service,it became increasingly dicult to assess and treat new patients. In act, or long


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periods, the main activity delivered by the services sta was to intervene duringthe postcrisis period o an acute episode o mental ill health and the subsequent

repetition o prescriptions with very limited clinical reviews [13]. In terms o stanumbers, there was also a reduction over the years so that in 1989 the service hadone nurse, one occupational therapist, two psychologists, seven psychiatrists, onenurse assistant, and one secretary, resources that were utterly insucient to meetthe mental health needs o the local population.

With the return to democratic rule in 1990, the new local authorities tried to start,not without diculties and errors, addressing the above situation. In particular,two actions revolving around reestablishing the contact between secondary andprimary care units were o particular importance. One step ocused on alcohol-

related and emotional disorders with a view to trying to control the fooding osecondary care level acilities by patients whose needs were best met at the primarycare level. An associated step was to start a gradual process o reerring the above-mentioned chronic ambulatory psychiatric patients back to the primary care levelwith a view o getting them back into their natural local health care network. Thisprocess was actively implemented and, despite the limited resources available,some o the psychiatrists started working directly with the primary care teams bothto help them to oster their clinical skills to manage the newly received patientsas well as to provide as needed direct clinical care or the more complex primary

care patients. It was this modality o care, developed out o necessity, that led usto envision the initial stages o the psychiatric consultation model that would laterbecome a distinctive eature o the relationship between primary care and mentalhealth secondary care in Chile.

While some o these changes were taking place, Chilean public opinion becameoutraged in 1993 as the media disclosed the extreme neglect suered by residents oa publicly unded private residential unit. The authorities responded to this scandalby somehow increasing the resources allocated to mental health. It was within thatcontext that the service was able to make some developments, such as emergency

admission beds, psychiatrists working at the Accidents and Emergency department,and the treatment and rehabilitation o addicts at the community level. Subsequently,the launch o the Day Hospital in 1999 was ollowed by, in 2002, the relocationo the psychiatric outpatient department to a new diagnostic center along with theother medical and surgical specialties. This setting made it possible to start oeringa variety o services to the patients. In 2003, change and development continuedwith newly ormed community psychiatry teams and the opening o a new acuteinpatient unit in 2004 [13]. Thus, the service has developed a multiaceted proleas the countrys largest general hospital-based psychiatry service.

Current Situation

The service currently provides mental health care or adults above 18 years o age,including people with addictions, with the sta levels described in Table 1. The


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services include an outpatient department, a twenty-eight-bed acute inpatient unit,a day hospital or twenty patients, a rehabilitation unit serving twenty patients, andan outpatient alcohol and substance dependence unit or twenty patients. Moreover,

there is a psychiatrist providing cover 24 hours a day/7 days a week at the hospitalsAccidents and Emergency department. In 2009, there were 14,000 consultations(including emergencies) as well as 336 discharges rom the acute inpatient unitwith an average length o stay o 27 days [14]. We will next briefy outline thecomponents o the service.

Outpatient Department

This department is organized around community psychiatry teams [15], each o

which is in charge o delivering care to the population o its commune within amodel o shared care [16] in close liaison with the districts primary care provid-ers [17]. These teams run outpatient clinics as well as regularly visit the primarycare centers, providing psychiatric consultation or the primary care teams. Thepsychiatric consultation model involves supporting primary care teams to developtheir skills in managing both patients with severe and enduring mental illness whoare currently stable or those patients who, although unwell, have not yet reachedthe threshold or reerral to secondary care. In 2010, aective disorder (bipolardisorder and depressive disorder) and schizophrenia and other psychotic disorders

accounted or just over 70 percent o the patients seen in the psychiatry outpatientdepartment.

More recently, outpatient care has started to be transerred rom the communitypsychiatric teams (made up o South Santiago Health Service sta) to district-basedcommunity mental health teams (made up o district/council sta); this has taken

Table 1

Barros Luco General Hospital, Psychiatry Service Staff, 1976 and 2011

Staff

Staff numbers Hours per week

1976 2011 1976 2011

Psychiatrists (within hours) 2 14 66 220

Psychiatrists (out of hours) 0 6 0 168

Nurses 0 8 0 352

Psychologists 5 11 220 286

Occupational therapists 1 10 44 330

Care assistants 2 16 88 704

Health care assistants 0 13 0 572

Administrative staff 0 5 0 220


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place in two districts so ar. The district-based community mental health team aimis to try and deal with mental ill health aecting people o all ages with the ex-

pectation that they will reer to the secondary care level unit (henceorth, reerredto as the service) only those more dicult, more severe, or treatment-resistantpatients (or whom the day hospital, the hospital inpatient unit, and the psychosocialrehabilitation unit will be available).

Day Hospital

The day hospitals work has developed as an alternative to hospital admission, pro-viding comprehensive care or patients with acute mental ill health. Its unctioning

has prevented hospitalizations and has also reduced the length o the admissionsto the hospital. The day hospital team has acquired experience over time in termso psychosocial interventions in amilies with high expressed emotion as well asin the psychoeducation o patients. It has been observed, in accordance with theliterature, that these interventions have had a positive eect on the course o theillness as well as promoting patients autonomy and sel-care, medication concor-dance, and engagement with psychosocial rehabilitation.

Rehabilitation Department

This department evolved rom the gardening and woodwork workshops that werepart o the existing services at the El Peral psychiatric hospital, one o two largepsychiatric hospitals in Santiago. The workshops initially evolved into a programthat supported the employment o ty patients as part o the Barros Luco Hospitalsta with jobs such as couriers, administrative sta, and cleaning. Unortunately,patients tended to remain in the same post or long periods, which led to the systembeing unable to provide more placements or new patients. When the situationwas critically reviewed, it was decided to increase the proessional input to it as

well as to emphasize the transitional nature o the hospital posts and the need tosupport patients to move toward competitive employment. The results o this newapproach have been encouraging, with 120 people having obtained and maintainedcompetitive employment posts.

Acute Inpatient Unit

This is a twenty-eight-bed unit with bedrooms o up to three beds each that aremanaged according to the patients gender and clinical needs. In 2010, aective

disorder (bipolar disorder and depressive disorder) and schizophrenia and otherpsychotic disorders accounted or just over 75 percent o the patients admitted tothe unit. The current average length o stay is twenty-seven days, which has recentlyincreased because o the prolonged stays o patients with developmental disorderswhose needs are not yet provided or by other services.


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Teaching and Training

Importantly, signicant teaching and training takes place at the service, includingthat o general adult psychiatry trainees as well as medical, nursing, psychology,and occupational health students. It is worth mentioning the general adult psychia-try training program o the Universidad Mayor medical school, which is uniquein that it is being developed and embedded within the community mental healthcare model [18].

Some Evidence of the Effect of the Implemented Changes

The structure described earlier has resulted in a reduction in the demand or emer-gency psychiatric care at the Barros Luco Hospitals Accident and Emergency de-partment [19, 20]. Just over 70 percent o patients requiring emergency psychiatriccare at the Accident and Emergency department come rom the hospitals catchmentarea, but the rest o the patients come rom adjacent areas that have less developedmental health community services. The proportion o emergency psychiatry patientsconsulting at the Barros Lucos Accident and Emergency department coming romits allocated catchment area compared to emergency psychiatry patients comingrom the adjacent catchment area has consistently dropped over the last 5 years

(down rom 4.27 to 3.02 during the period). We interpret this all in the ratio assuggesting a preliminary positive impact o the implementation o the communitymental health care model with the associated close work between the service (i.e.,the secondary care level) and the primary care level o this catchment area. Althoughthese gures may in part be accounted or by deciencies in data collection, it isour view that they support the above point, that is, the eectiveness o the commu-nity mental health care model to at least reduce unmet needs and thereore reduceunplanned emergency psychiatric consultations. Similarly, some evidence seems tosuggest that implementing the model has also been associated with a reduction in

the number o acutely unwell patients attending the day hospital [21]. Specically,the day hospital sees ewer acutely unwell schizophrenic or bipolar patients and hasbeen able to provide support to patients with severe depressive episodes, personalitydisorder patients in acute crisis, and patients with comorbid disorders (i.e., dualdiagnosis). At any rate, there are a considerable number o patients with highlycomplex unmet psychosocial needs who remain a signicant challenge [22] and whountil recently probably had no access to services at all. In particular, we have acedan increasing number o patients with comorbid psychoses and substance misuse,comorbid signicant learning disabilities and substance misuse, and patients with

organic brain damage and severe behavioral disturbances. Many o these patientsdid not come to the attention o services because their amilies and/or governmentagencies had given up on them; they suer a high degree o social exclusion andare highly vulnerable, and some o them pose a high risk to others. Our approachto these patients has included elements o promoting engagement with services,


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building continuity in their care, providing psychoeducation to their relatives andcaregivers, and incorporating them into rehabilitation. Some preliminary evidence

appears to indicate that these eorts may be improving their outcomes [23].Over the last 2 years, the service has started to gather evidence regarding the impacto the community mental health care model. In order to do that, a multidisciplinaryresearch unit has been created with input rom a psychiatrist, public health specialist,psychologist, occupational therapist, and epidemiologist. It is expected that this unitwill be able to provide evidence regarding the cost-eectiveness o the services work.Its main aims are to gather data to quantiy the changes in terms o readmission ratesand emergency consultations, and to develop instruments to map how the model isbeing introduced in the dierent areas o the services catchment area.

Challenges Ahead

We envisage three challenges that will need to be addressed in the near uture.First, the service, as any complex organization, has at times been torn betweenthe need, on the one hand, to develop dierent departments and expertise and, onthe other hand, the need to ensure the continuity o care, an essential part o thecommunity mental heath care model. This is a creative tension that we hope willprovide energy to the growth o the dierent teams. Second, we need to continue

transerring skills and responsibilities rom the secondary level unit (the service)to the district-based community mental heath teams while at the same time the ser-vice develops its skills and expertise to allow it to care or more complex patients.These two related processes will necessitate changes in the way the local primarycare level and the community at large deal with an increasing number o patientswho will require more long-term and specic care and support. Third, we need tobe able to gather reliable data at the dierent levels o the model to demonstratecost-eectiveness; this is a crucial issue i we are going to persuade authoritiesand skeptics that beyond the values that underpin the community care approach to

mental health it also oers value or money. Finally, we hope that by addressing theabove challenges the service will become a center o training and innovation thatmakes it possible or the model to be adopted in other regions o our country.

Conclusion

Regardless o whether the Barros Luco General Hospital has promoted the de-velopment o the community mental health care model or it has been graduallycolonized by the ideas and practices o that model, our service aspires to be part

o a mental health care network that goes beyond what is strictly considered healthcare and, in collaboration with the wider community, promotes recovery rom andghts the stigma associated with mental illness. We are aware that our service acessignicant challenges ahead and that urther growth and development are requirednot the least in terms o human resources and quality o the care delivered. Simi-


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larly, we realize that urther local progress will depend on clear leadership rom thecentral government, in particular providing evidence-based and patient-centered

policies and also making sure that such policies are consistently implemented acrossthe country. Finally, we believe that a mental health law that regulates the practiceo clinical psychiatry at all levels will be crucial i the quality o care is going toimprove, dignity and rights o patients are going to be protected and promoted, andthe stigma associated with mental illness is going to be deeated.

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implementing the community mental health care model in a large latin-american urban area

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