The TAPS project 38: level of training and its availability to carers within group homes in a London district. Team for the Assessment of Psychiatric Services

Who cares for it? How to provide psychosocial interventions in the community

BACKGROUND

Since the Mental Health Reform Law 1978/180, in Italy mental hospitals have been progressively closed and a community-centred psychiatric care oriented to rehabilitation began. After almost 35 years, the de-institutionalization process is now complete. However, psychosocial interventions in the community are provided only rarely, although a specific mental health professional, the psychiatric rehabilitation technician, has been established in Italy.

MATERIAL

Training courses and the education of psychosocial rehabilitation technicians have been analysed and the university degree has been described. Moreover, the practical and theoretical skills needed at the end of the training course have been discussed.

DISCUSSION

Psychiatric rehabilitation technicians are trained to perform multidisciplinary rehabilitative and educational interventions for people with severe mental disorders and their carers. They represent an innovative professional workforce in mental health care, not yet established outside Italy, whose role and activities are essential in a community-based mental health system model.

CONCLUSION

The skills needed for properly performing psychosocial interventions are not available in other mental health professionals and it is not possible that these interventions, which require in-depth training, are performed by professionals with a different background. It is advisable that psychiatric rehabilitation technicians become an integral and permanent component of an efficient community psychiatric staff.

How does the residential care system change? A longitudinal survey in a large region of Italy

To describe 5-year changes in the provision of Residential Facilities (RFs) in a large Italian Region and in the characteristics of their staffing and patients. 2000 census data of all RFs with >4 residential beds in the Emilia-Romagna Region were compared with 2005 census data. The number of residential beds increased from 3.1 per 10,000 inhabitants in 2000 to 4.1 per 10,000 inhabitants in 2005. The RFs operated by private non-profit associations increased at a greater rate than the number of NHS-operated facilities, and the percentage of non-qualified staff has also risen at a greater rate than that observed for qualified staff. The number of individuals with comorbid substance abuse increased from 2.1% in 2000 to 5.7% in 2005. Patient turnover rates were low in both 5-year periods. A process of new institutionalization might be taking place. Mental health care policy-makers should take these findings into account to enhance the planning of effective services, including RFs granting a satisfactory quality of life to patients with severe disorders requiring long-term, eventually unlimited care.

The environment and staff of residential facilities: findings from the Italian 'progres' national survey

We administered structured interviews to managers and staff of a random sample of 265 Italian psychiatric Residential Facilities (RFs). Most are independent buildings, located in urban and suburban areas. The median number of residents is 10. The few RFs (5.7%) with more than 20 beds have a higher rate of drop-outs and escapes. The average indoor space per resident is 36 square meters, there is often a garden, and residents generally live in two-bed rooms. Most facilities are located within walking distance of shopping centers or recreational facilities. Three-quarters have 24-hour staff coverage. On average, each facility has about 10 full-time equivalent workers, with a staff:resident ratio of 0.92. Most of the professional input is provided by nurses and auxiliary staff. Critical issues to be considered in planning facilities include the physical environment, the size, and the staffing patterns.

Clinical and social outcomes five years after closing a mental hospital: a trial of cognitive behavioural interventions

BACKGROUND

To investigate the outcome of patients transferred from hospital to community care in Como, Italy after 6 months intensive psychosocial rehabilitation prior to discharge.

METHOD

All 149 residents with a primary psychiatric diagnosis were assigned to receive either a 6-month pre-discharge course of goal-oriented rehabilitation, (IT), or routine management, (RT). BPRS and GAF ratings were made by blind, independent assessors before and at 12, 24, 36, 48, and 60 months after discharge and the results examined with repeated measures analysis of variance.

RESULTS

Overall change in residence was achieved without any major detriment to the health and welfare of most patients. The cohort of patients who received intensive rehabilitation, (IT), prior to discharge showed significantly lower impairment and disability throughout the five years compared to the cohort receiving routine management, (RT), prior to discharge. Total BPRS scores remained significant when initial differences in the cohorts were covaried, whereas GAF failed to remain significant (p = 0.051).

CONCLUSION

The treatment provided prior to transfer from long-stay hospital to community residence may have long-term clinical benefits for chronically disabled patients.

Residential care in Italy. National survey of non-hospital facilities

BACKGROUND

In Italy, where all mental hospitals have been gradually phased out since 1978, psychiatric patients requiring long-term care are being treated in non-hospital residential facilities (NHRFs). However, detailed data on these facilities are sparse.

AIMS

The Progetto Residenze (PROGRES) residential care project is a three-phase study, the first phase of which aims to survey the main characteristics of all Italian NHRFs.

METHOD

Structured interviews were conducted with the manager of each NHRF.

RESULTS

On 31 May 2000 there were 1370 NHRFs with 17 138 beds; an average of 12.5 beds each and a rate of 2.98 beds per 10 000 inhabitants. Residential provision varied ten-fold between regions and discharge rates were very low. Most had 24-hour staffing with 1.42 patients per full-time worker.

CONCLUSIONS

There is marked variability in the provision of residential places between different regions; discharge rates are generally low.

[Psychiatric residential facilities in Italy. Results of phase I of the PROGRES project]

OBJECTIVE

The 'PROGRES' (PROGetto RESidenze' Residential Project) project has 3 aims: 1. To survey all Italian psychiatric Non-Hospital Residential Facilities (NHRF) (Phase 1); 2. To assess in detail 20% of the NHRFs and the patients living there (Phase 2); and 3. To carry on training programmes for the mental health workers of these facilities (Phase 3). We report here the results of Phase 1.

METHODS

All NHRFs were surveyed using a structured interview administered to the manager of the facility. In some cases, this information was supplemented with data gathered from other mental health workers at the NHRFs.

RESULTS

On May 31, 2000, there were in Italy 1,370 NHRFs with 17,138 beds, giving an average number of beds per facility of 12.5 and a rate of 2.98 beds per 10,000 inhabitants. This rate varies greatly between regions, with a ratio of 1:10 between the two regions with the lowest and the highest bed rates. Seventy-three percent of the NHRFs have a 24-hour staff coverage; more than 50% are directly managed by the NHS Departments of Mental Health and more than three-quarters of the NHRFs are directly funded by the NHS. In the course of 1999 38% of the NHRFs discharged no patients, and another 32% discharged fewer than 3 patients. In about half of the NHRFs the most common patient age group was 40-59 years. In the Italian NHRFs there are 11,240 full-time mental health workers, plus several thousand half-time staff. The average number of full-time mental health workers in each NHRF is 8.2. In 58% of the NHRFs the operational chief is a psychiatrist; some 40% of the overall number of mental health workers in the NHRFs have no specific psychiatric training. The total number of patients resident in the NHRFs is 15,943; among them, 58% have never been admitted to a mental hospital, 40% have been admitted and a small percentage (1.6%) has been previously admitted to a forensic mental hospital. The availability of NHRF beds is negatively associated with the availability of non-hospital facilities (e.g., community mental health centres, day-centres) and positively associated with the number of beds in private psychiatric facilities in each region.

DISCUSSION

The current rate of NHRF beds in higher than the officially recommended national standard (2/10,000 inhabitants). However, there is a great variability between regions, which is related to the overall provision of different types of psychiatric facilities. Most NHRFs provide intensive care, and the continuum of residential facilities with different types of care, support, degree of autonomy, etc. recommended by several authors for the long-term treatment of severe patients with different disabilities, seem to be lacking. NHRFs have a very low patient turnover rate, and this may create problems in the future.

CONCLUSIONS

The PROGRES project is the first national study ever carried out in Italy to evaluate a specific type of psychiatric facilities in the context of the new system of psychiatric care. When all the data will be available, it will be possible to assess in detail for the first time a national representative sample of severe, long-stay patients and the care they are receiving; on this basis, it will also be possible to recommend evidence-based policies aimed at improving the care of the severely mentally ill.