Tätigkeiten ohne Patientenkontakt

[Implementing a Global Treatment Budget for Psychiatric Hospital Services - What are Incentives, Requirements, and Challenges?]

OBJECTIVE

Since 2013, flexible and integrative psychiatric treatment models (FIT64b) have been set up in 22 German hospitals. FIT64b is based on a global treatment budget (GTB) covering costs for all psychiatric hospital services and is related to the number of patients treated. As part of the "PsychCare"-study we are examining incentives, requirements and challenges which relate to the introduction of FIT64b.

METHODS

Expert interviews and focus groups (n = 29) were led with management and controlling staff from 7 FIT64b adopting hospitals and 3 statutory health insurance funds (SHI). A thematic analysis was conducted.

RESULTS

A central component for the introduction of a GTB is a cooperative relation based on mutual trust between hospitals and SHI. Challenging are, above all, performance documentation and performance control of cross-sectoral treatment as well as the parallel structure of FIT64b and standard care.

CONCLUSION

Apart from several surmountable obstacles to implementation, the GTB seems to be a strong driver for the future-oriented transformation of psychiatric hospital services in Germany. In the further development of GTB, the obligation to contract with all SHI should be considered.

[Staffing of inpatient psychiatric facilities : A patient-oriented and guideline-oriented staffing concept]

BACKGROUND AND GOAL

According to § 136a (2) SGB V (volume V of the German Social Security Code) the German legislator instructed the Federal Joint Committee (G-BA) to specify binding minimum standards for the staff needed for the treatment in inpatient psychiatric and psychosomatic facilities. This induced the expert associations/organizations to develop their own conceptional approach as to the future organization of staffing.

METHOD

Organization of regular expert workshops, the results of which were systematically documented and validated by the experts.

RESULTS

The essential elements of the concept are: the starting points for the calculation are the needs of all patients treated in the institution. The need for treatment has three dimensions: (a) psychiatric psychotherapeutic/psychosomatic psychotherapeutic/pediatric and adolescent psychiatric-psychotherapeutic, (b) somatic and (c) psychosocial needs. The model developed by the platform distinguishes between staff requirements being directly related to the treatment of the individual patient, staff requirements caused by the treatment setting and such staff requirements arising at an institutional level. Minimum staff requirement is understood as the staff structure which is, among others, needed to guarantee the multiprofessional, physician-led treatment and the required medical care services for all patients specified by the existing guidelines or an expert consensus as well as to ensure the protection of the patient, fellow patients and the employees working in the facility against hazards.

CONCLUSION

This model considers the medical progress within the meaning of the evidence-based guidelines and the modified healthcare practice including sociopolitical standards aimed at the patients' self-determination.

[Impact of the Zeitgeist and human rights on psychiatric actions]

BACKGROUND

Implementation of the United Nations (UN) Convention on the Rights of Persons with Disabilities (CRPD). The idea of human rights developed during the era of the Enlightenment. This idea has been publicly discussed since the French Revolution of 1789 and its specification has been demanded politically. Important steps in this process were the General Declaration of Human Rights adopted by the UN in 1948 and the CRPD from 2006, which was especially relevant for psychiatric actions. Meanwhile, the idea of human rights has influenced the legislation in many countries and has thus become normatively binding, e. g. in the Basic Law of Germany, in the regulations for patient care and in the professional rules for physicians.

AIM AND QUESTIONS

To sensitize for reflection on one's own actions and to gain a critical distance from the general overall opinion. Then not only the global validity of the CRPD is frequently violated, as in crisis regions but also in the everyday routine when, for example, the workload prevents psychiatric personnel from taking time for essential conversations with psychiatric patients in order to support their self-determination.

MATERIAL AND METHODS

These aspects are illustrated and explained with the aid of multifarious examples from the relevant literature and from own experience.

RESULTS AND DISCUSSION

Human rights are a regulative idea that provide a framework and direction for psychiatric actions; however, as an idea they compete with other ideas that try to control the trends of the day (the Zeitgeist) that determine daily practice. Not only the suppression of human rights from public consciousness, e. g. with the eugenics in the first third of the previous century but also their absolutization and poor implementation, as in the Italian psychiatry reform of 1978, damage psychiatric patients. Therefore, it appears necessary to sensitize psychiatrists to reflect on the Zeitgeist and its influence on their own actions and to recognize that their own opinions and actions can also influence the Zeitgeist.

[Staffing levels and patient-related outcomes : Systematic literature review on international evidence]

The objective of this study was to systematically review the international literature with respect to significant links between staffing levels or qualification on the one hand and patient-related outcomes on the other. Of the initial 7778 abstracts identified by means of a complex search strand in PubMed and CINAHL, 51 could finally be included in a qualitative synthesis. A total of nine different patient-related outcome categories with significant associations on an at least ordinally scaled level were distinguished. None of the studies included had a (quasi-)experimental research design. Despite, in some instances, high numbers of cases at multiple sites and efforts to control obvious confounding variables by regression analysis, no evidence-based conclusions for health policy or clinical practice can be drawn from the available observational studies. There is therefore a considerable need for prospective randomized or at least quasi-experimental studies also as accompanying research on novel models of financing.

[Staffing level: Survey among psychosomatic-psychotherapeutic institutions in Germany]

Staffing level: Survey among psychosomatic-psychotherapeutic institutions in Germany Objectives: To establish the first nationwide hospital survey to assess the level of staffing for inpatient and daycare treatment in psychosomatic hospitals and specialist departments in Germany.

METHODS

Using a standardized written hospital survey from the Deutsches Krankenhausinstitut (DKI), we invited a total of 218 psychosomatic-psychotherapeutic hospitals and specialist departments to participate. The participation rate of the institutions was 35%.

RESULTS

In the overall sample, one psychotherapist (physician/clinical psychologist) was responsible for treating a median of 3.9 beds/patients (interquartile range 3.1-5.1) and one nurse a median of 2.9 beds/patients (interquartile range 2.3-3.9). There were significant differences for the nurse-patient ratio depending on the organizational size of the institution. To ensure quality treatment, professional experts saw increased staffing needs of about 12-17% across both professions. For the professional groups of specialist therapists and social workers, broad variances were observed for the therapist-patient ratio in the overall sample.

CONCLUSIONS

The study provides an important and relevant data basis for the further discussion to determine mandatory minimal staffing levels in German psychosomatic-psychotherapeutic institutions.