New tools for mental health care into the community: participative health democracy, mobile teams, host families, ambulatory cares, supportive housing The experience of Eastern Lille Suburbs : Mons en Baroeul, Hellemmes, Lezennes, Faches Thumesnil, Ronchin, Lesquin
Dr DEFROMONT Laurent Head of service Public Mental Health Trust Lille-Métropole Our catchment area : Eastern Lille Suburbs : Mons en Baroeul, Hellemmes, Lezennes,Faches Thumesnil, Ronchin, Lesquin Our cactchement area
1 DIRM – EPSM Lille-Métropole The territory
6 municipalities, Eastern Lille Suburbs, 26 km²
84 193 inhabitants – Urban zone Eastern Lille Suburbs: Mental Health care needs
Mental Health in General Population study 2008
Number of Number of Number of people persons with inhabitants Impact Help and with a suicidal Aged of more at least one Number of perceived on Feeling of support found risk average or than 18 yars trouble at the inhabitants day life in the close high* old MINI* being ill circle *
85 300 63 790 22 710 11 482 14 662 3 636 5 592
People in care in 2014 : 3184 persons
*** Mini International Neuropsychiatric Interview SMPG NPDC Care utilisation – Perceptions “Imagine you’re unhappy. You have difficulties in your life. You’re feeling dissatisfaction100 and discomfort. You don’t know where you stand. You don’t understand what’s happening to you. Your state of mind is deteriorating”.
80 Who would you talk about that in first ?
60
42,3 40 38,4
20
11,8 7,3
0,2 0 General practicionners Psychiatrists Relations Nobody Others responses WHO recommendations for Europe: offer effective care in community (Helsinki Declaration 2005)
- Provide proximal care and crisis care, offering services where people live and work, preventing deterioration or hospital admission whenever possible
- Plan and implement specialist community-based services, accessible 24 hours a day, 7 days a week, with mobile multidisciplinary staff, to care for People in need of MH care
- Provide residential services in the community and develop rehabilitation services
- Empower service users and carers to access mental health and mainstream services and to take responsibility for their care in partnership with providers.
- Design programmes to develop the caring and coping skills and competencies of families and carers.
- Forster mental health promotion, prevention and information
- Effective partnership with primary care services and general hospitals
- Develop training and research activities in community mental health
- Cross sectorial linkage : Health, social protection, enployment, housing, justice, education, leisure…
AN EFFICIENT SYSTEM OF CARE: a whole system of care . A: Facilitating access to care Decrease the number of severe troubles leading to hospitalisation
. B: Early and continuing community based care Adjust to people needs: provideacceptable cares Prevent relapses, reccurences… it happens in the city Coordination with every care providers, emergency department, general practionner…
. C : Supporting social integration considering the disability Ensure the maintenance of health and the recovery Leisure, culture, employment, housing 1. Social perceptions in general population: a brake on access to care The “insane”, the “mentally ill”: it’s always someone else, it cannot be me
Mental health in general population study conclusions:
• Being “insane”, “mentally ill” is still strongly linked with violent and transgressive behaviours (murder, rape, incest, being violent against others…)
• Psychiatric hospital is still perceived as a place where “insane” and “mentally ill” persons must be locked. It is widely consider as the only care option
• Anyone can accept to identify his/her self to a “depressive” The general population consider that a “depressive” person must be cure at home with the help of his/her GP and family or other carers
• The general population think that a family can welcome back at home someone “insane”, “mentally ill” or “depressive” if he/she has been cured 2. Link with other partners
Or why it is impossible to work alone… Population expected versus population in care in one year At least one trouble at % of people with at the MINI in general least one trouble at the population MINI in care in one year
Depressive episodes 11.7% 1.39%
13 Données SMPG Data from MHGP and RIMP Develop Health Democracy
Integration in the territory organisation for health, mental health and citizenship
Participation of service users
Means offer high quality cares Communal Council for Health, Mental Health and Citizenship (MH local council)
An organisation (NGO) gathering 6 towns’ mayors, citizens users or not, families, artists, cultural services, Low Income Housing services, curators, social services, sanitary services, MH services.
Local elected official as the NGO President
A health thinking vision on the territory Communal Council for Health, Mental Health and Citizenship (MH local council)
1- A health thinking and vision on the territory 2- A functional NGO for supportive housing and insertion of people in MH « handicap » situations 3- Actions of prevention, MH promotion, information: - « Well being workshops »: co chair users – carers/professionals aim to raising awareness, forster destigmatisation and mutual support - Training for suicidal crisis management 4- Coordination of partners in the territory: - Group of complex situation analysis - Local Health Contracts Develop health democracy means support users and carers participations
Mutual support groups “Amitié Partage” “ les Ch’tis Bonheur”
- Etoile Bipolaire, Bipolar Star - Alcoolique Anonyme, narcotique anonyme ... - Le Réseau Entendeurs de Voix (REV) Hearing Voicers - Aftoc... (OCD French NGO)
UNAFAM (Family and Carers National NGO) Involve service users in the policy of the mental health service – Users forum – Elected users spokesman – Working groups for services organisation – Activity Sharing : training, information to the population – Awareness an destigmatization actions... Health democraty
Forster a co-design process of the MH services: users participation and involvement (Empowerment)
* Users forums – Elected users spokesman
* Development of participative gathering « Parole aux usagers » with peer support workers (médiateurs de santé)
* Data collection and analysis of service users inputs, users participation to events analysis and resolution proposals, restitution of users opinions and proposals
* Involvement of elected users spokesman in decision making bodies (general steering comitee, task forces) 3. Acceptable care providing for the population : EARLY, CONTINUING, COMMUNITY BASED CARE MH Services oriented by and for Recovery
Actions and services are based on :
1- une dynamique optimiste (positive, réactive avec des propositions multiples)
2- « l’éducation thérapeutique » : mobilise les connaissances des théories de l’éducation pour aider les personnes à développer des connaissances ou des savoirs-faire qu'ils jugent utiles
3- la responsabilité personnelle – l’auto-gestion (boite à outils « bien être », plan de crise)
4- le soutien au développement d’un réseau de soutien durable
* Copeland (1997) Wellness Recovery Action Plan, Broché, Paris
MH Services oriented by and for RECOVERY Recovery as a basis of action
. Role of « peer health mediators » ( peer support worker) from 2 to 5 persons . Partnership with self help groups and supportive peer networks – Encourage access to peer supporting and mutual help . Staff training by « expert of experience » users (from users NGOs) – Themes : « what does help / what doesn't help), care pathways... . Well being works shops (Ateliers mieux être) co- animation users / professionnals Valorisation of users experiences and expertises
- Among professionnals – Role of the peer support workers : « peer health mediators» – Training sessions run by users representatives (Self Help NGO etc)
- MH promotion, prevention, information – Ateliers mieux être - Well being workshops – Training for suicidal risk management
-In care and self help – Partnership with self help and supportive networks
- In the local policy and health democracy in the territory – Participation of local users and carers NGO
- Participation of users in the services organisation – Users forum (2012) in the city : qualitative assessment, quality process assesment – User Spokesmen election (2015) – Spokesmen elected participation (2016) in organisationnal meetings and working groups
* Davidson et al (2009) Handbook of service user involvement in mental health research (pp. 87-98). Chichester: Wiley-Blackwell.
76% of MH professionnals in ambulatory care
Psychiatrists, Psychologists, Nurses, Social Workers, Body Therapists, Peer Support Workers, Artists, Sports Instructors, Occupational Therapists, Health Managers, Social Managers, Cultural Managers...
Mobility of all professionnals trough the territory and the services HUMAN RESOURCES – 01 2016 76% of MH professionnals in ambulatory care New care demands
Systematic letter from the user General Practionner Early reception less than 48 hours in 90% Evaluation : free and structurated interwiews and questionnaires (MINI +/ - MMS), suicidal risk assessment If crisis or emergency: immediate assessment by a doctor (medical service on call 24h) Multidisciplinary evaluation (twice a week) Systematic mail of response to the user GP
=) 1084 new care demands in 2015 New demands increasing evidence of access to care facilitation
New demands
1200
1099 1093 1094 1100 1081
992 1000
900
816 826 800 721 724 700
600
500 2007 2008 2009 2010 2011 2012 2013 2014 2015 Consultations providing : Medico – psychological services of proximity (SMPP): Proximity, 10 spots of consultation Wide range of opening hours (9h-20h) and Saturday morning No waiting list Emergency consultation sessions (psychiatrist, psychologist, bodytherapist) Nurse presence 7 days a week (consumer’s home essentially)
Link with primary care services Mail to the GP (no prescription) Treatment delivery by private nurses and pharmacists
People in care in 2015 : 3200 persons Un contact with 4,85 % of the population
File active annuelle nombre de suivi
3300 3184 3092 3130 3029 3100 2916 2900 2793 2673 2886 2904 2700 2799 2774 File active Rim-P 25002384 2661 2572 File active totale 2507 2300 2336 2100 1900 1700 1500 2008 2009 2010 2011 2012 2013 2014 2015
the regional rate of acces of care is : 3,4 %
Psy.breve n4 : « le RIMP est il apte à décrire les prises en A amariei FR2SM
charge psychitrique et leur beneficiaires ? » L Plancke, Intensive care integrated in the city (SIIC) Intensive home care treatment : availability and mobility
• Availability for emergencies • Interventions at home : psychiatrist, psychologist, nurse, social worker • Mean lenght of stay 15 days
Aims: Early intervention Crisis management Intensive cares to limit trouble consequencies Avoid care disruptions Shortened the time of hospitalisation 255 persons in intensive care in 2015 700 emergency interventions Intensive care integrated in the city (SIIC)
Working with the environement :
- Preserve the familial and social network: support the carers - Essential role of carers in the pronostic of mental health troubles - Avoid care disruptions: create markers for access to care
General practionner Constant involvement: joint consultations to define the collaboration Pharmacist: treatments providing Private nurse: treatments deliveries at home
Mobile teams contribute to destigmatisation by their networking and their various places of intervention Host families (short term) alternative to hosptialisation
8 possibilities of hosting/ 6 families
Project : 16 possibilities of hosting...
Mean length of stay : 15-21 days
Full time and global care providing Territorialisation of the attention
Not only dare for people in beds. Necessy of an adaptated territory (catchment area)
Presence 24h/24 in the city - Psychiatrist on call available for emergencies and orientations, coordination of cares - Nurse : support, continuity between day and night cares
- Coordination - Telemedicine tools: emergency phone number spread to general practionner, emergencies unit in primary care hospitals… Mobile phones and computers - Conference call gathering all teams and units morning (9am) and evening - Daily contacts with emergencies services in primary care - Coordination of “risky situations” with high suicide risks - Electronic mails and agendas shared by every professionnals (open agenda for new demands, emergencies, orientations) - Computer user file (Cariatides)
Local suicidal rate
2007 2008 2009 2010 2011 2012 2013 2014 2015
France : 15/100 000 habitants suicide pour 100 000 pour le territoire 15,0 16,5 17,7 14,2 13,1 11,8 Données non encore accessibles
Suicide pour 100 000 pour les suivis* pas d'information 249,7 172,3 161,9 199,5 157 159,7
A stake: get information on suicides and death circonstances of persons in care to improve cares organisation
Source CépiDc Welcoming conditions are determinant in the future access to care
Clinique Jerome Bosch Open doors for every type of hospitalisation (compulsory, forensic)
Aim: 0 contention 0 seclusion
Liberty restriction must be an exception
New location in the Universitary Regional Hospital Center
CHRU 2013
10 beds (12 / 100 000 inhabitants)
+ 2 beds for accompanying carers Full time hospitalisation as an alternative to community cares
No direct orientation by general practionner
Mean length of stay (2014) : 7 days
148 compulsory hospitalisation for 100 000 hospitalisation
228 persons hospitalised in 2015
(347 for 100 000 inhabitants in 2015) C – ACCOMPANY THE SOCIAL INTEGRATION BEYOND THE HANDICAP :
HOUSING, CULTURE, LEASURE, EMPLOYMENT C- ACCOMPANY THE SOCIAL INTEGRATION BEYOND THE HANDICAP: HOUSING, CULTURE, LEASURE, EMPLOYMENT ACCESS
FRONTIERE$
Service of Contemporary activities Sagacité Filière travail art collection (cultural, sports, social…) Fernand Léger Frontiere$ integrated in the city Sagacity Art galery
Support users access to the benefits of physical, cultural, artistic, professional, volunteer, activities… to forster well being and social inclusion
De-stigmatisation of MH troubles promoting artistic practices CULTURE, LEASURE, EMPLOYMENT
« Frontiere$ »: Service d'activité et d'insertion intégré dans la cité SAISIC– Service of activities (cultural, sports, social...) integrated in the city
« Sagacité »: network with associatives activities
Fond d'art contemporain / contemporary art collection (intermunicipal association)
Employment support team Fernand Léger : Professional integration through : 1- Working life support center (CAVA) 2- Work based support institution and services (ESAT) Service of activities (cultural, sports, social...) integrated in the city (SAISIC Frontière$)
Benefit from the positive effects on mental heallth of artistic, sporting and professional activities
Service « outside the walls » providing activities in municipal facilities
18 activities divided on 32 time frames - Bien-être / Well being: esthetic, stimulation, body positive experiencing - Physical activities and nutrition: meals, therapeutic cooking, swimming pool, adjusted physical activities and collective sports - Artistic and cultural: singing, plastic – visual arts, engraving, music, bookbinding, theatre, cultural outing,,,
In 2012, 208 users have benefited from the SAISIC activities Activities provided all over the catchment area
16 places of activities disseminated all over the cities Social centres, retirement home, municipal swimming pools, municipal sportive centres, media library, associations
Partnership agreements and shared project with the welcoming places « SAGACITE / SAGACITY » device
From a protective environement to an integration into the city
Support user process of volunteering in social, cultural, artistic associations Support user process of registration in activities outside the mental health services
In, link with the associative and municipal network of the catchment area Contemporary art collection : Frontière$ - Border$
The contemporary art collection gather 450 art productions (painting) made by professional artists or not, users or not. The exhibitions of the collection is a tool of stigma tackling
The collection management, communication development and exhibition are shared with the local mental health council: l’Association Intercommunale Santé, Santé Mentale et Citoyenneté du territoire (AISSMC) Professional integration support team
Support the definition and the realisation of the users professional project
One key partner: Working life support centre / Centre d’Aide à la Vie Active (CAVA): volunteering agreement in the framework of the users assessment regarding working life
Other partners specialist of professional integration: Lille professional rehabiliation centre, local and municipal centres for professional integration, Cap Emploi and « Plateforme Handicap (specialists of professional insertion of people living with a disability) Centre le Centre Lillois de Rééducation Professionnel, sheltered employment organisations ESAT (traditionnal or in municipalities) « HabiCité » ReHabicity
Supportive housing service dedicated to: - Support users living with long term troubles in housing or support the housing access
- Forster autonomy and support the life project of users living with disabilities due to mental health troubles HabiCité - A mixed team nurses and social workers for 100 people in care at home
- Des outils d’intégration dans le logement * 20 supportive houses or flats and partnership agreement with social shelters of a case load of 60 users * André Breton residence 6 flats in community housing with professional presence 24h * 30 persons in individual housings
- Coordination with liberal nurses, GP, social services in the community
. Availability, Reactivity, Empowerment, Prevention
- Delelop the assertive approach (« l'aller vers »)
- Shift from an hospitalised based model to a territorial / community model inspired by public health and community health principles
- Not only care about people in hospital beds. A necessary practices shifting only possible with users involvement
- If you were experiencing yourself a MH trouble, what kind if care would you want ? Global funding for MH and psychiatry not the obligation to have beds and to use it.
- Forster the parnership private / users / hospital / civil society
Beyond cares toward recovery COHERENT AND EVOLUTIVE CARE SYSTEM
A whole system: notion of a global team
- No blocking in the system : create disponibilty to facilitate health paths - Responsability for the whole health path (priorisation, means utilisation)
Necessity to innovate
- Get out from the « hospital » constraint to develop community based services based on recovery principles
- Transform the health system in a continuous improvement tool (project management)
- Allocate funds and means to the population not to the institutions FROM ASYLUM TO COMMUNITY CARE Hospital care is an alternative to community care for
1972 85 300 inhabitants2016
10 beds in the general hospital, • 300 beds in open ward closed wards Ambulatory community care first • All compulsory (76% of the staff, mobile teams) treatments Variety of full time care in the community (home care, host families, acute home treatement…) Social inclusion together with all community partners (ie: 60 persons in associative flats) Organisation of CMH services of Eastern Lille suburbs '59G21' – 85 000 inhabitants based one WHO recommendations
Home care treatment and Housing + ACT team Crisis mobile team Habicité, S.Beckett, A. Breton SIICHost Families short term CMH Mobile teams AFT Social insertion SMPP Frontières Acute beds 10 Jérôme Bosch Primary Care GP, Private nurses, pharmacists General hospitals
Prevention, Self Help, Peer support, Sanitary democracy Local MH Council, users NGOs INTERNATIONAL NETWORKING : A SOURCE OF INSPIRATION Lille Founding member of the International Mental Health Collaborating Network : Mental Health and Citizenship (IMHCN)
– From asylum to the city (Trieste example, 1976) – Lille, 1977 – Family placement instead of hospitalisation 1 family = 1 bed (Madison, USA 1998) – Lille, 2000 – Home Care Service 7j/7 (Birmingham, 2000) – Lille, 2005 – Totally open wards (Merzig, 1997) – Lille, 1999 – Nurses in first line (Mauritania, 2001) – Lille, 2003 – Crisis centre 72 hours in Lille University Hospital, 2001 – Network with Gps (Oviedo, 2002) – Lille 2003 – Access to work by cooperatives (Trieste, 2003) – Lille 2007 – Clubs and volonteers (Quebec 1987, Luthon and Monaghan 2005) Lille 2006 – Peer support program (Canada 2008, USA 2009, UK 2009) Lille 2010 – FACT (NL 2012) Lille 2012 – User Involvement (UK 2008, Canada, UK, NL, It, Pot) Lille 2012.. – Staff training by users experts and partnership with Users NGO for self management (Canada, UK, Australia, Italie…) Lille 2013 – Flexible Assertive Community Treatment teams including peer support workers (Netherlands 2013) Lille 2015 Thank you for your attention
Contacts : - [email protected] - [email protected]