Isr J Psychiatry Relat Sci Vol 43 No. 4 (2006) 252–257 A 10-Year Review of a Hong Kong Model for Mental Health Care of People with Intellectual Disability Henry Kwok Psychiatric Unit for Learning Disabilities, Kwai Chung Hospital, Hong Kong. Abstract: Following the movement from institutionalization to community care, there has been a transformation of services for people with intellectual disability over the past few decades. Kwai Chung Hospital in Hong Kong is a pio- neer in Asia that took the initiative of improving the mental health care for this underserved population by setting up a specialist unit called the Psychiatric Unit for Learning Difficulties (PULD) 10 years ago. This new service was estab- lished through re-engineering of existing resources and re-distribution of manpower within the psychiatric hospital. This paper reviews the work of PULD and examines its achievements. By sharing the experiences of PULD, it is hoped that health providers currently without such a specialist service can make similar reforms to enhance their provisions for people with intellectual disability and mental health problems. Introduction length of stay was remarkably long and some patients had been in the hospital for over 10 years Hong Kong is a city in the southern part of China. It without any discharge plans. has a gross area of 1,098 square km and a total popu- lation of about 7 million. Over 95% of the citizens are The need for specialized psychiatric services Chinese. According to government statistics, the Literature has consistently shown that psychiatric number of people with intellectual disability (ID) in disorders are more prevalent in adults with ID than Hong Kong is approximately 62,000 to 87,000 in the general population (2) and they do experience 2001, which represented a prevalence rate of about the full range of mental disorders (3, 4). However, 0.9 to 1.3 % (1). until recently, the area of mental health and chal- Kwai Chung Hospital (KCH) is one of the two lenging behaviors in people with ID rarely received major psychiatric hospitals in Hong Kong. It was the attention of psychiatrists and health administra- opened in October 1981 and initially comprised a tors. Appropriate services are often lacking in avail- total of 1,622 beds distributed over 34 wards. In line ability, accessibility and adequacy (5). with the global de-institutionalization process and There are many studies showing that generic community approach to mental health care, the hos- adult psychiatric services cannot satisfactorily meet pital gradually reduced its beds to 1,272 by 2005. thetreatmentandcareneedsofpeoplewithIDand KCH has four psychiatric outpatient clinics located psychiatric or behavioral problems (6, 7). This is es- in its catchment area and, together with its inpatient pecially true when this group requires inpatient care. facilities, currently provides a comprehensive psy- Thestaffingenericwardsmaynothavetheneces- chiatric service to a population of about two million sary skills and training to handle them (8). Special people. expertise is required for the proper assessment, accu- An unpublished hospital survey conducted in rate diagnosis and appropriate treatment. These in- mid-1995 found that there were 158 patients with ID dividuals may have difficulties in getting on with in KCH. The ratio of males to females was 3:2 and otherpatientswithmentaldisordersingeneric their mean age was 35.5 years. They accounted for wards, and are vulnerable and generally disadvan- about 10% of the total inpatient population at that taged in such settings. On the other hand, the physi- time and were under the care of different general cal environment of the ward should be modified adult psychiatric teams in different wards. Their with extra facilities to meet their special needs (9). Address for Correspondence: Henry Kwok, Psychiatric Unit for Learning Disabilities, Kwai Chung Hospital, 3-15 Kwai Chung Hospital Road, New Territories, Hong Kong, China. E-mail: [email protected] HENRY KWOK 253 Currently, there is still a lack of research studies with Service Provision good methodology to compare the effectiveness of specialist units with general adult mental health Inpatient service units. However, as pointed out by Clements, special- Two general adult psychiatric wards were trans- ized services increase staff competence and skills, formed into specialist wards. Funding was sought bring benefits of cumulative experience, accept from the hospital management to renovate these responsibity for the care of the ID patients without areas and equip the wards with extra facilities such as allowing them to fall in to service gaps, and increase a time-out room, a domestic training room, a small the probability of successful treatment (10). This school and a model home. The model home is a supports the findings of a recent study which dem- room with two beds where many home furnishings onstrated that patients with ID and mental health and appliances (e.g., iron, vacuum cleaner, etc.) are problems who were admitted to a specialist inpatient available. Patients assigned to this room are expected unit showed significant improvements on measures to look after themselves with less supervision from including psychopathology and overall level of func- ward staff. Suitable patients are usually those in the tioning (11). mild grade ID range at the stage of pre-discharge. Each ward consisted of 45 beds. This made up a total Establishment of PULD of 90 beds for the inpatient service. It is beyond the scope of this paper to describe in de- Thebedsineachwardareclassifiedintothree tail how the service was developed. Readers are re- types: long-stay, short-stay (less than three months) ferred to an article published earlier for more and respite care. Apart from internal referrals from information (9) and only a brief account will be pre- within the hospital, patients can also be admitted sentedhere.Inessence,acommitteewasformedin through the outpatient psychiatric clinics and emer- late 1995 to deal with the logistic, administrative, po- gency departments of general hospitals within the litical and clinical issues involved in setting up such a catchment area. specialist psychiatric unit in KCH. The service had to be run using existing staff from two general adult Outpatient clinic psychiatric wards. This was made possible by re-en- Patients discharged from the inpatient unit are fol- gineering, redeployment and redistribution of du- lowed up by psychiatrists of PULD at this clinic. Be- ties. The Unit was officially named the Psychiatric sides, it also takes over other outpatients with ID Unit for Learning Disabilities (PULD). who are under the care of general adult psychiatrists. The mission of PULD is to meet the mental Referrals are accepted from a wide range of sources, healthneedsofpeoplewithIDbyprovidingahigh- including general practitioners, social services, quality, coordinated and comprehensive psychiatric courts and probation officers. The clinic also helps service that incorporates the principles of normal- the Social Welfare Department to evaluate the eligi- ization and integration. The Unit also aims to de- bility of individuals for a social security allowance on velop the abilities of each individual patient and medical grounds. widen their repertoire of skills. A logo was designed in the shape of a rocket and the Unit’s slogan is “over- Outreach service coming hurdles and maximizing potentials.” The outreach service supports carers and organiza- The target clients include people with ID over the tions providing services to people with ID in the age of 16 years with superimposed mental illness, community. Through outreach to homes, hostels, challenging behaviors, forensic and any other mental day activity centers and sheltered workshops, clients health problems. The staff mix consists of psychia- areseenatthesiteswheretheyliveandworkbythe trists, psychiatric nurses, clinical psychologist, occu- multidisciplinary team. More information can be pational therapist, social worker and health care gathered from various staff members about behav- assistants. Other forms of professional support such ior, functioning and social relationships, facilitating as dental care, dietetic service and physiotherapy are both assessment and diagnosis. Advice can also be also available by referral. provided to staff on the spot and treatment proce- 254 HONG KONG MODEL FOR MENTAL HEALTH CARE OF PEOPLE WITH INTELLECTUAL DISABILITY dures such as behavioral modification programs can Center of PULD on a monthly basis so that assess- be implemented more successfully. In addition, this ment, treatment and follow-up can be provided for service brings convenience to the organizations the whole group of clients coming from the same sincetheycansavetheeffortofescortingtheircli- agency. This will save the traveling time of the staff, ents to outpatient clinics for follow-up. but still allows good and direct communication with the carers. Respite service b) At the outpatient department, a Guardianship The aim of the respite service is to provide a break Clinic has been set up specifically to provide two and relief for carers, to help reduce family stress, and medical reports on people with ID applying for to improve the well-being of carers (9). People with guardianship. These reports will then be forwarded challenging behaviors or mental illness often face to the Guardianship Board for hearings in accor- difficulties in finding a respite in centers run by so- dance with the Mental Health Ordinance.