There exists a wide range of opinion as to the place of the nurse in the management of psychiatric inpatients. Some writers 1 have expressed the opinion that the nurse should maintain a "professional distance" so as not to interfere with the doctor's psychotherapeutic management of the patient. A number of other articles have stressed acceptance but objective uninvolvement as the attitude of choice for psychiatric nurses 2 toward their patients.
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In these train-the-trainer sessions, local specialists and the outpatient psychiatric care team were educated in the theory and practice of psychoeducation based on the APES manual. Among others, the content addressed the symptoms and course of the disease, stress coping models, issues of salutogenesis and empowerment, early warning symptoms, and crisis management. Participants were qualified to conduct future psychoeducation as trainers. The workshops on how to conduct psychoeducation took place in 1-day blocks. Didactics of knowledge transfer, visualization methods, and interactive conversation were central learning units.
Role-playing exercises consolidated the theoretical knowledge. When establishing a new form of health care, it is essential to verifiably ensure and transparently document the quality of care. In contrast to the somatic area, in the psychiatric field quality indicators are not standard practice in Germany yet. The subjective perception of disease and concomitant personal assessment of the treatment results make valid and reliable quality measurement based on objective criteria an extremely challenging task.
To face this challenge, in , the Federal Association of the AOK initiated a project to develop quality indicators for patient-centered care of people affected by schizophrenia 5. The following indicators derived from this are aimed not simply at individual care areas, but rather at an integrated cross-sector treatment approach. They were used to monitor the status quo of the initiative:. A Continuity of outpatient treatment after discharge from hospital : the percentage of patients who received further outpatient treatment within 7 days after being discharged.
B Hospital readmission rate : the percentage of patients who were readmitted to hospital within 30 days after an inpatient psychiatric treatment.
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C Antipsychotic polypharmacy : the number of patients who took at least two antipsychotics simultaneously over a timespan of at least 4 weeks during the reference period. D Compulsory treatment : this indicator describes how many patients in the Integrated Care Initiative Schizophrenia were hospitalized due to legal requirements.
E Discontinuation of treatment for more than 90 days : the percentage of patients who had no contact with health care providers within the Integrated Care Initiative Schizophrenia for more than 90 days. F Case management : the percentage of severely ill patients [defined by a global assessment of functioning GAF scale value below 50] who were in contact with a case manager during the last 6 months of the reference period. G Inclusion of relatives into the treatment : the proportion of patients whose relatives were included in the treatment support during the reference period.
H Availability of a disease self-education program : the proportion of patients who participated in psychoeducational training during the reference period. I Number of suicides and suicide attempts : all documented suicides and suicide attempts per 1, patients. In , patients were retrospectively interviewed concerning their experience with this initiative. The patient interviews were conducted from May 1 to June 15, using a standardized eight-item questionnaire modified ZUF-8 6.
Every answer was graded from 1 lowest satisfaction to 4 highest satisfaction. Scores from all of the eight answers on the patient questionnaire were summed up to form an overall rating so that 32 was the highest rating and 8 was the lowest rating for minimum participant satisfaction. The time that patients spent in the hospital was routinely monitored in the quality assurance review. All patients who participated in the Integrated Care Initiative for more than a year were included into a pre—post analysis of this parameter in July , regardless of schizophrenia severity.
The analysis compared the total number of days spent in hospital during the year before enrollment with the total number of days spent in hospital within the first year after enrollment. The mean ages in the male and female group were By the end of , patients were enrolled in the Integrated Care Initiative for an average of Ninety-five out of patients Data on comorbidities were available from patients who participated during the period from July to June In all, This correlates with other epidemiological data obtained for Germany 7 , 8.
More than half of the hospitalized patients In the Integrated Care Initiative Schizophrenia, a total of International literature reports readmission rates between In the Integrated Care Initiative Schizophrenia, By comparison, international literature reports Out of 95 patients who had a temporary stay at an inpatient facility, 6. Weinmann et al. As no rating by GAF value was available, the analysis included not only severely ill persons but all the patients enrolled in the reference period. International literature reports values between In the Integrated Care Initiative Schizophrenia, the percentage of patients whose relatives were included into the treatment support was By the end of , 2.
Since the launch of the initiative in autumn , the model was tested in pilot regions in Lower Saxony until the first quarter of The rollout in Lower Saxony was started in April Thus, the analysis of data included only the startphase of outpatient psychoeducation, which was in the phase of implementation.
Schizophrenia: Update on Treatment Options
In this area, 8. As per Hor et al. In the Integrated Care Initiative Schizophrenia, the documented suicide rate amounted to 0. A total of patients could be identified who were registered after the start of the initiative in October and participated for at least 12 months. After a period of 1 year, patients can be expected to be fully integrated in the integrated care program and therefore be able to give a valid rating. In June , of the patients males: 67 and females: 54 from 25 specialist practices took part in interviews.
At the time of the survey, the participating patients were enrolled in the initiative on average for almost 2 years Figure 2 shows the gender-specific age pattern of this population. Figure 2. Age and gender distribution of the patients who completed the modified ZUF-8 questionnaire. The findings from the interview analyses showed high patient satisfaction scores for each of the eight items of the questionnaire Table 1. The mean total score was Table 1.
Patient responses to the eight items of the modified ZUF-8 questionnaire. Of the patients enrolled in the Integrated Care Schizophrenia at the end of , On average, the length of hospital stays for all enrolled patients was 5. In comparison, the accumulated length of stay in for all schizophrenia patients insured by AOK Lower Saxony was 11 days. This positive trend was confirmed by a pre—post analysis performed in , which compared the sum of days spent in hospital in the year before and the year after enrollment in the Integrated Care Schizophrenia.
Statistical analysis was performed in July and evaluated the data of patients. The quality monitoring covered an observation period of about 2 years for the entire group. In the year before enrolling in this initiative, the patients spent a total of 6, days in hospital due to schizophrenia F20 diagnosis.
During the first year of enrollment, they spent a total of 3, days in hospital due to an F20 diagnosis.
Living with Schizophrenia: A Family Perspective
This means a reduction of Figure 3. Today, the routine care setting of mental ill patients remains fragmented 3. By offering more patient-centered care, the patient outcomes regarding primary, secondary, and health system parameters can be improved In our opinion, a key driver was the actual implementation of psychoeducation. The Integrated Care network partners often report that the biggest obstacle is motivating the patients to participate.
Interpersonal Nurse-Patient Relationship With a Young Schizophrenic Pregnant Woman
However, in our experience, once the patients are convinced and take part, they are enthusiastic about the psychoeducational spectrum. Psychoeducation is defined as systematic, structured, and didactic provision of information on the disorder and its treatment. This educational method allows the afflicted and their relatives to obtain information about schizophrenia, to receive support with coping strategies, and thus to be empowered to make informed decisions concerning relapse prevention There is a body of evidence supporting the fact that psychoeducation of patients with schizophrenia improves understanding of mental illness, increases quality of life, enhances compliance with antipsychotics, and can reduce relapse rates 17 , National and international guidelines classify the psychoeducation as a highly effective intervention in order to reduce hospital readmission rates, the resultant costs, and substantial human suffering Clinical practice shows, however, that there still exists an enormous gap between scientific findings and clinical reality.
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Although the benefit of psychoeducation for the empowerment of patients and the effectiveness of the therapy are proven, to date, it is provided only for every fifth inpatient with schizophrenia and only for one family member of every 50th patient In the outpatient sector, psychoeducation is barely part of standard care so far. It therefore seems to be essential to offer structured psychoeducation for more patients with schizophrenia and their families than is the case today.
In the Integrated Care Initiative, the network partner himself or herself organized the training for the patients. This may be of importance because the patients confided in their caregiver. This mutual trust was essential in convincing the patients to participate. Since the initiative started, the Integrated Care Initiative continuously developed new regions in the federal state of Lower Saxony, and, from the beginning of , is now available area-wide.
The first experiences with the Integrated Care Initiative in a federal state of Germany are encouraging. The introduction of the initiative improved communication between all carers. As a consequence, patients benefited from shorter waiting times, reduced bureaucracy, shorter distances, and an unchanging point of contact. The closer integration of relatives into the initiative may additionally help to better manage crisis situations. Correspondingly, patient interviews showed high patient satisfaction with the treatment path selected by the initiative.
etspiranlibag.tk This concept paves a way for optimizing health-care systems. Efforts and strengths of all participants who are involved in patient care could be joined successfully beyond existing structures. Linking and integrating of all the participants in the health-care system, including health-care providers, funding bodies, and health-care industry, may further improve quality of care in a sustainable manner.
A health care company, in particular, can make essential contributions to achieving this goal by participating in the development and implementation of comprehensive solutions, as shown in the present Integrated Care Initiative. Two years earlier than planned, the AOK continued the successfully implemented Integrated Care Initiative and adopted it in the regular care setting starting from January The AOK carried on ensuring optimum treatment for the insurees.
The established procedures for participating physicians and psychiatric nursing services remained in place.
Parallel to this, the pharmaceutical company Janssen continues to work on optimizing modular health-care concepts to increase outcomes for patients who are suffering from mental health disorders. It is important to note that the present paper is not a research study but a quality monitoring report of a novel care setting initiative. The data presented here were collected in the framework of the quality assurance of the integrated care project.
An evaluation designed as a prospective, observational cohort study with two independent control groups was originally planned but could not be finalized by the independent contractor due to minor recruitment numbers. In our view, the Integrated Care Initiative can serve as a learning case for how to set up and measure integrated care systems that may improve outcomes for schizophrenic patients. Such real-world quality monitoring data are as yet rare and can make an important contribution to reflection on appropriate ways to optimize patient health-care services for mental health reasons.
Please note: This is not a research study but a quality monitoring report of a novel care setting initiative. Quality monitoring of health-care performance is mandatory according to the German Law. The data were collected in the framework of the quality assurance of the integrated care project. Those data are rare and are often seen as an important real-life contribution to the mental health-care issue.
Further routine data analyses will compare the integrated care schizophrenia against standard care. NM-A: significant contribution during IVS program conduction and analyses, especially on the psychoeducational content: substantial intellectual contribution to concept, revising this article critically for important intellectual content, final approval of the version to be published.
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