"The Simpler, the Better." A Qualitative Study on Digital Health Transformation in Early Adopter Rheumatology Outpatient Clinics.

Workforce shortage and the increasing burden of rheumatic and musculoskeletal diseases lead to extreme time constraints in rheumatology outpatient care. Digital services promise to facilitate care by relieving employees and unleash new capacities. This study aims to explore the perspectives of early adopter health care professionals (HCP) on digital transformation in outpatient rheumatology. In-depth qualitative interviews were conducted with rheumatology nurses and physicians in 3 German rheumatology outpatient clinics, each characterized by an advanced level of digital adaption. Qualitative data were subsequently analyzed using deductive-inductive qualitative content analysis. Interviews with 11 rheumatology nurses and 5 rheumatologists were completed. Three key themes emerged from the qualitative analysis: (i) Digital transformation of care; (ii) impact of digital transformation on health care delivery; and (iii) perceived drivers of successful digitalization. The interviews revealed that digital technologies are widely used throughout the complete patient pathway. Digitalization enables more continuity and flexibility in rheumatology care. Patient information can be electronically obtained in a standardized manner prior to planned visits, enabling an informed consultation and more time for in-depth patient discussion. Although digitalization restructures work, it can also increase the current workload. Improved accessibility for patient calls leads to more work for HCP. Important drivers of successful digital technology implementation are low-threshold and interoperable services, a medical team that is interested and educated in eHealth, and comprehensive patient information and onboarding. Digital transformation is increasingly redefining rheumatology care. While accelerating communication and workflows, improved service accessibility leads to more work for HCP.

[Support for families with a mentally ill parent : Which forms of help do mentally ill parents utilize and which would they like to have?] / Unterstützung für Familien mit einem psychisch erkrankten Elternteil : Welche Hilfen nehmen psychisch erkrankte Eltern in Anspruch und welche wünschen sie sich?

BACKGROUND: In Germany different offers of social support are available for families that are provided by different sectors, e.g., the youth welfare and the healthcare systems. OBJECTIVE: Documentation of the utilized help, child-related factors that are associated with the utilization and the parental desires for support. MATERIAL AND METHODS: Survey of 160 parents undergoing (partial) inpatient treatment in psychiatric hospitals via an oral interview using standardized and semi-standardized instruments. RESULTS: The results show that nonprofessional help by family and friends as well as support offers provided by the healthcare system are used most frequently. Families that perceived their children as more burdened receive more help than families with children judged as being less burdened. There are regional differences especially in the utilization of high-threshold help by the healthcare system. DISCUSSION: Support offers seem to reach families with mental illnesses, especially those that are particularly burdened; however, there are regional differences regarding the utilization of support as well as the wishes for specific support offers.

Equal access to outreach mental health care? Exploring how the place of residence influences the use of intensive home treatment in a rural catchment area in Germany.

BACKGROUND: Internationally, intensive psychiatric home treatment has been increasingly implemented as a community-based alternative to inpatient admission. Since 2018, the so-called Inpatient Equivalent Home Treatment (IEHT; German: "Stationsäquivalente Behandlung", short: "StäB") has been introduced as a particularly intensive form of home treatment that provides at least one daily treatment contact in the service users' (SU) home environment. Prior research shows that this can be challenging in rural catchment areas. Our paper investigates to which extent the location of the SU home location within the catchment area as well as the distance between the home and the clinic influence the utilisation of inpatient treatment compared to IEHT. METHOD: Routine data of one psychiatric hospital in the federal state of Brandenburg in Germany were analysed for the observational period 07/2018-06/2021. Two comparison groups were formed: SU receiving inpatient treatment and SU receiving IEHT. The SU places of residence were respectively anonymised and converted into geo-coordinates. A geographic information system (GIS) was used to visualise the places of residence, and car travel distances as well as travel times to the clinic were determined. Spatial analyses were performed to show the differences between comparison groups. In a more in-depth analysis, the proximity of SU residences to each other was examined as an indicator of possible clustering. RESULTS: During the observational period, the location of 687 inpatient and 140 IEHT unique SU were mapped using the GIS. SU receiving treatment resided predominantly within the catchment area, and this proportion was slightly higher for SU receiving IEHT than for those treated in inpatient setting (95.3% vs. 84.7%). In the catchment area, the geographical distribution of SU place of residence was similar in the two groups. There was a general higher service provision in the more densely populated communities close to Berlin. SU with residence in peripheral communities were mainly treated within the inpatient setting. The mean travel times and distances to the place of residence only differed minimally between the two groups of SU (p > 0.05). The places of residence of SU treated with IEHT were located in greater proximity to each other than those of SU treated in inpatient setting (p < 0.1). CONCLUSION: In especially peripheral parts of the examined catchment area, it may be more difficult to have access to IEHT rather than to inpatient services. The results raise questions regarding health equity and the planning of health care services and have important implications for the further development of intensive home treatment. Telehealth interventions such as blended-care approaches and an increase of flexibility in treatment intensity, e.g. eliminating the daily visit requirement, could ease the implementation of intensive home treatment especially in rural areas.

Not in Their Right Mind? Right-Wing Extremism Is Not a Mental Illness, but Still a Challenge for Psychiatry.

Most research in psychiatry on extremism focuses on the question whether there is a connection between extremism and psychiatric diagnoses. In addition, practitioners are increasingly asked to take part in programs aimed at preventing and countering violent extremism by assessing risk for radicalization. However, an issue that remains largely unaddressed is that the rise of the far right in many countries during the last years poses a challenge for psychiatric services as working with right-wing patients can be a source of conflict for practitioners and patients alike. In this article, we assert that the narrow conceptual scope on psychological vulnerabilities and the practical focus on risk assessment contribute to processes of psychiatrization and limit the scope of research on right-wing extremism in psychiatry. By giving a brief overview of social research into right-wing extremism, the article argues that right wing beliefs should not be conceptualized as an expression of psychological vulnerabilities but rather as attempts to deal with conflict-laden social reality. Thus, a shift of perspective in psychiatric research on extremism is needed. On a conceptional level, the scope needs to be broadened to grasp the interplay of individual and social factors in radicalization with sufficient complexity. On a practical level, it is necessary to further investigate challenges for practitioners and institutions working with right-wing extremist patients.

Needs and Experiences in Psychiatric Treatment (NEPT)- Piloting a Collaboratively Generated, Initial Research Tool to Evaluate Cross-Sectoral Mental Health Services.

BACKGROUND: Research tools to evaluate institutions or interventions in the field of mental health have rarely been constructed by researchers with personal experience of using the mental health system ("experiential expertise"). This paper presents a preliminary tool that has been developed within a participatory-collaborative process evaluation as part of a controlled, multi-center, prospective cohort study (PsychCare) to evaluate psychiatric flexible and integrative treatment, FIT for short, models in Germany. METHOD: The collaborative research team consisting of researchers with and without experiential expertise developed 12 experiential program components of FIT models by an iterative research process based on the Grounded Theory Methodology. These components were transformed into a preliminary research tool that was evaluated by a participatory expert panel, and during a pilot and validation study, the latter using a random sample of 327 users from 14 mental health departments. Internal consistency of the tool was tested using Cronbach's alpha. Construct validity was evaluated using a Principal Components Analysis (PCA) and a Jonckheere Terpstra test in relation to different implementation levels of the FIT model. Concurrent validity was tested against a German version of the Client Satisfaction Questionnaire (ZUF-8) using correlation analysis and a linear regression model. RESULTS: The evaluation of the expert panel reduced 29 initial items to 16 that were further reduced to 11 items during the pilot study, resulting into a research tool (Needs and Experiences in Psychiatric Treatment-NEPT) that demonstrated good internal consistency (Cronbach's alpha of 0.89). PCA yielded a 1-component structure, which accounted for 49% of the total variance supporting the unidimensional structure of the tool. The total NEPT score increased alongside the increasing implementation of the FIT model (p < 0.05). There was evidence (p < 0.001) for convergent validity assessed against the ZUF-8 as criterion measure. CONCLUSIONS: The NEPT tool seems to be promising for further development to assess the experiences with and fulfillment of needs of psychiatric care models from the perspective of users. This paper demonstrates that it is possible to use a participatory-collaborative approach within the methodologically rigorous confines of a prospective, controlled research design.

[Flexible and integrative treatment in psychiatry: implementation of specific care components at model and standard care clinics in Germany (PsychCare study)]. / Settingübergreifende Behandlung in der Psychiatrie: Umsetzung spezifischer Versorgungsmerkmale an Kliniken der Modell- und Regelversorgung (PsychCare-Studie).

BACKGROUND: Since 2003 a new remuneration and care model has been implemented in currently 22 psychiatric clinics in Germany, which provides flexible and integrative treatment (FIT) across different settings of treatment, including assertive outreach care. The FIT is based on a global treatment budget covering costs for all psychiatric hospital services and is related to the number of patients treated per year. Previous research identified 11 program components that describe treatment structures and processes of FIT. The present analysis quantitatively compared FIT with standard care, aiming to validate these components. METHODS: As part of the PsychCare study, grading according to FIT-specific components was carried out and comparatively analyzed in nine hospitals that used FIT and seven hospitals of standard care. The FIT models were examined in depth in subgroups, which were divided according to the share of the FIT model in the total hospital budget. RESULTS: Of the 11 FIT program components 7 (flexible care management across settings, therapeutic group sessions across all settings, outreach home care, involvement of informal caregivers, accessibility of services, cooperation across sectors and expansion of professional expertise) showed a high statistical differentiation. These differences were even stronger in the subgroup of those hospitals that had a model contract with all health insurers. CONCLUSION: Specific components of FIT are suitable for evaluating the quality of implementation of intersectoral, flexible and outreach psychiatric care.

[Outsourcing of nursing staff costs in psychiatry? : A secondary data analysis of possible effects on the remuneration system in psychiatry]. / Ausgliederung der Pflegekosten in der Psychiatrie? : Eine Sekundärdatenanalyse möglicher Auswirkungen auf das PEPP-System.

BACKGROUND: Nursing staff were excluded from the German DRG system for somatic hospital treatment and will be funded separately in the future. In psychiatry and psychosomatic medicine, binding personnel requirements have been defined but there has been no regulation of how these personnel requirements are adequately financed. OBJECTIVE: The objective of this study was to analyze the costs of inpatient psychiatry and psychosomatic medicine and to evaluate possible effects of funding nursing staff separately. MATERIAL AND METHODS: This analysis is based on aggregated daily treatment costs of selected hospitals (data year 2018), which annually submit their performance and cost data to the Institute for the Hospital Remuneration System (InEK) for the empirical further development of the remuneration system. RESULTS: Nursing staff represent the largest cost factor in inpatient psychiatry and psychosomatic medicine. Excluding nursing staff drastically reduces the variance of psychiatric DRG renumeration and even exceeds its proportion of the total costs. After outsourcing nursing costs, psychiatric DRGs achieve only a very limited cost separation. CONCLUSION: The binding personnel requirements necessitate adequate financing of nursing staff. This raises the debate about the further development of psychiatric remuneration. The question arises as to whether the effort associated with using the psychiatric DRG system justifies its usefulness as an instrument for budgeting when core functions such as cost separation are only given to a limited extent. Alternative approaches to budgeting should also be examined for putting costs and benefits in a better ratio.

[Implementing a Global Treatment Budget for Psychiatric Hospital Services - What are Incentives, Requirements, and Challenges?] / Implementierung eines globalen Behandlungsbudgets in der Psychiatrie ­ Welche Anreize, Voraussetzungen und Herausforderungen gibt es?

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.

Implementation, efficacy, costs and processes of inpatient equivalent home-treatment in German mental health care (AKtiV): protocol of a mixed-method, participatory, quasi-experimental trial.

BACKGROUND: Over the last decades, many high-income countries have successfully implemented assertive outreach mental health services for acute care. Despite evidence that these services entail several benefits for service users, Germany has lagged behind and has been slow in implementing outreach services. In 2018, a new law enabled national mental health care providers to implement team-based crisis intervention services on a regular basis, allowing for different forms of Inpatient Equivalent Home Treatment (IEHT). IEHT is similar to the internationally known Home Treatment or Crisis Resolution Teams. It provides acute psychiatric treatment at the user's home, similar to inpatient hospital treatment in terms of content, flexibility, and complexity. METHODS/DESIGN: The presented naturalistic, quasi-experimental cohort study will evaluate IEHT in ten hospitals running IEHT services in different German regions. Within a multi-method research approach, it will evaluate stakeholders' experiences of care, service use, efficacy, costs, treatment processes and implementation processes of IEHT from different perspectives. Quantitative surveys will be used to recruit 360 service users. Subsequently, 180 service users receiving IEHT will be compared with 180 matched statistical 'twins' receiving standard inpatient treatment. Assessments will take place at baseline as well as after 6 and 12 months. The primary outcome is the hospital re-admission rate within 12 months. Secondary outcomes include the combined readmission rate, total number of inpatient hospital days, treatment discontinuation rate, quality of life, psycho-social functioning, job integration, recovery, satisfaction with care, shared decision-making, and treatment costs. Additionally, the study will assess the burden of care and satisfaction with care among relatives or informal caregivers. A collaborative research team made up of researchers with and without lived experience of mental distress will conduct qualitative investigations with service users, caregivers and IEHT staff teams to explore critical ingredients and interactions between implementation processes, treatment processes, and outcomes from a stakeholder perspective. DISCUSSION: By integrating outcome, process and implementation research as well as different stakeholder perspectives and experiences in one study, this trial captures the various facets of IEHT as a special form of home treatment. Therefore, it allows for an adequate, comprehensive evaluation on different levels of this complex intervention. TRIAL REGISTRATION: Trial registrations: 1) German Clinical Trials Register (DRKS), DRKS000224769. Registered December 3rd 2020, https://www.drks.de/drks_web/setLocale_EN.do ; 2) ClinicalTrials.gov, Identifier: NCT0474550 . Registered February 9th 2021.

Flexible and Integrative Psychiatric Care Based on a Global Treatment Budget: Comparing the Implementation in Germany and Poland.

Background: The past decade has witnessed the establishment of flexible and integrative treatment (FIT) models in 55 German and Polish psychiatric catchment areas. FIT is based on a global treatment budget (GTB), which integrates funding of all acute psychiatric hospital services for a regional population. Prior research has identified 11 specific program components of FIT in Germany. In this paper we aim at assessing the applicability of these components to the Polish context and at comparatively analysing FIT implementation in Poland and Germany. Methods: Qualitative interviews about the applicability of the 11 FIT-specific components were conducted with the program managers of the Polish FIT models (n = 19). Semi-quantitative data on the FIT-specific components were then collected in 19 Polish and 10 German FIT models. We assessed the grading of each component, their overall degree of implementation and compared them between the two countries. In all study hospitals, structural and statistical parameters of service delivery were collected and compared. Results: The qualitative results showed that the German FIT-specific components are in principle applicable to the polish context. This allowed the comparative assessment of components grading and degree of implementation, which showed only subtle discrepancies between German and Polish FIT models. The little discrepancies point to specific aspects of care such as home treatment, peer support, and cooperation with non-clinical and social welfare institutions that should be further integrated in the components' definition. Conclusions: The specific program components of FIT as first defined from the German experience, serves as a powerful tool to measure, and evaluate implementation of integrated psychiatric care both within and between health systems.

Implementation of a Global Treatment Budget in Psychiatric Departments in Germany-Results and Critical Factors for Success From the Staff Perspective.

BACKGROUND: Despite evidence from other countries for its effectiveness, flexible and integrative psychiatric treatment (FIT) is not part of the German standard healthcare system. Since 2013, German legislative reform has enabled a test implementation of FIT based on a global treatment budget. Because the budget is not restricted to any particular activity, this legislation opens the possibility of enhancing linkages between inpatient-, outpatient- and day-patient treatment structures. As staff involvement is a relevant component in successful implementation, we aimed in this study to judge the degree of FIT implementation based on staff members' experiences and evaluations of FIT. METHOD: Within an exploratory study design, we administered a standardized written survey to rate experiences and evaluations of physicians, psychologists, and nurses in the first 13 FIT projects between October 2016 and February 2017. The sample consisted of 352 nurses, 127 physicians, 84 psychologists, and 132 special therapists. We identified critical factors for successful implementation from the staff perspective by logistic regression analysis. RESULTS: Staff evaluations of the degree of FIT implementation were generally favorable, although some staff reported no experiences with one or several FIT-specific components. We found considerable differences in the assessments between the occupational groups. The only common factor for successful FIT implementation shared by physicians, psychologists, and nurses was the opportunity to join training programs on the objectives of FIT. Other critical factors for successful implementation were work conditions, the number of nurses/special therapists per physician/psychologist, and project duration. These factors together explained 49% of the variance of physician/psychologist evaluations and 34% for nurse evaluations. Individual staff members' characteristics were less important than structural- or FIT characteristics as explanatory factors for the degree of FIT implementation. IMPLICATIONS: Results point to the importance of new forms of multi-professional cooperation, training programs, improvement of work conditions, and guidance of the implementation process by systematic Change Management for future implementations of FIT. Our exploratory findings require further validation to guide practical improvements in FIT implementation. Longitudinal observations and a multilevel analysis should yield a better understanding of the relevant variables from different organization levels and their possible interactions.

Changes in German Mental Health Care by Implementing a Global Treatment Budget-A Mixed-Method Process Evaluation Study.

BACKGROUND: Internationally, there is a broad spectrum of outreach and integrative care models, whereas in Germany acute psychiatric treatment is still mostly provided in inpatient settings. To overcome this, a new legal framework (§64b Social Code V) has been introduced, promoting "Flexible and Integrative Treatment" Models (FIT64b), based on a "Global Treatment Budget" (GTB) financing approach. 23 hospitals have implemented the framework according to local needs and concepts. Prior research has already identified specific components of FIT64b. Based on this, our paper aims to examine the implementation process and underpinning change mechanisms of GTB-based FIT64b models from a staff, service user and caregiver perspective. METHOD: 31 focus groups and 15 semi-structured interviews were conducted with hospital staff (n = 138), service users (n = 63), and caregivers (n = 35) in 10 psychiatric hospitals implementing FIT64b. Using qualitative analysis, we identified 5 core themes describing the implementation process, which were theoretically modeled into a logical diagram. The core mechanisms of change were thus identified across themes. Additional structural and semi-quantitative performance data was collected from all study departments. RESULTS: The qualitative analysis showed that the shift from a daily- and performance-based payment to a lump-sum GTB and the shift of resources from in- to outpatient settings were of crucial importance for the process of change. Saved budget shares could be reinvested to integrate in-, out-, and day-patient units and to set up outreach home care. Clinicians reported feeling relieved by the increase of treatment options. They also emphasized a stronger relationship with and a better understanding of service users and a simplification of bureaucracy. Finally, service users and caregivers experienced higher need-adaptedness of treatment, a feeling of deeper understanding and safety, and the possibility to maintain everyday life during treatment. Finally, two FIT64b implementation prototypes were classified according to the semi-quantitative performance data. CONCLUSION: Based on the results, we developed 3 core mechanisms of change of FIT64b models: (1) Need-adaptedness and flexibility; (2) Continuity of care; (3) Maintaining everyday life. Our findings outline and emphasize the potential a GTB approach may have for improving psychiatric hospital services.

[Stakeholders' experiences with flexible and integrative treatment models in German child and adolescent psychiatry according to § 64b SGB V - A qualitative study]. / Erfahrungen der Stakeholder mit den Modellvorhaben nach § 64b SGB V in der Kinder- und Jugendpsychiatrie und -psychotherapie ­ eine qualitative Studie.

Stakeholders' experiences with flexible and integrative treatment models in German child and adolescent psychiatry according to § 64b SGB V - A qualitative study Abstract. Background and Aims: Since 2013, new possibilities for flexible and integrative forms of treatment (FIT) exist within the German mental healthcare system. These FIT models, created according to § 64b of the Social Security Code V, have been implemented in adult as well as child and adolescent psychiatry over the past years. This paper investigates stakeholders' experiences with these innovative FIT models. Methods: Focus groups were conducted in two hospital departments that had implemented a FIT model according to § 64b. In total, 36 participants were included, comprising employees, patients, and their caretakers. We also conducted a thematic analysis. Results: According to all stakeholders, these forms of acute outpatient treatment form a core component of FIT models that may serve to prepare, replace, or follow-up on inpatient treatment. In addition, the flexibility of treatment and increased continuity of care were mentioned as benefits of FIT models according to § 64b. Third, these FIT models allow for a better integration of caretakers in the treatment of their kin, which also produces various challenges for this stakeholder group. Conclusions: The introduction of FIT models in German child and adolescent psychiatry has complex implications for the treatment process and the experiences of all stakeholders. They perceive it as a needs-adapted extension of current forms of psychiatric support.

Pharmacotherapy of psychiatric inpatients with adjustment disorder: current status and changes between 2000 and 2016.

Adjustment disorder is a temporary change in behaviour or emotion as a reaction to a stress factor. Therapy consists of psychotherapy, and pharmacotherapy can be advised. However, data on the real-life pharmacological treatment are sparse. Prescription data for 4.235 psychiatric inpatients diagnosed with adjustment disorder in the time period 2000-2016 were analysed. The data were obtained from the Drug Safety Programme in Psychiatry (AMSP). Data were collected on two reference days per year; prescription patterns and changes over time were analysed. Of all patients, 81.2% received some type of psychotropic drug. Mostly antidepressants (59.8%), antipsychotics (35.5%), and tranquilisers (22.6%) were prescribed. Prescription rates for antidepressants decreased slightly over the years, while rates for antipsychotics increased, especially for atypical antipsychotics. It is important to note that the diagnosis "adjustment disorder" is most likely a working diagnosis that is used for patients in immediate need of psychiatric aid. Overall, pharmacotherapy for inpatients with this diagnosis is mostly symptom-oriented and focuses on depressive moods, agitation and anxiety. Therapy regimes changed over time and show an increased use of atypical antipsychotics with sedative properties. However, for most of the medication, there are neither evidence-based studies nor guidelines, and drugs might be contraindicated in some cases.

Hospital length of stay among older people treated with flexible and integrative psychiatric service models in Germany.

OBJECTIVE: Since 2012, a new law (§64b, Book V of the Social Security Code [SGB V]) regulates the implementation of flexible and integrative psychiatric treatment projects (FIT64b) in Germany. FIT64b allows rapid discharge of patients from inpatient to outpatient settings and cost reductions of hospital stays. Several psychiatric centres exclusively provide FIT64b; others provide FIT64b alongside with standard health care. The aim of the study was to assess the average hospital length of stay (AHLS) of older patients with mental illness included in FIT64b projects. METHODS: A secondary data analysis was conducted using administrative data from eight German mental health centres providing FIT64b. The effects of gender, age, type of centre, and main diagnosis on AHLS were calculated for all older patients with age 65 years or older (n = 3495) treated in FIT64b in the year 2016. Data were analysed with descriptive statistics and robust multiway procedures. RESULTS: The AHLS of older people with mental illness was 4.8 (SD = 11.5) days. The AHLS was shorter in centres exclusively providing FIT64b than in centres providing FIT64b alongside with standard health care: 3.2 (SD = 6.4) vs 8.4 (SD = 17.8) days, P = .001. This difference was particularly marked among patients with schizophrenia spectrum disorders, mood disorders, and neurotic, stress-related, and somatoform disorders. CONCLUSIONS: FIT64b relates to very short AHLS even among older people. Centres using FIT64b alongside with standard health care usually provide standard care to most patients, which could lead to lower fidelity in the implementation of FIT64b.

Evaluation of new flexible and integrative psychiatric treatment models in Germany- assessment and preliminary validation of specific program components.

BACKGROUND: Flexible and integrative treatment (FIT) models are rather novel in German mental health care. This study aimed at identifying and evaluating empirically based, practicable, and quantifiable program components that describe the specific treatment structures and processes of German FIT models. METHODS: A multi-step, iterative research process, based on Grounded Theory Methodology (GTM), was used to identify and operationalise components. A complex algorithm and expert-interviews were applied to quantify the relative weight of each component and to develop a sum score. Face and content validity were examined and internal consistency was tested by Cronbach's α coefficient. RESULTS: Ten of eleven FIT components could be operationalised, quantified and united in the total score. All operationalised components showed sufficient face and content validity and eight components had a good reliability. CONCLUSIONS: The components are a first step in the process of operationally defining German FIT models. They considerably overlap with various critical ingredients of international FIT models and may serve as a theoretical basis for constructing fidelity tools and research guides to enable process and outcome evaluation of German FIT models.

Los médicos especialistas en México.

INTRODUCCIÓN: No hay datos recientes en México sobre el estado de los médicos especialistas que permitan diseñar políticas de formación y empleo de los recursos humanos para la salud. OBJETIVO: Analizar el estado actual de los médicos especialistas en México: número, distribución (geográfica, por sexo y especialidad), vigencia de la certificación (por sexo y especialidad) y tasa de especialistas por 100 000 habitantes. MÉTODO: estudio transversal descriptivo. Se consultaron múltiples fuentes disponibles en México: consejos, asociaciones, colegios, instituciones hospitalarias, universidades y otros. RESULTADOS: Se contabilizaron 147 910 especialistas para una población de 123 518 272 habitantes; 69 % contaba con certificación vigente de la especialidad. Se obtuvo una tasa de 119 especialistas por 100 000 habitantes; 54.2 % se encontraba en la Ciudad de México, Estado México, Jalisco y Nuevo León. En promedio había 1.7 especialistas varones por cada mujer. CONCLUSIONES: El número de especialistas es inferior al recomendado internacionalmente e insuficiente para cubrir las necesidades en salud del país. La distribución por género está cambiando hacia una más equitativa. Los especialistas están agrupados mayormente en zonas urbanas. Es el primer censo de especialistas con base en el número comprobable de médicos, que permitirá el diseño de políticas de planificación de recursos humanos en salud. INTRODUCTION: There are no recent data in Mexico about the state of medical specialists that allow the design of policies for training and use of human resources for health. OBJECTIVE: To analyze the current state of medical specialists in Mexico: number, distribution (geographical, by gender and specialty), certification validity (by gender and specialty) and the rate of specialists per 100 000 population. METHOD: Cross-sectional, descriptive study. Multiple sources available in Mexico were consulted: councils, associations, schools, hospital institutions, universities, and others. RESULTS: A total of 147,910 specialists were counted for a total population of 123,518,272 inhabitants; 69 % had current specialty certification. A rate of 119 specialists per 100 000 population was obtained; 54.2 % are in Mexico City and in the States of Mexico, Jalisco and Nuevo León. On average, there are 1.7 male specialists per female specialist. CONCLUSIONS: The number of specialists is lower than that internationally recommended and insufficient to cover the health needs of the country. Gender distribution is shifting towards a more equitable one. Specialists are mainly grouped in urban areas. This is the first census of specialists based on total verifiable number of physicians, which will allow the design of policies for human resources planning in health.

[Subscription Rates of Psychiatric Patients to an Integrated Care Program in the Context of a Psychiatric Model Project]. / Einschreibeverhalten von psychisch Kranken in die integrierte Versorgung einer psychiatrischen Klinik.

Objective: In the past years different model projects have been developed in Germany to counteract the known deficits of the German psychiatric care system. Among these, an "integrated care" model project has been set up which offers a more flexible way of managing psychiatric care, especially for patients with a severe mental illness. It however implies an active subscription to the program. In this study we analyzed factors influencing patients' subscription rates. Methods: Subscription rates during the first 18 months of the program were analyzed with regard to the patients' main diagnoses and gender. Results: We found an overall subscription rate of 59.3 %. Diagnosis explained 24.1 % of the overall variance of the inpatients' subscription rate. This effect was significantly smaller in outpatients. No effect of gender could be observed. The highest subscription rate was found by patients with an affective disorder. Only 34.6 % of the patients with an F2 diagnosis subscribed. Conclusion: The target groups of the program could not be sufficiently reached in this model. The need of a new legal basis for psychiatric care models, namely a subscription-free program, is thereby reinforced.