Deinstitutionalization in the Caribbean

Deinstitutionalization, the process of moving patients from large mental hospitals into the community is new to the Caribbean region. In keeping with trends of the more developed countries, World Banks' conditionality have requested the downsizing of psychiatry hospitals in order to qualify for monetary aid. Unfortunately, in the Caribbean region, there is an absence of extramural services for patient care and this has been a major handicap. This study seeks to investigate the pattern of admission of patients to the psychiatric hospital in Trinidad and to make comparison with Jamaica, a country with a more robust community care programme. Data was collected from hospital records on gender and total admissions over a sixteen year period (1985-2000) in Trinidad and Tobago. For Jamaica, secondary data of total admissions and gender rates were extracted from published works for the years 1960-1990. Data was analyzed using SPSS Version 11. One-sample t-tests were used to test the significance of reduction in admission rates. Trinidad and Tobago experienced a 46% significant decrease in admissions from 3,076 in 1985 to 1,659 in 2000 (p<0.001), while Jamaica admissions were reduced by 58% from 3,094 in 1960 to 1,296 in 1990. Over these periods, there has been a reduction in both male and female admissions. In Trinidad, male admissions have decreased by 49% and female by 39% while in Jamaica male admissions have decreased by 52.8% and female 43.9%. In Trinidad voluntary admissions accounted for 50.6%, urgent 29.8%, court orders 16.6% and medically recommended and mental health order 1.5% each. Pearson Product Moment correlation revealed that a positive correlation existed between voluntary admission and court order (p<0.05) and negative relationship between mental health order and urgent admissions (p<0.05). Notwithstanding a greater investment in community psychiatry in Jamaica, the patterns of admissions and deinstitutionalization are similar in Jamaica and Trinidad. It seems deinstitutionalization in these countries are an unforced process with less admission to psychiatric hospitals and alternative treatment for patient care. These findings are useful in providing invaluable information for the development of community care programmes in developing countries.

A contribuição da atenção domiciliar para a configuração de redes substitutivas de saúde: desinstitucionalização e transformação de práticas / Home care's contribution to alternative health care networks: deinstitutionalization and transformation of practices

OBJETIVO: Identificar o estado da arte da atenção domiciliar no âmbito do sistema público de saúde no Brasil, analisar o seu potencial de inovação no sentido da integralidade e da humanização da atenção e indicar pistas para a sua ampliação. MÉTODOS: Sete experiências de cuidado domiciliar em cinco municípios brasileiros foram analisadas por meio de estudos de caso, com base em entrevistas com os cinco gestores municipais e os sete coordenadores dos serviços, com todos os componentes das equipes de atenção domiciliar e com os usuários e os familiares dos 27 casos selecionados. Todas as entrevistas foram gravadas e depois transcritas. Foram ainda analisados documentos produzidos pelos serviços (proposta política, relatórios de gestão, relatórios de avaliação, rotinas e protocolos de atenção), observados atendimentos (ao menos um de cada uma das equipes em todos os sete serviços) e analisados os casos traçadores. RESULTADOS: Foram identificados os seguintes tipos de atendimento domiciliar: cuidado paliativo, cuidado a pacientes com AIDS, cuidado a portadores de feridas e lesões de pele, acompanhamento de bebês prematuros, acompanhamento de acamados crônicos, antibioticoterapia endovenosa como complementação do tratamento para infecções agudas. São aspectos a destacar: a qualidade e a humanização da atenção, o trabalho em equipe, o desenvolvimento de vínculo e a responsabilização por parte dos trabalhadores e a participação efetiva dos cuidadores e das famílias na produção dos projetos terapêuticos. CONCLUSÃO: As iniciativas examinadas mostraram que a atenção domiciliar é possível até em ambientes economicamente precários e que pode contribuir efetivamente para a produção de integralidade e de continuidade do cuidado, devendo ser ampliada no âmbito do sistema público de saúde.

OBJECTIVE: To identify state-of-the-art home care within Brazil's public health system, evaluate its potential for improving the comprehensiveness and humanization of care, and identify areas for expanding this care modality. METHODS: Seven home care initiatives were examined and cases were analyzed through interviews with five municipal services managers, seven service coordinators, all home-care team members, and with the service recipients, as well as the family members of the 27 cases selected. All of the interviews were recorded and transcribed. We also analyzed documents created by the home care services (policy manuals, management reports, evaluation reports, and care protocols), observed each team providing care (at least once for each of the seven service types), and analyzed the selected cases. RESULTS: The following types of home care were identified: palliative, AIDS, skin lesions/wounds, premature infant, bedridden patient, and supplemental intravenous antibiotic therapy for acute infection. The following positive aspects should be highlighted: the quality and humanization of care, team work, the bond developed with patients and family, the sense of responsibility taken on by the health workers, and the effective participation of caretakers and families in carrying out therapy plans. CONCLUSION: The initiatives examined show that home care is possible even in economically disadvantaged environments and that it may effectively contribute to providing integrated and continued care. Home care should be expanded in the context of the public health system.

Acerca del programa de asistencia familiar de la Colonia de Asistencia psiquiátrica Dr. Bernardo Etchepare / Family Assistance Program at Dr. Bernardo Etchepare psychiatric Hospital

Se efectúa un seguimiento a lo largo de cinco años de una muestra representativa de pacientes psiquiátricos crónicos del Programa de Asistencia Familiar abocado a egresos y rehabilitación, que funciona en el Hospital Dr. Bernardo Etchepare. La finalidad es efectuar una evaluación del funcionamiento del mismo y del equipo interdisciplinario que lo sustenta. El aporte de este trabajo surge de que este es el primer estudio estadístico de dicho programa que, pese a ser priorizado por el Programa Nacional de Salud Mental de nuestro país (1986) y por la institución donde funciona, no logra un crecimiento adecuado debido a las barreras inherentes a los dinamismos institucionales y sociales. Dicha conclusión verificada por un análisis real y su evaluación habilitaría a tomar medidas a nivel institucional para modificar esta situación. Este es el único programa con estas características, cuya función es favorecer la reinserción social de los pacientes y al mismo tiempo desgravitar las grandes instituciones psiquiátricas. De los resultados de la presente investigación destacamos la permanencia de los pacientes en el programa, en un alto porcentaje con el mismo cuidador, el bajo número de reingresos, la reducción de la medicación recibida y un buen índice de rehabilitación