A theory of change of an innovation for therapeutic care and meaningful living in a German nursing home.

BACKGROUND: Demographic changes are leading to growing care needs of older people and creating a challenge for healthcare systems worldwide. Nursing homes (NHs) need to provide care for growing numbers of residents while ensuring a high-quality care. We aimed to examine an innovative NH in Germany and apply a theory of change (ToC) approach to develop a best practice model (BPM) for therapeutic care in NHs. METHODS: A multimethod qualitative study conducted from February to July 2021 in Germany involved interviews with 14 staff members of an innovative NH and 10 directors and care managers of other NHs. The interview guidelines included questions on nursing practices, infrastructure, resources, interprofessional collaboration, and working culture. Additional material on the participating NH (website, promotion videos, newsletters, care documentation) were collected. Contextual literature on NH culture and therapeutic care in Germany, ToC methodology, and NH culture change were reviewed. Following a question-focused analysis of all material, we generated a ToC model towards a BPM of therapeutic care and meaningful living in NHs. Results were verified in interdisciplinary team meetings, with study participants and other stakeholders to establish consensus. RESULTS: The participating NH's care concept aims to improve residents' functional abilities and wellbeing as well as staff members' job satisfaction. Central components of their approach include therapeutic elements such as music and movement in all nursing activities, multidisciplinary collaboration, a broad therapy and social activity offer, the continuation of therapy in everyday activities, a focus on individual life history, values, needs, and skills, social integration into the regional community, and the creation of a meaningful living environment for residents and staff. CONCLUSION: The BPM we developed shows how a meaningful living environment can be created through therapeutic care and integrative activities. The ToC sheds light onto the contextual factors and cultural values which should be considered in the development of NH interventions. Research on not only biomedical aspects, but also psychosocial dynamics and narrative co-constructions in nursing practice should inform NH innovations. The ToC also highlights the importance of developing adequate political frameworks and infrastructures for implementing such innovative practices on a larger scale.

Qualidade de vida e níveis de atividade física de moradores de residências terapêuticas do sul do Brasil / Quality of life and levels of physical activity of residents living in therapeutic residential care facilities in Southern Brazil

Resumo O interesse na qualidade de vida de pessoas com transtornos mentais moradores de residências terapêuticas é um importante indicador para a avaliação da intervenção terapêutica na área da saúde. A atividade física pode contribuir para uma boa qualidade de vida. Avaliamos a qualidade de vida e os níveis de atividade física em moradores das residências terapêuticas da grande Porto Alegre. Estudo de série de casos (n = 68), tendo como instrumentos SF-36, EuroQol, IPAQ e questões sociodemográficas. Os resultados obtidos pelo SF-36 demonstraram que o domínio do estado geral de saúde foi o menor (57,47 ± 14,27). Os maiores scores encontrados foram nos aspectos sociais (77,39 ± 20,21) e nos físicos (77,57 ± 39,71). Ao menos um problema (moderado ou extremo), em no mínimo uma dimensão, foi evidenciado em 82% dos moradores por meio do EuroQol. Os níveis de atividade física mostraram que a maioria dos moradores são insuficientemente ativos (48,5%) e 14,7% sedentários. Os domínios dor e mobilidade sugerem que os moradores não são incentivados suficientemente à atividade física. Conhecer a percepção da qualidade de vida dos moradores das residências terapêuticas é fundamental para estabelecer políticas públicas eficazes.

Abstract Interest in the quality of life of people with mental disorders living in therapeutic residential care facilities is an important indicator for the evaluation of therapeutic interventions in the area of health. Physical activity can contribute to a good quality of life. This study evaluated the quality of life and levels of physical activity of people living in therapeutic residential care facilities in the metropolitan area of Porto Alegre. This case series study (n = 68) used SF-36, EuroQol and IPAQ and social-demographic questions. The SF-36 results showed that the domain of general health received the lowest scores (57.47 ± 14.27). The highest scores were in terms of social aspects (77.39 ± 20.21) and physical aspects (77.57 ± 39.71). When using EuroQol, at least one problem (mild or extreme) in at least one dimension was evident among 82% of the residents. The physical activity levels showed that most of the participants were insufficiently active (48.5%) and 14.7% were sedentary. The domains of pain and mobility suggested that the residents were not being encouraged enough to perform physical activities. Knowledge about the perceptions of those living in therapeutic residential care facilities is critical in order to establish effective public policies.

Investigating the influence of contextual factors in the coordination of chronic mental illness care in a district health system.

BACKGROUND: The global shift from institution-based to community-based care for chronic mental illness (CMI) care resulted in the de-institutionalization of clients with CMI. However, health systems which have been originally designed for acute hospital-based care do not seem to be appropriately transformed to manage CMI care at a community level. AIM: The aim of this study was to investigate how contextual factors influenced care coordination for chronic mental illness care within the eThekwini District. METHODS: This study employed a qualitative multiple case study design with instrumental approach. Maximum variation sampling was used to select five Community Health Centres (CHC's) and 48 health providers who worked with mentally ill clients in the sample CHC's. Framework analysis was used to analyze the results. RESULTS: Inequitably resourced catchment areas, unclear referral systems, high staff turnover, freezing of posts, chronic staff shortage and adverse working conditions contributed to care fragmentation, poor client care and client loss in the system. On the other hand, limited community support systems constituted barriers for client reintegration into society and relapses. CONCLUSION: The study concluded that the eThekwini District health facility settings were not adequately equipped to respond to care coordination demands for chronic mental illness care.

Reconstructing the eclectic psychiatry of Thomas Ferguson Rodger.

This article provides an introduction to the approach of the Scottish psychiatrist Thomas Ferguson Rodger (1907-78), as reconstructed from his archive. Rodger's contribution has been largely neglected within the history of Scottish psychiatry. This paper amends this neglect through situating Rodger's eclecticism in relation to both the biopsychosocial approach of his mentors, Adolf Meyer and David Henderson, and psychiatry's de-institutionalization in the 1950s and 1960s. It is posited that Rodger's eclecticism was a considered response to the pressures of this transitional phase to balance physical, psychological and social approaches, and a critical acknowledgement of the instability of contemporary psychiatric therapeutics. More psychodynamic than his predecessors, the importance of social relations for Rodger led him to acknowledge psychiatry's limitations.

Partnership: The Missing Link in the Process of De-Institutionalization of Mental Health Care.

This study discusses the main barriers to partnership between family and health services in the context of schizophrenia and de-institutionalization (reduction of the length of hospitalization whenever possible and returning the patient to the community) addressed to deal with the increasing costs and demand for health care services. Thus, in de-institutionalization the burden of care is not resolved but shared with the family, under the assumption that the patient has someone-a family caregiver-who can take up the responsibility of care at home. Despite the high burden of care faced by the family caregiver in mental illness, the necessary systematic partnership between the medical team and the family caregiver is missing. Subjects were 47 family caregivers of persons living with schizophrenia. Data were collected using in-depth interviews, structured questionnaires and attitudinal scales. Data analysis included factor analysis and odds ratios. Two types of barriers to partnership are identified in the literature: health services barriers and barriers attributed to the family. The findings confirm the health services barriers but reject the assumed family barriers.

Reforma Psiquiátrica no Rio de Janeiro: situação atual e perspectivas futuras / Psychiatric Reform in Rio de Janeiro: the current situation and future perspectives

Resumo O artigo analisa a rede de saúde mental do município do Rio de Janeiro, objetivando efetuar um balanço sobre a atual situação da implementação da Reforma Psiquiátrica e apontar avanços, limites e desafios. Foi realizada pesquisa documental através de documentos oficiais, portarias, bancos de dados do SUS e informações disponíveis na Superintendência de Saúde Mental do Município do Rio de Janeiro, e revisão de literatura especializada em artigos científicos nacionais e internacionais. Os resultados apontam para importantes avanços na desinstitucionalização da assistência, com substantiva redução de leitos psiquiátricos e aumento dos dispositivos comunitários. Entretanto, permanecem ainda como desafios importantes: o aumento de cobertura dos centros de atenção psicossocial, a implantação de leitos psiquiátricos em hospitais gerais, a integração da saúde mental com a atenção primária, a desinstitucionalização de pessoas em situação de longa permanência hospitalar, a ampliação do quantitativo de dispositivos residenciais e o aumento da provisão dos serviços específicos para pessoas em uso prejudicial de álcool e outras drogas.

Abstract This article analyzes the mental health network in the city of Rio de Janeiro. It provides a report on the current status of the implementation of psychiatric reform and identifies progress, limitations and challenges in this area. Documentary research was carried out by examining official documents, ordinances, SUS databases, information that was available at the Superintendency of Mental Health of the city of Rio de Janeiro, and a literature review of Brazilian and international scientific articles. The results point to important advances in the de-institutionalization of care, with a substantial reduction in the numbers of psychiatric beds, and increased community facilities. However, the following significant challenges remain: the need for increased coverage by psychosocial care centers; the implementation of psychiatric beds in general hospitals; the integration of mental health with primary health care; the de-institutionalization of people who remain in hospitals for long periods; the expansion of the number of residential facilities; and an increase in the provision of specific services for people using alcohol and other drugs.

Are long-term psychiatric patients causing more crisis consultations outside office hours in mental health care?

BACKGROUND: As well as an improvement in community services, the de-institutionalization of patients receiving long-term psychiatric care can lead to marginally staffed mental health services, more homelessness, rising admission rates and more people in prison cells. It is assumed that an imbalance between community and hospital care for chronic patients puts pressure on crisis services. AIMS: In this study, the central question is whether patients receiving long-term psychiatric care in Amsterdam do indeed put pressure on the city's emergency mental health services. We compare the pressure exerted by this group with the pressure resulting from the use of these services by all registered patients. METHODS: Data were taken from the client registration systems of three mental health organizations in Amsterdam in the period from 2000 to 2004. Inclusion criteria for long-term psychiatric patients were age above 19 years and uninterrupted receipt of mental health care for a minimum of two successive years. RESULTS: Annually, 6%-8% of all non-long-term patients experienced a crisis outside office hours in the period under investigation; this was 4%-6% for long-term patients. The non-long-term patients accounted for 83% of crisis contacts outside office hours over the entire study period, with long-term patients accounting for 17%. CONCLUSIONS: The assumption that crises are more prevalent in long-term patients in the community seems to be an example of stigmatization rather than an observation based on fact.

El P.R.E.A., una experiencia alternativa a las lógicas manicomiales / P.R.E.A. (Rehabilitation and assisted outpatient care program): an alternate experience to the Asylum logic

El propósito del siguiente escrito es dar a conocer el trabajo realizado desde hace ya 9 años en el Programa de Rehabilitación y Externación Asistida (P.R.E.A.) en el Hospital “Estevez", de Temperley, Provincia de Buenos Aires. Se intenta dar cuenta del contexto histórico-político que dio origen al surgimiento de este programa, así como de las distintas actividades que el mismo realiza a través de sus dispositivos para lograr el objetivo primordial del P.R.E.A.: la externación y reinserción social de personé con años de internación, cronificadas en la institución neuropsiquiátrica. Es el relato de una experiencia que, junto con otras ya consolidadas en nuestro país y en el mundo, demuestran a las claras que existen alternativas prácticas y sustentables a la manicomialización y al encierro en el tratamiento del padecimiento mental severo y la cronicidad. Y que eso es posible en las condiciones concretas de nuestra provincia y nuestro sistema público de salud.

The purpose of the following article is show the work that has been going on for the past nine years in the Assisted Discharge and Rehabilitation Program (PREA, from its Spanish initials), at the Estevez Hospital, Temperley, Province of Buenos Aires, Argentina. Our aim is to describe the historical and political context that gave rise to this program as well as the different activities carried out through its mechanisms to achieve the program's main objective: institutional discharge and resocialization of long-term patients with high chronicity in the psychiatric facility. This is the account of an experiment which, together with other similar ones already carried out in our country and elsewhere in the world, proves clearly that there are practical al sustainable alternatives to institutionalization and confinement for the treatment of serious mental disorders and chronicity and that this is feasible within our province's current situation and our public health system.

El P.R.E.A., una experiencia alternativa a las lógicas manicomiales / P.R.E.A. (Rehabilitation and assisted outpatient care program): an alternate experience to the Asylum logic

El propósito del siguiente escrito es dar a conocer el trabajo realizado desde hace ya 9 años en el Programa de Rehabilitación y Externación Asistida (P.R.E.A.) en el Hospital ¶Estevez", de Temperley, Provincia de Buenos Aires. Se intenta dar cuenta del contexto histórico-político que dio origen al surgimiento de este programa, así como de las distintas actividades que el mismo realiza a través de sus dispositivos para lograr el objetivo primordial del P.R.E.A.: la externación y reinserción social de personé con años de internación, cronificadas en la institución neuropsiquiátrica. Es el relato de una experiencia que, junto con otras ya consolidadas en nuestro país y en el mundo, demuestran a las claras que existen alternativas prácticas y sustentables a la manicomialización y al encierro en el tratamiento del padecimiento mental severo y la cronicidad. Y que eso es posible en las condiciones concretas de nuestra provincia y nuestro sistema público de salud.(AU)

The purpose of the following article is show the work that has been going on for the past nine years in the Assisted Discharge and Rehabilitation Program (PREA, from its Spanish initials), at the Estevez Hospital, Temperley, Province of Buenos Aires, Argentina. Our aim is to describe the historical and political context that gave rise to this program as well as the different activities carried out through its mechanisms to achieve the programs main objective: institutional discharge and resocialization of long-term patients with high chronicity in the psychiatric facility. This is the account of an experiment which, together with other similar ones already carried out in our country and elsewhere in the world, proves clearly that there are practical al sustainable alternatives to institutionalization and confinement for the treatment of serious mental disorders and chronicity and that this is feasible within our provinces current situation and our public health system.(AU)

Psychiatric reform revisited.

The trend towards the establishment of community psychiatric services seems to be universal. However, before closing down a mental hospital, it is necessary to establish the appropriate alternative facilities in the community. Every de-institutionalization program should have a diachronic component, and cultural issues should be taken into consideration. Care for each patient has to be decided upon on the basis of the characteristics of that patient. Finally, de-institutionalization is just one aspect of psychiatric reform. Primary psychiatric prevention is equally or even more important.

Desinstitucionalização em saúde mental e práticas de cuidado no contexto do serviço residencial terapêutico / De-institutionalization of mental health and care practices in the context of home-based care

Os serviços residenciais terapêuticos (SRT) no Brasil são considerados estratégicos e imprescindíveis no processo de desinstitucionalização de egressos de longas internações psiquiátricas que perderam vínculos sociais e familiares. No entanto, muitos são os problemas e desafios que este serviço evidencia no contexto mais amplo da atenção à saúde. Este artigo procura analisar alguns desses problemas e desafios a partir da experiência do SRT de Natal, Rio Grande do Norte, e de contribuições da literatura do campo. Propostos com base na idéia de que os encontros entre loucura e cidade são potentes no sentido da desconstrução da " lógica manicomial" , os SRT são problematizadores do modelo de atenção em saúde vigente, pois exigem a desconstrução das formas rígidas e hegemônicas de morar e cuidar. Pretende-se problematizar essa " lógica manicomial" que atravessa os limites dos manicômios concretos e se atualiza no cotidiano dos serviços substitutivos em certas práticas e na frágil articulação da rede de saúde mental. A falta de articulação efetiva entre SRT e Centro de Atenção Psicossocial (CAPS) dá lugar a dispositivos biopolíticos no cotidiano através dos quais essa lógica opera. Discutimos, então, os riscos de captura por esta lógica e indicamos algumas das possibilidades de desconstrução, defendendo uma clínica que possibilite encontros potentes com a cidade e a construção de " redes de trabalho afetivo" produtoras de vida e liberdade.

In Brazil, the home-based care services (HCS) are considered strategic and essential in the de-institutionalization process of patients who passed years in psychiatric hospitals and lost their family and social links. However, this service faces a series of problems and challenges in the wider context of health care. This article seeks to analyze some of these problems and challenges based on the experience of the home-based care service in Natal RN and on the literature in this field. Proposed on the basis of the idea that the encounters between insanity and city are potent destructors of the " asylum logic" , these home-based care services put in question the current healthcare model, claiming to destruct the rigid and hegemonic forms of residence and care. The aim of this article is to discuss this " asylum logic" that surpasses the limits of the concrete insane asylum penetrating some daily practices of the substitute services, taking advantage of the weak articulation between the mental health services. The lack of a strong connection between the home-based care service and the psychosocial care center allows this logic to operate through day-by-day bio-political devices. Thus, we discuss the risks of this logic taking over and indicate some possibilities of avoiding this, defending a care model allowing for potent meetings with the city and for the construction of " affectionate networks" producing life and liberty.

Habitar a cidade: análise de serviços residenciais terapêuticos / Inhabiting the city: analysis of therapeutic home services

Trata de uma análise sobre o embate de pressupostos subjacentes à implantação/funcionamento e produção de sentidos dos denominados "Serviços Residenciais Terapêuticos", ressaltando o atual debate sobre o tema. Aponta como este 'dispositivo' tem se conformado em diferentes sociedades que aderiram ao movimento anti-manicomial, tendo como inspiração o trabalho de Basaglia, no sistema psiquiátrico italiano. Delineia-se a 'localização' sócio-histórica desse dispositivo, procurando associà-lo aos embates próprios às diversas realidades. A análise destaca uma relação imanente entre cultura (valores/sensibilidades predominantes nos modos existenciais societários) e duas formas antagônicas de conceber uma vida: como autopoiese, autocriação expansiva ou como conservação, sujeita a leis genéricas e transcendentes, que comportam prescrições e avaliações externas sobre a 'pertinência' do ser vivo. Estes pressupostos ontológico/epistemológicos emergem como centrais no atual debate sobre a loucura, carecendo de uma abordagem mais direta e rigorosa nos discursos/ações que sustentam a criação e funcionamento das moradias ou residências "terapêuticas".

The paper is about the analysis on the impact of presuppositions underlying the implementation/operation and production of meanings of the so-called "Therapeutic Home Services", emphasizing present discussions on the subject. It points out how such a "arrangement" has been adjusted within different societies which have joined the anti-asylum movement, inspired on Basaglia's work within the Italian psychiatric system. While socially and historically "localizing" the arrangement, they are associated to the usual clashes of opposed realities. The analysis highlights an immanent relationship between culture (values/feelings which prevail among social ways of living) and two antagonistic forms of conceiving life: autopoiese, expansive self-creation or surviving, subject to generic and transcendental laws, which involve external prescriptions and evaluation on the "pertinence" of the living being. Such ontological/epistemological presuppositions emerge as fundamental to the present discussion on insanity, which lacks a more direct and firmer approach in discourses/actions which support the implementation and operation of "therapeutic" homes for those who have been inpatients for an excessive period of time.

A residência terapeutica: o melhor lugar de viver / Therapeutic residence: the best place to live / El hogar terapéutico: el mejor lugar para vivir

Este estudo buscou compreender o significado da travessia do hospício para a residência terapêutica na percepção dos portadores de transtornos psíquicos. Para desvelar as experiências vividas por estes sujeitos, optei pela pesquisa qualitativa na modalidade fenomenológica. A reflexão e a compreensão deste tema possibilitaram um novo olhar sobre a questão da desinstitucionalização e proporcionaram discussões acerca deste processo contínuo de criação de novas formas de lidar com a loucura, a diferença e o sofrimento humano

This study sought to understand the meaning of the move from the mental institution to therapeutic residence as perceived by patients with psychic disturbances. In order to understand the experiences lived by these subjects, I chose qualitative research in a phenomenological mode. Reflection and the understanding of this theme made it possible to have a new understanding on de-institutionalization and provided input for the discussion on this continuous process of creating new ways of dealing with madness, difference and human suffering

Este estudio busca entender el significado del camino del hospicio al hogar terapéutico en la percepción de los portadores de trastornos psíquicos. Para desvendar las experiencias de estos sujetos he optado por la investigación cualitativa en la modalidad fenomenológica. La reflexión y la comprensión de este tema permitieron darle una nueva mirada al problema de la desintitucionalización además de causar debates sobre este proceso continuo de creación de nuevas formas de manejar la locura, la diferencia y el sufrimiento humano