[Implementation of New Flexible and Integrative Psychiatric Care Models (According to §64b SGB V) in Rural Northern Germany in Comparison to Federal Territory]. / Analyse von Implementierungsmerkmalen psychiatrischer Modellvorhaben (nach §64b SGB V) in Schleswig-Holstein im Vergleich zum Bundesgebiet.

AIM: New treatment models (according to §64b German Social Code) have been introduced in Germany to improve flexible and integrated forms of psychiatric care. The aim of this study was to analyse the specific conditions under which many of these models have been implemented in the federal state of Schleswig-Holstein (SH) in comparison to other federal regions. METHODS: A standardized survey reached 383 patients in seven psychiatric departments, among them three departments in SH. In addition, routine data and data evaluating the grade of implementation in these departments were analysed. RESULTS: Departments in SH showed more developed implementation processes, compared with departments in other regions. Implemented changes were perceived and evaluated as being better by patients in SH. CONCLUSIONS: Implementation processes of flexible and integrated forms of care according to §64b were particularly successful in SH. Extensive political support is discussed as a major reason, among others, for this development.

Individual and Needs-Based: The Platform-Model for Personnel Allocation in Child and Adolescent Psychiatry and Psychotherapy.

Objective: An initiative by scientific societies of psychiatry, child and adolescent psychiatry, psychosomatic medicine, and further associations established the Platform-Model for the development of a needs-based system for adequate personnel allocation in psychiatric inpatient and day clinic units. We present the development of the instrument and a pilot study to identify feasibility and limitations. Methods: The basis of the study was a threefold methodological approach. Paradigmatic case vignettes adequately reflecting symptomatology and circumstances were described and validated, working profiles were generated and validated, and a matrix representing different needs-based dimensions was developed. Through reference date surveys, patients were assigned to needs-based clusters and Psych-PV categories. The required treatment effort under consideration of guidelines or expert consensus was estimated in several rounds of expert panels (Delphi method). Results: The pilot study proves the feasibility of the Platform-Model. Methodological findings as well as limitations of the model were identified in order to further develop the Platform-Model. Conclusions: The Platform-Model cannot serve as a tool to describe clinical pathways, but it appears to be an adequate and practical tool for assessment of the required staffing level based on patient needs independent of diagnosis and setting.

[Staffing of inpatient psychiatric facilities : A patient-oriented and guideline-oriented staffing concept]. / Personalausstattung in stationären psychiatrischen Einrichtungen : Ein patientenorientiertes und leitliniengerechtes Konzept zur Personalbemessung.

BACKGROUND AND GOAL: According to § 136a (2) SGB V (volume V of the German Social Security Code) the German legislator instructed the Federal Joint Committee (G-BA) to specify binding minimum standards for the staff needed for the treatment in inpatient psychiatric and psychosomatic facilities. This induced the expert associations/organizations to develop their own conceptional approach as to the future organization of staffing. METHOD: Organization of regular expert workshops, the results of which were systematically documented and validated by the experts. RESULTS: The essential elements of the concept are: the starting points for the calculation are the needs of all patients treated in the institution. The need for treatment has three dimensions: (a) psychiatric psychotherapeutic/psychosomatic psychotherapeutic/pediatric and adolescent psychiatric-psychotherapeutic, (b) somatic and (c) psychosocial needs. The model developed by the platform distinguishes between staff requirements being directly related to the treatment of the individual patient, staff requirements caused by the treatment setting and such staff requirements arising at an institutional level. Minimum staff requirement is understood as the staff structure which is, among others, needed to guarantee the multiprofessional, physician-led treatment and the required medical care services for all patients specified by the existing guidelines or an expert consensus as well as to ensure the protection of the patient, fellow patients and the employees working in the facility against hazards. CONCLUSION: This model considers the medical progress within the meaning of the evidence-based guidelines and the modified healthcare practice including sociopolitical standards aimed at the patients' self-determination.

[The region as a cooperation framework in psychiatric care]. / Die Region als Kooperationsrahmen in der psychiatrischen Versorgung.

Mental illnesses regularly impair participation in social life. Therefore it is from a therapeutic point of view very important to offer community-based therapy focused to individual needs. The psychiatric treatment system in Germany, which is currently highly fragmented, must be modified in the sense of a functionally networked structure.Various control aspects are of particular importance. In terms of regional care, there are different care models in Germany. The focus is on "regional budgets", which are implemented in 19 regions in Germany. In addition, there are care approaches in the form of "stepped care," "home treatment," and "assertive community treatment."It turns out that new care structures based on regional framework conditions and new provision of care in psychiatry and psychotherapy are suitable for offering treatment measures tailored to individual needs. Due to the principle of regional responsibility, a reorientation to a more ambulant psychiatric and psychotherapeutic care that supports participation in life can be achieved.

[Attention-deficit/hyperactivity disorder (ADHD) in adult psychiatry: Data on 12-month prevalence, risk factors and comorbidity]. / Die Aufmerksamkeitsdefizit- und Hyperaktivitätsstörung (ADHS) in der Erwachsenenpsychiatrie: Erfassung der ADHS-12-Monatsprävalenz, der Risikofaktoren und Komorbidität bei ADHS.

AIMS AND METHODS: To examine the 12-month prevalence, risk factors, and comorbidity of ADHD in a collective of adult psychiatric patients admitted to an open general ward in a psychiatric hospital in Schleswig-Holstein (Germany) over a period of one year (n = 166). RESULTS: The 12-month prevalence of ADHD was 59.0 % (severe symptomatology: 33.1 %), high rates of comorbid disorders (92.9 % depression, 5.1 % bipolar disorder, 28.6 % anxiety disorder, 30.6 % emotional unstable (Borderline) personality disorder, 31.6 % avoidant personality disorder, 18.4 % dependent personality disorder, 25.5 % combined personality disorder, 10.2 % obsessive-compulsive personality disorder, 26.5 % PTSD, 25.5 % restless legs syndrome, 24.5 % adiposity, 11.2 % eating disorder, 45.9 % learning difficulty, 51.0 % nicotine dependency, 4.1 % alcohol dependency, 7.1 % illegal substance dependency), risk factors for ADHD, a high genetic risk (72.4 %) and problems in psychosocial functioning. CONCLUSIONS: Because of the high prevalence of ADHD in hospitalized psychiatric patients, it is mandatory to examine these for the presence of ADHD using questionnaires and identify comorbid diseases.

Stepped, evidence-based and integrated care service model vs. usual care for mental disorders: A randomized controlled trial (RECOVER).

Stepped, evidence-based and integrated care service models have the potential to be used as a reference for mental health services. RECOVER aimed to evaluate cost savings, effectiveness, and cost-effectiveness of such a model within a two arm, assessor- and data analysist-blinded RCT in Hamburg, Germany. Participants aged 16-79 years with mental disorders were randomly assigned either to RECOVER or treatment as usual (TAU). Primary outcomes comprised costs, effectiveness (combined symptoms, functioning, quality of life), and cost-effectiveness, hierarchically ordered. Outcomes were evaluated according to the ITT principle, group differences regarding costs with adjusted generalized linear models, effectiveness with ANCOVA models, and cost-effectiveness with the incremental cost-effectiveness ratio (ICER) and cost-effectiveness acceptability curves (CEACs). Between 1/1/2018 and 12/31/2020, n = 891 were finally included (n = 477 in RECOVER, n = 444 in TAU). RECOVER was associated with significantly lower annual total costs (-22 %), health and social care costs (-25 %) and hospital costs (-50 %). Effectiveness analyses showed a significantly better outcome for RECOVER with the fully imputed data . The CEACs descriptively demonstrated that RECOVER was cost-effective with a probability of >95 %. Treatment in RECOVER resulted in substantial cost reductions with better cost-effectiveness. RECOVER can be recommended as a reference model for comprehensive and integrated mental health services.

[From Model to Regional Regular Care - Long-Term Effects of a Regional Budget]. / Vom Modell zur Regionalen Regelversorgung.

AIM: Model projects of a regional budget or a model project according to §â€Š64b SGB V have been for more than 18 years. The structural, economic, and therapeutic long-term effects are described in this paper. METHODOLOGY: The model project in the Steinburg district (Schleswig-Holstein) describes the developments between 2002 (index year) and 2020 that have developed through the regional budget. The article describes the situation and its specific changes in the first german model region. There is no comparable control group. RESULTS: In the observed period, the number of people treated was stable within a corridor that has been in the contract with the stakeholders. Care has shifted relevantly from fully inpatient to outpatient and day clinic treatment. The costs have remained stable and thus differ significantly from the overall increase in health care costs. New supply concepts could be implemented. CONCLUSION: The model projects described lead to setting-independent care and are suitable for standard care in a defined region.

Accuracy of self-reports of mental health care utilization and calculated costs compared to hospital records.

Assessments of service utilization is often based on self-reports. Concerns regarding the accuracy of self-reports are raised especially in mental health care. The purpose of this study was to analyze the accuracy of self-reports and calculated costs of mental health services. In a prospective cohort study in Germany, self-reports regarding psychiatric inpatient and day-care use collected by telephone interviews based on the Client Socio-Demographic and Service Receipt Inventory (CSSRI) as well as calculated costs were compared to computerized hospital records. The sample consisted of patients with mental and behavioral disorders resulting from alcohol (ICD-10 F10, n=84), schizophrenia, schizophrenic and delusional disturbances (F2, n=122) and affective disorders (F3, n=124). Agreement was assessed using the concordance correlation coefficient (CCC), mean difference (95% confidence intervals (CI)) and the 95% limits of agreement. Predictors for disagreement were derived. Overall agreement of mean total costs was excellent (CCC=0.8432). Costs calculated based on self-reports were higher than costs calculated based on hospital records (15 EUR (95% CI -434 to 405)). Overall agreement of total costs for F2 patients was CCC=0.8651, for F3 CCC=0.7850 and for F10 CCC=0.6180. Depending on type of service, measure of service utilization and costs agreement ranged from excellent to poor and varied substantially between individuals. The number of admissions documented in hospital records was significantly associated with disagreement. Telephone interviews can be an accurate data collection method for calculating mean total costs in mental health care. In the future more standardization is needed.

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.

Study protocol for a randomised controlled trial evaluating an evidence-based, stepped and coordinated care service model for mental disorders (RECOVER).

INTRODUCTION: Healthcare systems around the world are looking for solutions to the growing problem of mental disorders. RECOVER is the synonym for an evidence-based, stepped and cross-sectoral coordinated care service model for mental disorders. RECOVER implements a cross-sectoral network with managed care, comprehensive psychological, somatic and social diagnostics, crisis resolution and a general structure of four severity levels, each with assigned evidence-based therapy models (eg, assertive community treatment) and therapies (eg, psychotherapy). The study rationale is the investigation of the effectiveness and efficiency of stepped and integrated care in comparison to standard care. METHODS AND ANALYSIS: The trial is conducted in accordance to the Standard Protocol Items: Recommendations for Interventional Trials Statement. The study aims to compare the RECOVER model with treatment as usual (TAU). The following questions are examined: Does RECOVER reduce healthcare costs compared with TAU? Does RECOVER improve patient-relevant outcomes? Is RECOVER cost-effective compared with TAU? A total sample of 890 patients with mental disorders will be assessed at baseline and individually randomised into RECOVER or TAU. Follow-up assessments are conducted after 6 and 12 months. As primary outcomes, cost reduction, improvement in symptoms, daily functioning and quality of life as well as cost-effectiveness ratios will be measured. In addition, several secondary outcomes will be assessed. Primary and secondary outcomes are evaluated according to the intention-to-treat principle. Mixed linear or logistic regression models are used with the direct maximum likelihood estimation procedure which results in unbiassed estimators under the missing-at-random assumption. Costs due to healthcare utilisation and productivity losses are evaluated using difference-in-difference regressions. ETHICS AND DISSEMINATION: Ethical approval from the ethics committee of the Hamburg Medical Association has been obtained (PV5672). The results will be disseminated to service users and their families via the media, to healthcare professionals via professional training and meetings and to researchers via conferences and publications. TRIAL REGISTRATION NUMBER AND REGISTRY NAME: ClinicalTrials.gov (NCT03459664), RECOVER PROTOCOL VERSION: 19 March 2020 (V.3.0).

Evaluation of Flexible and Integrative Psychiatric Treatment Models in Germany-A Mixed-Method Patient and Staff-Oriented Exploratory Study.

Contrary to the practice in some countries, access to flexible and integrated forms of psychiatric care (FIT models) is limited in Germany. Several legislations have been introduced to improve this situation, notably the recent §64b (flexible and integrative treatment model; FIT64b) of the German Social Code, which allows for a capitation-based accounting of fees for services. The aim of this study was to explore the effects of FIT64b implementation on various stakeholders (patients, informal caregivers and staff) in 12 psychiatric hospital departments across Germany. Structural as well as quantitative and qualitative data are included, with integration of different methodological approaches. In all departments, the implementation of the new accounting system resulted into a relatively stable set of structural and processual changes where rigid forms of mainly inpatient care shifted to more flexible and integrated types of outpatient and outreach treatments. These changes were more likely to be perceived by patients and staff, and likewise received better evaluations, in those departments showing higher level or longer duration of implementation. Patients' evaluations, furthermore, were largely influenced by the advent of continuous forms of care, better accessibility, and by their degree of autonomy in steering of their services.

Risk of hepatitis C virus transmission from an infected gynecologist to patients: results of a 7-year retrospective investigation.

BACKGROUND: Currently, it is not known how often hepatitis C virus (HCV) is transmitted from infected health care workers to patients during medical care. In the present investigation, we tried to determine the rate of provider-to-patient transmission of HCV among former patients of an HCV-positive gynecologist after it was proven that he infected one of his patients with HCV during a cesarean section. METHODS: All 2907 women who had been operated on by the HCV-positive gynecologist between July 1993 and March 2000 were notified about potential exposure and were offered free counseling and testing. The crucial differentiation between HCV transmissions caused by the gynecologist and infections contracted from other sources was achieved by epidemiological investigations, nucleotide sequencing, and phylogenetic analysis. RESULTS: Of the 2907 women affected, 78.6% could be screened for markers of HCV infection. Seven of these former patients were found to have HCV. Phylogenetic analysis of HCV sequences from the gynecologist and the women did not indicate that the virus strains were linked. Therefore, no further iatrogenic HCV infections caused by the gynecologist could be detected. The resulting overall HCV transmission rate was 0.04% (1 per 2286; 95% confidence interval, 0.008%-0.25%). CONCLUSION: To our knowledge, this is the largest retrospective investigation of the risk of provider-to-patient transmission of HCV conducted so far. Our findings support the notion that such transmissions are relatively rare events and might provide a basis for future recommendations on the management of HCV-infected health care workers.

[Changes in mental health care by a regional budget: results of a pilot Project in Schleswig-Holstein (Germany)]. / Veränderung der psychiatrischen Versorgung durch ein Regionales Budget: Ergebnisse eines Modellprojektes in Schleswig-Holstein.

OBJECTIVES: In a region of Schleswig-Holstein, a regional budget was used to investigate which structural changes would be brought about by a financial plan which enables (clinical) treatment that defies rigid financial limits and makes flexible treatment in various settings possible. RESULTS: In 5 years, the number of inpatient treatment places in the care region was reduced considerably. The length of stay per patient and year decreased by 25 %. Day care and outpatient treatment offers were expanded substantially and new treatment concepts were established. The quality of treatment remained safeguarded. CONCLUSIONS: A regional budget is suitable for bringing about fundamental changes in terms of content and structure in psychiatric care. The result is clearly improved flexibility as compared to previous care structures; incentives for disorders are reduced. The principle "outpatient before inpatient" is strengthened. The financial plan can be transposed onto other regions, whereby modifications according to the structure of the care region seem necessary.

[The regional psychiatry budget (RPB): a model for a new payment system of hospital based mental health care services]. / Das Regionale Psychiatriebudget (RPB): Ein Modell für das neue pauschalierende Entgeltsystem psychiatrischer Krankenhausleistungen?

OBJECTIVE: To analyze the impact of a capitated multi-sector-financing model for psychiatric care (RPB) on costs and effectiveness of care. METHODS: Patients with a diagnosis according to ICD-10 F10, F2 or F3 were interviewed in the model region (MR, n = 258) and a control region (CR, n = 244) financed according to the fee-for-service principle. At baseline, 1.5 years and 3.5 years follow-up patients were interviewed using measures of psychopathology (CGI-S, HoNOS, SCL-90R, PANSS, BRMAS / BRMES), functioning (GAF, SOFAS) and quality of life (WHOQOL-BREF, EQ-5D). Use of care was determined semi-annually. RESULTS: There were no significant differences in the development of psychopathology and quality of life between MR and CR. In the MR, functioning of patients with schizophrenia and affective disorders improved significantly more strongly. The development of total mental health care costs was not different between MR and CR. However, the costs of office based mental health care increased slightly more strongly in the MR, indicating a small cost-shift from the RPB to extrabudgetary financed services. CONCLUSIONS: The RPB showed slight advantages regarding the effectiveness of care and did not significantly change the total mental health care costs.

[The regional psychiatry budget: costs and effects of a new multisector financing model for psychiatric care]. / Das Regionale Psychiatriebudget: Kosten und Effekte eines neuen sektorübergreifenden Finanzierungsmodells für die psychiatrische Versorgung.

OBJECTIVE: To evaluate a new multi-sector financing model for psychiatric care based on the capitation principle (Regional Psychiatry Budget, RPB). METHODS: Patients with a diagnosis according to ICD-10 F10, F2, and F3 were interviewed in the model region (MR, N=258) and a control region (CR, N=244) financed according to the fee-for-service principle. Effectiveness of care was assessed before RPB-introduction and after 1.5 years. Use of care was determined semi-annually. RESULTS: Costs of inpatient psychiatric treatment decreased more strongly in the MR, while hospital based outpatient care and day clinic treatment were intensified in comparison to the CR. Quality of life, severity of illness and illness-specific symptoms in patients improved similarly in MR and CR. The functional level improved more in the MR than in the CR, which was especially evident in schizophrenia patients. CONCLUSIONS: Inpatient psychiatric care costs can be reduced with the RPB without compromising the quality of care.