Sakaeo Rajchanakarindra Memorial Psychiatric Hospital

The Problem

The World Health Organization (WHO) has predicted that in this decade, mental illness will be a major cause of burden for the quality of life 20-30% of the adult population and 25-35% of children around the world.
Thailand has a population of more than 72 million people and has a psychiatric service in the health care system that is regulated by universal coverage. Around 12 million people in Thailand have some kind of mental health issue, but only 6% of them are engaged the health services via a general hospital or psychiatric hospitals-the later have 17 centers covering all regions in Thailand.
Sakaeo Rajchanakarindra Memorial Psychiatric Hospital (which will called JVSK in this document) has a 90-bed capacity and is the only psychiatric hospital that covers psychiatric services in the eastern region of Thailand. Patients also come from the southern part of North Eastern Thailand, part of the Central region of Thailand, which has a population of around 12 million. JVSK is located at Wattananakorn district in Sakaeo province, surrounded by large areas of farmland that makes access to hospital facilities difficult. The cost of access to care was about 2,600 Baht per visit (costs of vehicle, loss of earning opportunities of relatives and the patient) that is very high for them because mean income per head is 170 Baht per day.
One of the major concerns facing providers of mental healthcare is the possibility of patient relapse. Some relapsed patients displayed violent behavior and harmed others, such as children. Previous to the introduction of the initiative, JVSK had a missed appointment rate of 82.75% and a relapse rate of around 40%.
The major cause of relapsing is discontinuation of psychiatric services in patients' communities.
The network of health care providers, such as primary health care units (PCU), general hospitals (about 243 sites in JVSK's catchment area) didn't know much about psychiatric problems and especially didn't know the plans of continuous psychiatric care for the patients that lived near their workplaces, so that was a problem regarding continuity of care. Better data communication and improved peripheral supporting system were needed. In previous JVSK initiatives there was no support from other local organizations for the continuous psychiatric care for patients. The referral system was obstacle from local emergency personnel because of the fear and lack of knowledge about emergency psychiatric management.

Solution and Key Benefits

 What is the initiative about? (the solution)
The solution to the problem is to provide easier access for psychiatric evaluation and services via a well-trained nearest health care service that can be share the data of continuous care via an internet-based two-way communication data management system (we developed and named it SINAP-stand for Sakaeo Inter Network Assisting Program).
Local health care personnel and emergency personnel were trained about effective psychiatric care.
There were many projects and budget from local government organizations for the support of psychiatric services.
There was new cooperation with academic organizations about psychiatric problems in school children.
There were many local health volunteers helping government health care personnel to take care of psychiatric patients, one volunteer per village.
We reduced paper work by shifting from referral documents to electronics medias.
The psychiatric patients in the catchment area are the most affected by the initiative. The number of participated patients in these four years of action increased to 1,200. The rate of missed appointments reduced from 82.75% to 13.61%. The rate of admission due to relapsed symptoms reduced from
40% to 9%, that means that the cost of treatment was reduced from 11,515,812 Baht to 885,134 Baht (a 92% reduction). This will be beneficial for budget improvement to other health service systems. We found from research that most of the participated patients' symptoms were stable and they could do everyday activities by themselves, they could come to nearest health service center to participate psychiatric evaluation and service by themselves, that cost of access is only about 200 Bhats per visit, and only a very small number of them had drug side effects.

Actors and Stakeholders

 Who proposed the solution, who implemented it and who were the stakeholders?
The policy of the Department of Mental Health of Thailand intends to reduce the mental health service gap of the Thai population. The need for access to psychiatric services of patients and health care providers in the catchment area met this policy. The discontinuation of psychiatric support in the JVSK catchment area was the major force behind the search for a solution.
The network of health care centers in the community of both Sakaeo and Prajeenburi provinces, community psychiatric service centers, and an information technology center of JVSK set meetings and brainstormed for the solution of problems. Psychiatrists from the medical service organization of JVSK joined together to improve knowledge of mental illness evaluation and management and transferred to local health care personnel via multiple site seminars. Supervisory monitoring was maintained by a community psychiatric center of JVSK that was granted by the National Health Security Office and the Department of Mental Health. The main stakeholders were psychiatric patients, the community population and government organizations.

(a) Strategies

 Describe how and when the initiative was implemented by answering these questions
 a.      What were the strategies used to implement the initiative? In no more than 500 words, provide a summary of the main objectives and strategies of the initiative, how they were established and by whom.
The prevalence and burden of mental illness in Thailand and the service gap has increased and this has resulted in the Department of Mental Health of Thailand attempting to comply with the needs of remote populations that included psychiatric patients. JVSK's catchment area shared the same needs and the collaboration of services that were necessary to achieve our common goals.

The objectives consists of:

1.Increase nearest health care service competency to do psychiatric evaluations and provide care in community.
2.Improve access to continuous psychiatric service of remote patients.
3.Promote a network of health care service centers.
4. Provide maintenance and a continuous network of care.

The strategies used to achieve the above objectives are:

1. Motivate health care personnel in the community network to be aware of their own problems if the psychiatric patients relapse and how much patient potential has to be restored.
2. Influence general hospitals to meet the criteria of standard psychiatric services before accreditation and offer to provide a partnership or be a consultant of improvement.
3. Usage of intercommunication technology such as telephones, web applications, web database systems to facilitate good communication about data of continuous psychiatric care, spread through the existing hardware support of civil service organizations in their own local health care centers.
4. Promote best practice local health care centers to achieve psychiatric service awards from the Department of Mental Health of Thailand.
5. Present this project to health exhibitions, in order to convince the population and other health care service centers of the possibilities and benefits to patients, the health care system, and society.
6. Road mapping the extension and improvement of this project to the health care system of Thailand, and at the beginning, to the Department of Mental Health.

(b) Implementation

 b.      What were the key development and implementation steps and the chronology? No more than 500 words
The quality of psychiatric care policy of The Department of Mental Health and according to the quality of service standard that has been accredited by the Institute of Hospital Quality Improvement and Accreditation since 2003. in the domain of continuous care, JVSK faced a problem of discontinuation of treatment plans as mention earlier.
In 2005, personnel from local health service provider network seta up meeting to share and learn about psychiatric care problems in our area. We found the poor insight and poor adherence of patients, other villagers fear of patients and rejection of them, the emergency referral personnel' lack of psychiatric management knowledge and skills were common problems. Better communicationn was proposed to be the solution but lack of budget and programing personnel were major obstacles.
In 2007, one psychiatrist that can also do the network database programming developed SINAP, without additional budget, as a solution for communicating problems in the care network. We had two local primary health care units piloting this psychiatric communication and care system. We gave them knowledge of psychiatric evaluation and management, and prepared a good communication and referral system. Then we collated the data of use and presented the results at a meeting of the Sakaeo provincial health office.
In late 2007, there was a policy for other areas in Sakeo to participate in this new psychiatric network system. At the same time, the leader of Prajeenburi provincial hospital saw this system and decided to adapt this system to psychiatric care networks throughout Prajeenburi province.
In 2008, JVSK presented the results to a meeting of The Department of Mental Health, to other psychiatric hospitals' directors and other parts of the Department to illustrate the progression of this community psychiatric service facilitation system. Subsequently, we received support to extend the service to other areas.
Many civil service centers visited and studied this facilitation system, and in 2011, JVSK had another three psychiatric service centers join the SINAP database. In early 2011, we conducted a survey and found improvement points of the program and workload of network personnel.
In late 2011, JVSK shared and taught its psychiatric care and health referral network in Sakeo province. We trained some of villagers who volunteer to take care of psychiatric patients in their own communities ,and they were the good human resource for our continuous care network.
In June 2011, The Department of Mental Health received notification from The Office of the Public Sector Development Commission to extend the internet-facilitated psychiatric service, SINAP, through all 17 psychiatric service centers of The Department of Mental Health.
The road map of SINAP is for JVSK to be a project manager for the improvement of the internet-facilitated psychiatric service of The Department of Mental Health in 2011. The plan is to extend through about 3 of 17 psychiatric service centers every year in the 5 years from 2012, so that at the end, all 17 psychiatric service centers would join the SINAP model. At the same time, JVSK would be a resource of data for analyzing the costs of the service to be pronounced and granted by The National Health Security Office to implement all areas of the health care system.
Throughout the execution time, we had psychiatric service data from the SINAP database to analyze how the service was and what was the trend of service problems and knowledge sharing about improvements to the facilitated psychiatric service itself. This knowledge was then transferred to extend the psychiatric service model to apply to other countries that have same context of problems.

(c) Overcoming Obstacles

 c.      What were the main obstacles encountered? How were they overcome? No more than 500 words
Although improving community psychiatric services decreases patients rate of relapse, the burden to families and the community and increases the quality of living of patients, there are major obstacles that still exist.
There was a lack of local health care personnel to take care of psychiatric patients, but we can train and empower the network to help each other and be open to help whenever they need via all communication channels. There were numbers of healthcare volunteers to help government personnel. There were many network supporting activities granted by The National Health Security Office and The Department of Mental Health. There was a policy from The Department of Mental Health to increase psychiatric nurses to manage and to offer a partnership of psychiatric care in the community. We shared knowledge and trained management of psychiatric problems to our network and volunteers and adjusted the psychiatric evaluation and communication procedures to be more easily understood and clearer.
Changing from a satellite-based to fiber optic-based system has solved the discontinuation of data transferring due to hardware problems.
The lack of network programming budget was solved with the full usage of human capacity, and gave opportunities to trial and error programming skills of existing personnel.

This new system of psychiatric service faces problems due to the non-insurance of extra budget for increased workload. Possibly once the research has concluded, extra funding may be available.
The security of data in the cloud (on the internet) cannot be 100% confidently protected because the security technique and resources for protection can still be improved. Even though SINAP had user identifying and password protection of reaching the data protocol, we keep consulting IT experts in the main service in the Department of Mental Health to take care of this point.
Some of the patients' care takers and/or patients themselves do not recognize the importance of continuation of psychiatric care, and have overlooked their psychiatric illness to struggle with other life challenging tasks, such as returning to work, lack of sleep, or even taking the stimulants or substances for earning or socializing (many substances they used such as methamphetamine or alcohol, makes them work longer hours), and the illness relapse to become a burden for the community again. We reached out with the local health care network to prepare patients to return to the community with proper continuous care when this type of problem was detected before discharge from the hospital.

(d) Use of Resources

 d.      What resources were used for the initiative and what were its key benefits? In no more than 500 words, specify what were the financial, technical and human resources’ costs associated with this initiative. Describe how resources were mobilized
There were many health care personnel, from local health care providers and psychiatric hospital personnel including health volunteers, nurses, general practitioners, psychiatrists, and local supporting organization such as Emergency Medical Service, local government organizations that joined together to improve psychiatric care concurrent with general medical community services. The network is supported by:

1. The National Health Security Office.
2. The Disabled Rehabilitation Fund.
3. From the budget of local government organizations.
The main goal of all these institutions is to reduce the burden and increase the quality of life for psychiatric patients in the community.
The Department of Mental Health of Thailand supported the maintenance of the SINAP database and supported the main IT system continuously.
(Table of data presented in attached document to

Sustainability and Transferability

  Is the initiative sustainable and transferable?
According to the reduction of the mental health gap policy from The Department of Mental Health that is accepted by The Ministry of Health of Thailand, the connection of budget providers and policy makers was established to offer great opportunities to this model of service to extend to all psychiatric hospitals throughout Thailand over next five years. Also from the Hospital Quality Accreditation point of view, the continuous health care standard could be facilitated by this model, and still be an important point of quality care of any quality accredited hospitals.
-The awareness of psychiatric issues in the community itself and added psychiatric care processes in existing community activities, which can reduce the extra budget necessity of our network.
-There are curriculums for health care volunteers to attend before being registered, and this is the chance of psychiatric knowledge transferring to them for better psychiatric care in community.
The results of public hearings especially from patients and their relatives showed great satisfaction in the participation of this model of service, stat was one of the major force to initiate and maintain psychiatric services in their own community.
As well as the reduction of patients' access costs, the hospitals' reduced costs of relapsing treatment could be an interested point to the health system administrators.
The availability and accessibility of Internet services and lower cost of information technology system makes SINAP easily extendable through many health service centers. Routine health care personnel work adapted to electronics information system makes users' competency suitable for health data communication. We can ourselves adjust the networking database program to the changing context of health service problem.
There were many health care organizations visited JVSK to study the SINAP model and joined or rebuilt their own models of health data communication.

Lessons Learned

 What are the impact of your initiative and the lessons learned?
After we has initiated this model of continuous psychiatric care, we had the ultimate result such as:
-Winner of Hospital Quality Improvement prize in Knowledge Management exhibition of Sakaeo Provincial Health Office, 5th -7th August 2008.
-Winner of innovation prize in the 3rd Department of Mental Health Knowledge Management exhibition 2008.
-Presentation the process of "Lean and Seamless Health Care" as the open ceremony of 11th Thailand Hospital Accreditation national forum March 2009.
-Winner of "Continuously Develop Knowledge Asset " prize at 4th Department of Mental Health Knowledge Management exhibition, July 2009
-Winner of "Innovation of service" in Quality of civil service best practices exhibition from Office of the Public Sector Development Commission, December 2010.
-Free paper presentation "Characters of psychiatric patients reported through web-administered database system assisted extended continuous care in Sakaeo and Prajeenburi provinces" at 13th Johor Mental Health Convention, towards excellence in care: Preserving traditions, embracing innovations. May 2011. Johor Bahru, Malaysia.
-Winner of 24th Thailand QC prize, April 2010 and presented at Singapore, June 2011.
-Winner of Psychiatric Nurse Association of Thailand Academic presentation: "Challenging role of psychiatric nurses", September 2010.
-Winner of Disaster and mental health academic presentation, "the improving routine work" prize, July 2011 Songkhla, Thailand.

Lessons learned

-The abstract nature of mental health issues presents a particularly unique problem in the field of health care. The instruction of evaluation and management of the local personnel should be modified to be clearer and easier to do.
-There were many volunteers to help with the continuous care in the communities that reflected the good sign of reduced stigma of psychiatric patients, and it is the Thai value of human care. We will provide adequate psychiatric knowledge for them to take care of patients more effectively and confidently.
-The peer (network) pressure and the evidence of good results of psychiatric drugs and continuous care could extend and maintain the network of services. The good results of psychiatric patients provided safety to the community and raised self-esteem of caretakers as well as providing hope in the community. In the future we will ensure our network personnel receive support from health and non-health government organizations (Make sure that you will never walk alone.).
-The additional workload problem of the psychiatric continuous care, in the near future, extra funding will be researched and may be available.
-Another benefit of the introduction of the initiative was that the data obtained could be used to persuade health care executives to invest time and money in the new model. We have learnt that our budgetary and economic management skills must be improved, while dealing with health care executives. As the health care provider, we were relatively inexperienced in dealing with financial matters, it was not our main priority. We know this is a matter that must be addressed in the future.

Contact Information

Institution Name:   Sakaeo Rajchanakarindra Memorial Psychiatric Hospital
Institution Type:   Government Agency  
Contact Person:   Dr.Korakot Sajjariyarax
Title:   psychiatrist  
Telephone/ Fax:   +(66)811727627
Institution's / Project's Website:
Address:   176 M.3 Sub-district Nongnumsai
Postal Code:   27160
City:   wattananakorn
State/Province:   Sakaeo
Country:   Thailand

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