| 4. In which ways is the initiative creative and innovative?
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The strategies for mental health in the community have been improved in the last 10 years, especially in Bangkok where people’s lifestyles are very different. Since the process, the advantages and disadvantages are analyzed. There are important strategies;
Cooperation between departments. In 2005, the director of Somdet Chaopraya Institute of Psychiatry did a summary and presented the problems of schizophrenia in Bangkok to the director of the Bangkok Health Department. At that time, the media and society focused on patients who harm others, it was an important factor to make the directors realize the issue and how to solve problems. The staff was empowered by changing their attitudes via seminars, training, and sharing opinions to create the same working concepts. The staff had ‘confederate’ and realized their importance.
Comprehensive development for taking care of schizophrenics. In 2006, the institute’s staff and Department of Health set taking care of patient’s system from the hospital to the home. It was ‘collaborated’ and making plan by every department. They realized their roles and gave equal importance to all of them. In 2007, the institute and the public health centers ‘participated’ systematically. The taking care of patients after discharge system was created. The institute and the public health centers set follow-at-home system which had institute’s nurses, community psychiatric nurses, and the public health centers’ nurses planned the individual look after plan for each patient. The information transferred in the team, it made a good relationship between patients and visit-home teams. In 2010, the schizophrenic’s rehabilitation was created and supported many activities in the community. The psychiatric referred system for policemen and emergency medical officers was developed in 2013.
Documents and handbooks development. The psychiatric experts in the institute led production of handbooks. The staff; institute’s and Health Department’s, in many events shared their information, suggestions, assessment, and test before published and trained. The project needs many people in many fields; the handbooks have to be produced for their understanding for efficient treatment.
Training and educated. The institute was a lead to train visit-home nurses and the volunteers. The institute supported scholarships in psychiatric nursing for 4 months course for the public health center’s nurses. The institute provided training for patient screening; psychiatric taking care, primary symptom assessment, and rehabilitation were trained for the volunteers. The volunteers could primary find, observe, evaluate, and taking care of schizophrenic. The policemen and emergency medical officers were trained for evaluating and referring patients safely.
Two-way communication. The community psychiatric nurses took responsibility to coordinate between the institute and public health centers. The nurses were also supporters and consultants. Moreover, they also gave patients’ information back to the institute for more convenience and made confidence of taking care of schizophrenics.
From the above strategies, they could summary as the success requires ‘confederate’ for the same goal. It needs ‘collaborate’ for making plan as a part of the plan. The last one is ‘participate’ in each own duty for schizophrenic’s lives.
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| 5. Who implemented the initiative and what is the size of the population affected by this initiative?
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This project was the cooperation between Somdet Chaopraya Institute of Psychiatry and Bangkok Health Department. They took part in planning for problem solving. The related departments are;
The Somdet Chaopraya Institute of Psychiatry took care of patients while they were in the institute. The patients were taken care by the multidisciplinary team, the team referred patient’s information to the public health centers for house-following. The community psychiatric nurses followed-up after discharge every 3 months for a year. The nurses made treatment plans and gave advice for the public health centers’ nurse if there were any problems. The patients got continued treatment from experts.
The public health centers took a role as planning treatment and patient’s rehabilitation with the nurses from institute and the community. They did symptom evaluation and gave suggestions every month to the family about taking care of the patient. The centers were coordinators in transferring of patients’ information, problems, and help.
The public health volunteers were backbones in the community to regularly observe and assess patients. The rehabilitation activities were created via the Ruk Jai Association. The associations were NGOs which had groups of volunteers to look after patients’ mental health. The public health volunteers were coordinators between the schizophrenic’s family and visit-home nurses for the efficient taking care of patients.
The policemen and emergency medical officers helped to refer execrative schizophrenics, or uncooperative patients to the institute. The volunteers gave information and policemen prevented any harm from uncontrolled schizophrenics. The 2 areas were proceeded and 7 more in Bangkok were planned.
The schizophrenic’s family needed to be the main caregiver. The family had to support for the continued and correct treatment, helped the patients to adapt themselves, helped them to take care themselves, social living, and working with others.
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| 6. How was the strategy implemented and what resources were mobilized?
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This project is the policy of two executives, so the budget came from both two. The institute’s budget was used for 40 percent for training every officer about taking care of schizophrenics, seminars between Somdet Chaopraya Institute of Psychiatry’s nurses and public health’s nurses for annual plans, and producing lessons for handbooks. The other budget was from Health Department for 60 percent for the fundamental training, developing the standards of patient services in Bangkok, demonstration the psychiatric working of the public health centers to be modern. The Mental Health Department supported 10-15 scholarships for 4 months about mental health every year. The Community Department of Health took part of providing food for patients’ activities.
The human resources were from Somdet Chaopraya Institute of Psychiatry; nurses, community psychiatric team, and multidisciplinary team. The team that followed patients to home was visit-home nurses, and volunteers who were important for community activities for patients.
Any resources were 1.Operational manuals; individual management for house visiting, standards for taking care of complicated schizophrenics, standards of mental services in Bangkok, mental health awareness guide for services, lists of mental health network in Bangkok, mental rehabilitation guide, schizophrenic’s society in the community for nurses, guidelines of schizophrenic’s activities for Right Support Volunteers; those were from knowledge in real events, they were made and published to every officers. 2. At-home assessments; Brief Psychiatric Rating Scale (BPRS), Quality of Life (QOL), Burden of Care; those were efficient and tasted reliability. 3. Communicate technology; Facebook, Line; were used for convenience, speed, and informal news of the institute.
The very important health process are treatment, rehabilitation, and prevent people from mental sickness. The resource has to be up-to-date and to be used appropriately. The users are medical and health officers, and people. The processes of research, development, and management of knowledge are used for real usages.
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| 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
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In the past the Somdet Chaopraya Institute of Psychiatry and Bangkok Health Department were separate. Each department worked on its own without any connections. After this project, the cooperation between two departments went well and smoothly. The two executives had the same thought about mental services extension. Those two officers have a good relationship which promotes good work.
After developing the comprehensive system for taking care of schizophrenics, the standardized services were created; intensive cure in hospital, watch over at home, rehabilitation, find new patients, and emergency refer patients. The looking patients after was wide to the public health centers, the schizophrenic could spend less time than going to hospital. 2 more centers were opened; they got level of standard of mental patient services for 12 public health centers (17.65 percent). There were 158 new patients. The 106 un-continued patients were back for treatment and 405 of rehabilitation.
The development in producing documents and handbooks created 8 new guidebooks e.g. guides for taking care of schizophrenics both inpatient and visit-home, standards of mental services, mental rehabilitation activities guidebook, mental health awareness guide for services, and lists of mental health network in Bangkok. This knowledge can be used in real situations; they came from the summaries of working and taking care of patients.
From the training strategy; the Somdet Chaopraya Institute of Psychiatry is an educational institution, the training for more knowledge and skills in psychiatric field were held for every officer. The 104 nurses from the public health center participated in special nursing for mental health; that made enough nurses for every center in Bangkok for care psychiatric patients. The 1145 volunteers from the Ruk Jai Association participated in the training also. Before this project there were no psychiatric officers in the centers. All nurses in the institute got guidelines and adjusted attitudes about community work.
The two-way community created more convenience between departments. The telephone, fax, social network; line, Facebook, e-mail, 1323 hotline of mental consultation were made to get advice from experts.
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| 8. What were the most successful outputs and why was the initiative effective?
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The assessments of the project were made every year. The assessments came from patients and families assessment for service, percentage of burden feeling of caregiver, psychiatric symptom level, quality of life of patients in their houses, the period of living home, the quantity of re-cured in the institute, and the satisfaction of patients and families. The details of patients and relatives was collected every 6 months in March and September.
The evaluation within the institute had summaries of every patient and sent the information back to the public health centers’ nurses to improve their treatment. The 90 percent of patients got treatment from multidisciplinary. The remaining 10 percent had to be disposed before finished the course. There was visit-home assessment of the center; it followed patients who were referred to the centers. The processes were letting the center send patients’ information back to the institute every time after visiting, and followed the patients of community mental nurses every 3 months. The 88.47 percent of patients could stay at home; the volunteers took care of them also.
The evaluation of the public health centers was the efficiency of work inside the center according to the standardization of psychiatric service in Bangkok. In the past the centers never worked about community mental health, so there was no standard for mental working. This project aimed the centers to increase their abilities of psychiatric services. The center could be evaluated themselves according to the standards of psychiatric service in Bangkok, the experts would re-evaluate again. The satisfaction of nurse evaluation was provided. The 12 of centers got assessment (17.65 percent) in a good level; the nurses had 96.66 satisfaction about community mental work.
The cooperated evaluation by holding seminars, evaluation, and planning every year which was worker evaluation and presented workings to executives for more cooperation, and also setting working directions to be appropriate for situations, were well supported by workers. The executives emphasized on mental working, and expanded patients’ treatment in every area.
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| 9. What were the main obstacles encountered and how were they overcome?
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Setting mental services system for urban people certainly had obstacles. The problems came from urban structures which caused;
The cooperation between departments needed role learning of each department. The problems were attitude of public health service’s nurses. The nurses never worked with schizophrenics, they felt anxious and scared to look after the patients. The good attitude for patients had to be built, and also trained for taking care skills, knowledge, and provided correct knowledge to society via volunteers to reduce prejudices on schizophrenia.
The role changing of the nurses in the institute who never visited patients at their house created the attitude that, the taking care of patients when they were home was not the nurses’ responsibility. It created a feeling of extra work. The meetings and seminars were held to explain and change their attitudes. The nurses could be part of making plan, and the executives of the institute went along with the policies and changed some patients’ treatment for more convenience of the nurses. So the nurses had enough time to visit.
The expertise of psychiatric treatments was one of the problems. The treatment required sensitive techniques for efficiency. The essential regular training, appropriate handbooks, and closely consult for nurses such as telephone, LINE, or Facebook are important. The nurses would treat well with the same standards.
The severe exacerbation of schizophrenics made losing control of themselves a possibility. They might express aggressive behavior and harm other people. The policemen and emergency medical officers had to control the situation and referred them to experts. However, the policemen and emergency medical officers had less knowledge and skill to handle with that case, so they scared to manage the situation. The training and skill development of controlling and referring schizophrenics correctly and safely were held for the officers’ confidence and working security.
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