David LeCount Report

Guiding Principles of Community-Based Treatment

Community-based treatment principles were emphasized throughout my PowerPoint presentation. The assumption is that hospitals are self-contained communities where all needs are met on site, whereas the community represents a broad array of services in environments that require many people and systems to work closely together. Some of these principles based on our experience in Madison, WI, are as follows:

• One central authority or agency that oversees the entire system of care. This agency has the responsibility to fund, plan, develop, implement, and evaluate services. This entity can provide the services directly, contract for services, or a combination of these approaches. All sources of funding for mental health services would go to this agency which in turn, would be responsible for distributing the money and paying for services in the community and in the hospital. This approach offers the best methodology to assure that all other community mental health principles will be followed.
  
• Keeping the focus of treatment in the community. All of the decision making is derived from the community, including who should be hospitalized and for what period of time.
  
• All participants in the service delivery process must work together as a system of care. This is essential to ensure well-coordinated services along with service continuity.
  
• Likewise, all programs must work together as a system of care maximizing integrated, comprehensive, and coordinated services across the entire spectrum of services, instead of each program acting as an independent model.
  
• Services should be comprehensive continuums to assure a broad array of services can be provided in keeping with the level of service needed for each participant. Choice should be afforded wherever possible. Other centralized functions and decisions include fixed points of responsibilities, entry points, authorization for services, case management (within programs and system wide), tracking, evaluation, management information system, etc.
  
• Least restrictive environment and treatment modalities should be adhered to in the treatment decision making process. Natural support systems in the community should be ruled out before more restrictive approaches are implemented. The emphasis is on normalization that maximizes natural supports and strengths.
  
• A bill of rights should be established, along with a consumer grievance process.
  
• Services should be provided in a consumer centered and recovery oriented manner.
  
• Consumers should be involved in all aspects of the service delivery system, including service delivery, peer supports, evaluation (satisfaction outcomes), governance committees, hiring processes, etc.
  
• Treatment and business management should be provided on the basis of the best known practices. Services should be clinically sound and cost effective.
  
• Most time spent should be in psychosocial rehabilitation and in functional approaches, instead of high cost medical models.
  
• Interdisciplinary teaming should be developed based on community psychiatric principles in which an individual from any discipline can be head of the team. All disciplines expertise is respected and understood. Expertise is used in the most efficient manner possible. Responsibility and positions on the team are earned based on skills and abilities. The emphasis is on working together as a team and knowing the roles of each member of the team. This includes knowing how to use each other as consultants with respect to their particular areas of expertise as it pertains to work, daily living skills, medical decisions, second opinions, etc.
  
• Community acceptance, integration, inclusion; the community is involved in the process of inclusion and change at various levels, not exclusively professional supports.
  
• "Dignity of risk" places the primary emphasis on responsible decision making throughout the entire system.
  
• Level of service based on the level of need?this principle also emphasizes the need to develop the level of services to maximize the potential for people to live in the community most of the time, except for instances in which the symptoms become so pronounced that a brief hospital episode is needed. In this respect, the service continuum and comprehensiveness of the community service delivery system can dictate the length of hospitalization. If a supervised living arrangement is not available, a person may have to be treated to the point where they can live independently. The danger in this is that prolonged inpatient can lead to hopelessness, helplessness, dependency, and other factors inherent in the hospitalization experience.
  
• Some general system goals should be: Systems of care should work toward at least 80% of funding going for community, and only 20% for hospitalization. People with the highest needs are prioritized. Ninety-five percent of the people should be able to live in the community with support. Work should be provided in real and natural work setting. Up to 50% of the people should be involved in paid work. Supervised living arrangements should be transitional. Consumer satisfaction and outcomes should be measured in each program.
  
• While hospitalization is an essential ingredient in the system of care, the psychiatric in-patient time needs to be limited in relationship to the context of the illness so that community living skills are not jeopardized or compromised. Within this context in Madison, we have the following average lengths of stay over the past decade:

-Five days for voluntary acute admissions.
-Fifteen days for involuntary acute admissions.
-One year for the less than 2% of people with the most severe psychiatric disorders whose symptoms remain the most treatment resistant.