Reinforce!-Project Description & Final Conclusions

RO032BZ – REINFORCE!

Reinforcement of the Integrated System of Extramural Mental Health Care Service in Three Counties in Romania

1. INTRODUCTION

The mental health system in Romania is centered on hospital services. The population is served with 39 psychiatric hospitals (13 of them for chronicle psychiatric patients, 4 of them for forensic psychiatry) with a total of 12.027 beds. Further there are 75 psychiatric units with total of 4.373 beds in the general hospitals. Romania has 37 Community Mental Health Centres (CMHC) for adults and 14 centres for children. In total 1.200 psychiatrists and 800 psychologists work in mostly private practices. Further approximately 5.000 psychiatrist nurses work in mental healthcare.

In Romania work 13.000 general practitioners (GPs). GPs are only formal gatekeepers for psychiatric patients. They are not trained in treatment of psychiatric patients, and except of antidepressants, they are not allowed to prescribe any other medication and they are not financial motivated to treat those patients. Given that, GPs send psychiatric patients directly to specialists or hospitals and they do not follow further the patient’s condition and they do not support him/her in the re-socializing process after treatment.

The Ministry of Health has a Mental Health Strategy since 2002. Dating the same year, the Law of Mental Health got its’ methodological norms only in 2006, due to media pressure before admission to EU.

The reform provisioned, among others, to split Romania in psychiatric sectors of 100-150.000 adult, to create Mental Health Centers (Centru de Sanatate Mintala – CSM), to train and create multidisciplinary teams to offer psychosocial rehabilitation services (e.g. OT, vocational training, etc.) and to make possible the offering of  mobile team interventions (home care) and crisis intervention

Also in 2006, the MoH issued a mental health reform action plan that mentioned the creation of new CSM (one for each psychiatric sector, so a minimum of 100 new centers). Also, training of health staff and general practitioners in mental health was envisaged. The National Center in Mental Health (Centrul National de Sanatate Mintala – CNSM) is the institution responsible with the MH reform implementation; since 2007 CNSM is directly subordinated to the MoH.

Since the fall of communism, scarce private not- for – profit initiatives in the field of mental health came into being. Foreign organizations, among which the Dutch ones were the most active, and Romanian NGOs tried, on a local level, to address mainly the field of extramural mental health care services, the most underdeveloped sector in the health care system in Romania.

1. MATRA PROJECT

Based on the previsions of the MH strategy, four Dutch organizations with their Romanian counterparts (in Bucharest: GGZ Dijk & Duin and RIBW, together with Estuar Foundation and Trepte Center; in Brasov:  GGZ Oost Brabant together with SCUT Association for Social Services; in Timisoara: MAD Foundation together with CSM 1 and patients’ association Armonia initiated a 3 years (from 1 December 2006 until 30 November 2009) project “Reinforcement of the Integrated System of Extramural Mental Health Care Service in Three Countries in Romania”. The project was coordinated by HealthNet TPO, targeted the psychiatric patients and their relatives, the mental health care professionals and general practitioners being the direct beneficiaries of the activities. The project had a budget of EUR 1,062,539 out of which EUR 693,152 were granted by the Dutch Ministry of Foreign Affairs, through the Matra Programme. The project summary is presented hereunder.

PROJECT SUMMARY

1. 1. Key problem(s)

The de-institutionalization process of psychiatric care in Romania is characterized by a lack of community-based services. These services are needed to provide the necessary follow up and maintenance care to patients who have been dismissed by the psychiatric institutions. This situation results in a vicious cycle of psychiatric patients who, after being released by psychiatric institutions, are neglected by society and subsequently relapse.

1. 1. Overall objective(s)

To improve the quality of life of people with mental health problems in Romania

1. 1. Project goal

Reinforcement of the integrated system of extramural mental health care services in three counties in Romania

1. 1. Project results

1. Sustainable integrated system of extramural mental health care is implemented;

2. Mental health care is integrated into the linked system of primary health care;

3. Mental health care professionals are able to provide extramural mental health care services;

4. Users and their families are more involved in community mental health care;

5. Authorities and other bodies are aware about the existence and benefits of extramural mental health care.

1. 1. Main activities

Project result 1:

1.1 Project implementation workshop;

1.2 In Bucharest: establishment of a service for protected and guided living;

1.3 In Timisoara: establishment of a centre for crisis intervention and outreaching psychiatry;

1.4 In Brasov: establishment of a day centre for psychiatric and psychosocial rehabilitation and psychiatric home care;

1.5 Creation of a website for information sharing and e-learning;

1. 1. Monitoring and evaluation.

Project result 2:

2.1 Development protocols and training modules for primary mental health care;

2.2 Training primary health care professionals;

2.3 Pilot projects “state-of-the-art” primary mental health care.

Project result 3:

3.1 In Bucharest: training in protected and guided living;

3.2 In Bucharest: training in occupational therapy;

3.3 In Bucharest: training in outreaching psychiatry;

3.4 In Timisoara: training in crisis intervention and outreaching psychiatry;

3.5 In Brasov: training in psychiatric and psychosocial rehabilitation;

3.6 In Brasov: training in psychiatric home care.

Project result 4:

1. 1. In Timisoara: creation of a patients’ and family education centre.

Project result 5:

5.1 Increase awareness of authorities in the field of mental health;

5.2 Organize publicity around extramural mental health.

The project started with an implementation workshop in Brasov, where all the partners met each other and planned for the future. Each Dutch partner collaborated with the local partners towards the achievement of project results. The project trained 900 mental health professionals from the three locations in crisis intervention, psychosocial rehabilitation (occupational therapy, day care activities), outreaching psychiatry (guided living, psychiatric home care) and mental health approach in primary care. More than 1300 clients and family members benefited from the project activities.

In order to promote and replicate the services piloted in the project, regular contacts with the local and central authorities took place. A memorandum of understanding with CNSM was about to be signed but it did not succeed due to modifications in the structure of the later. Local media campaigns took place in order to promote the concept of extramural mental health services.

The training activities contributed to the knowledge and skills enhancement of the professionals involved in the project, allowing them to offer quality innovative services in their communities. They also created the premises for the editing of two manuals: the “Guide in Crisis Intervention” (which includes organizational requirements for the creation of a crisis intervention center and the professional aspects to offer these specific services) and the training “Manual on Occupational Therapy”, the base for a curriculum of training in this specialty.

The experience gained in the project was summarized in the Guide of Community Mental Health Services which offers the description of a comprehensive model of a community mental health center, that encompass crisis intervention, assertive community treatment (home care, guided living), psychosocial rehabilitation (occupational therapy) services. The guide presents also the model piloted in seven state-of-the-art general practitioners practices for the active involvement of GPs in mental health services; also the training modules offered throughout the project. An important chapter of the guide is represented by the cost analysis of the community services offered in the project that shows their efficiency compared to the existing “intramural” services existent for the moment in Romania.

The project ended with a final conference, where partners, local and central authorities shared information about the achievements of the project and discussed about the future sustainability and replication of the extramural community mental health services. CNSM, seen as the revolving board in this process, received all the written products of the Matra project. Among the questions left opened for the future were:

- Clarification of means by which the local communities will be able to develop new CSMs (decentralization of the health system is the key phrase of the moment)

- Creation of regulations for the existence of crisis intervention centers (merely taking over the Matra model and including it in a Ministry order to gain power of regulation in the health system)

- Finding ways of financing the involvement of GP in MH services (decision on behalf of the Insurance Company to pay per-service or decision of the MoH to include these services in the existing MH national financing program)

1. CONCLUSIONS

The Matra project deployed international and local expertise to provide innovative extramural mental health services in the communities. The results were documented efficient and were shared with mental health professionals, local and central authorities.

All Matra project extensive expertise can be immediately utilized for the benefit of the mental health patients in Romania. It is up to the Romanian society to take over this role, to achieve the its programmatic objectives and reach a level of development of the mental health system according to the statute of a EU member country.

Dr. Tudor Simionescu, Programme Manager HealthNet TPO