This small-scale initiative in the Eksjö municipality of Sweden, successfully reduced rates of involuntary psychiatric interventions through a program that focused on improving the interactions between individuals in mental health crises, nurses providing home based care, and inpatient and outpatient psychiatrists (Submission 30). Over a six-month period, the trial saw a 66% reduction in compulsory admissions. The cohort of patients was small, with 170 patients enrolled in home care during this period.
According to the submission:
In order to reduce the number of admissions by [an involuntary psychiatric intervention order, which is made under Swedish law after a ‘care certificate’ is issued], the nurses driving the improvement work needed to build a deeper relationship with the patients who accounted for the majority of forced admissions. The relationship can be an end in itself, but also a means to achieve other goals. [The nurses] therefore visited these patients regularly and had ongoing and longer conversations with them. In person-centred care, the patient narrative is essential to enable the partnership. Nurses also made contact with relatives, where the patient in question agreed to this.
Improving the communication between psychiatrists and the nurses/municipal homecare providers was also important. Research at the beginning of the project indicated that interactions between homecare nurses and inpatient and outpatient psychiatrists were fraught, and perceived by staff to be generally negative (Submission 30).
According to the submission, the practice had three key elements:
- First, the service drew on a preexisting service-development process for ‘continuous improvement’ based on the four steps of ‘plan’, ‘do’, ‘study’ and ‘learn’ (for which the Swedish acronym is PDSA).
- Second, the mental health practitioners aimed to provide ‘personcentred care’, on which a large international body of literature exists. The model was described in the submission as avoiding reducing the person to his or her mental health condition, and ‘involv[ing] a shift from a model in which the patient is [viewed as] passive to one in which he or she is active in planning and implementing his or her own health plan’ (Submission 30).
- Third, teamwork was a primary focus among healthcare practitioners, as previous research had identified tension and dissatisfaction in encounters between municipal homecare providers and inpatient and outpatient psychiatrists. This had led to friction in the experience of individuals in mental health crises as they transitioned between emergency, inpatient and outpatient care.
Practical steps taken as a result of this process included adjustments to improve home-based care (for example, extending the period of outpatient psychiatric care for individuals with higher support needs) and additional training (including training on old age-related psychosocial and cognitive disabilities).
In the six-months prior to the trial, six involuntary admissions were issued by the home health service. In the six-month period of the trial, only two such admissions were made—again, representing a 66% reduction.