Max Lachman, PhD. & David Roe, PhD. The Laszlo Tauber Family Foundation

1. Recovery, Psychiatric Rehabilitation and Community Integration: The role of the Rehabilitation Case Manager’s Service Max Lachman, PhD. & David Roe, PhD. The Laszlo Tauber Family Foundation Mental Health Community Dep’t , Haifa University Israel

2. Outline of presentation • Recovery, Psychiatric Rehabilitation and Community Integration – a theoretical framework • Psychiatric Rehabilitation in Israel • The Rehabilitation Case Manager’s new service • Research • What can we learn from the Israeli experience into the International Psychiatric Rehabilitation Movement

3. From Recovery to Community Integration 3

4. The role of Self Determination 4

6. Values of Psychiatric Rehabilitation • Self-determination • Dignity and worth of the individual • Optimism or hopefulness for progress of improvement • Belief in the capacity of individuals to improve self, learn, and grow • Sensitivity/understanding to the culture of others

7. Normalized Roles & Relationships Potential for Growth Pragmatism Learn by Doing Egalitarian Relationships Holistic Approach Blurred Professional Roles Core Values of PSR

8. Guiding Principles • Individualize services • Maximize client preference and choice • Ensure normalized, community basis • Focus on strengths • Use situational assessments • Integrate efforts with treatment holistically • Coordinate services, make them accessible

9. Multicultural Sensitivity Consumer Empowerment Family Role Hope Respect & Dignity Eclectic Approach Outcomes Focus Collaboration “Recovery” Prevention of Hospitalization Goal achievement Strengths Emerging Principles

10. Prevention - Case Management Social Residential Vocational Education Activities of Daily Living Health & Well Being PSR Program Elements

11. Housing Employment Education Health Status Leisure/Recreation Spirituality Citizenship and civic engagement Valued Social Roles (e.g., marriage, parenting) PEER SUPPORT Self-Determination Community Integration Definition The opportunity to live in the community and be valued for abilities and unique qualities like everyone else

12. Some data’s… • In Israel 7.500.000 citizens. • We evaluate 10 % of the population as having Disabilities. • 70.000 – 120.000 Persons have Psychiatric Disabilities. • This is the bigger group from all the Disabilities groups. • People with Psychiatric Disabilities are underprivileged and suffer from discrimination.

13. Barriers to Recovery and PR implementation in Israel • Stigma • Hegemony of the medical model • Citizenship, war and recovery • No enough basic training in Mental Health policy and practice inside the Universities • Political base practice

14. Developments of the Israel System of Care • Reforms and deinstitutionalization process • Shift in societal attitudes towards persons with disabilities • Consumers movement (Family members & “Coppers”) • New legislation and government appointed committees reports

15. New Legislations Treatment of Mental Health Patient Act 1991National Health Insurance Act 1995Patient’s Rights Act 1996Equal Opportunity for Disabled Persons Act 1998Rehabilitation of Mentally Handicapped Persons in the Community Act 2000

16. Basket Rehabilitation Services • Admission Criteria • Types of services (“The Basket itself”) • Individual Choice and Partnership

17. The Role of the District Rehabilitation Coordinator • Responsible for all rehabilitation actives in their district. • Coordinates the committees for “basket of Services”. • Responsible for follow up on every client Plan in rehabilitation services in district. • Ongoing assessment of the need for new services in district.

18. Basket Rehabilitation Services • Admission Criteria • Types of services (“The Basket itself”) • Individual Choice and Partnership

19. Number of Persons using Psychiatric Rehabilitation Services

20. Challenges No data management at all levels (referrals are very poor in quality and quantity, no data monitoring, no connection between the clinical and the rehabilitation data) Many clients are referred to rehabilitation without readiness to change Many clients use services without connections to their personal goals (self determination, abilities development, motivation) The community service system (Health, Mental Health, Welfare and Psychiatric Rehabilitation) is not coordinated and organized

21. (Marianne Farkas, 2006) Recovery means regaining a meaningful life within a given cultural context and according to the person’s personal goals

22. The right according to the law The psychiatric rehabilitation law states that any adult with at least 40% Medical Psychiatric Disability of has the right to apply to a Regional Rehabilitation Basket Committee and present “an individual rehabilitation plan”. In a meeting with the committee, the person will be eligible to receive formal resources (services and rehabilitation interventions) so he/she can reach his personals goals and implement their individual plan.

23. Obstacles to the implementation of the law • Lack of motivation and involvement of the consumer during the plan creation. (domination of paternalistic attitude and forced elements during the process) • A lack of preparation and guidance in implementing the plan after the committee decisions. • "The client’s choice” throughout all the stages of the implementation of the plan is still limited. • Conflict of interests between the consumer ’ will and ability and the economics interests of services providers. • A lack of use of “Individual Rehabilitation Plan” as practice in the services. No systematic evaluation of micro-outcomes. • The policy and the practice in Psychiatric Rehabilitation is not based enough on evidences of the efficacy of the services to enhance personal goals of the clients. (E.B.P.)

24. The Service Definition The “Individual Rehabilitation Plan – Case management Service” is a new Rehabilitation Service to support persons with Psychiatric Disabilities. (who applied and receive approbation to their personal programs from the Regional Psychiatric Basket of Services Committee – Psychiatric Rehabilitation in the Community Law-2000).

25. Research Treatment Ministry of Health Baskets Committees Regional Coordinator Family New Service Case Managers Community Services Welfare, Heath Rights Consumers Psychiatric Rehab. Services Access to Services Rehabilitation Readiness Evaluation and Relationship Individual Planning Recommendations For ending the process Follow up 25

26. Models and Instruments • Strengths Model- Rapp C. • Rehabilitation Readiness, Boston University, Farkas M. et al. • Definition ofSetting an Overall Rehabilitation Goal (SORG) • Collaborative Goal Technology (CGT)- Oades L. G. et al. • Prochaska and DiClemente’s Stages of Change Model • Recovery Interview – Lachman M. 26

27. Values and Attitudes The case managers will work in respect to the “client’s choice”. The relationship between the client and the case manager will be base on the principle of self-determination and full partnership. The main activities and tasks are: • Help the person access psychiatric rehabilitation services (defined by the regional committee) and follow the progress in achieving the different goals by the services. (Micro -Outcomes) • Assist the client redefine and initiate new plans and change to achieve more community integration and quality of life. This support will be based on the client’s will, strengths, and capacities in cooperation and support from the family and others professionals involved. Ministry of Health, Procedure No 88.001

28. Service components – Tasks and Expectations • Mediation and brokerage between the client, the desire to build and advance an individual rehabilitation plan and the formal and informal resources. • Establish a systematic way of monitoring the Rehabilitation service of care. • Support and advocate the client voice in the decision process. • Identify and recruit community resources to strengthening the individual rehabilitation plan . • Make more resources available in the system by helping client use fit services, redefine needs and want and not be stock.

29. Case manager Activities and tasks • Individual support, given attention to the client preferences and will, follow-up and helping the process of change in a way the process of change can continue. • Tailoring the individual rehabilitation plans by listening and knowing the particular expectations and needs of the client. • Create coordination and division of tasks between all the partners (family, services, professionals and significant others). • Assist in the demands of the Law for individual follow-up. • Evaluation of outcomes (efficiency and efficacy of the services) • Give interventions to client for enhancing readiness to change and be able define personal goals.

30. Direct Professional activities • Getting to know the clients and create a trust relationship. • Evaluate the client’ desire of change. • Define the the individual plan in the most operative level (objectives, tasks, scheduling, …) • Recruiting internal and external resources for the plan realization. • Knowing and being in contacts with the partners involved in the realization of the plan . • Reporting and document the activities to the service and the “Rehabilitation Basket Committee”

31. The Pilot deployment • The service will be available in two “rehabilitation areas: • An office will be established in each area, as a centre for operating the service. • Each service will included: a professional area coordinator, 15 “rehabilitation case-managers”, and administrative staff. • Most of the interventions will be provided close to the rehabilitation activity (mobility)

32. Main role of the rehabilitation case managers • Accompanying and serve a caseload of 30-42 clients • Routine individual meetings with each clients for implementing and follow-up progress in their individual rehabilitation plan (at least twice a month) • Routine sessions with the rehab service providers' staff for consolidating the plan and gaining detailed information on the advancement towards achieving personal goals that were specifically defined in the plan. • Meetings with the program partners according to the need. • Recruiting essential resources for enhancing the chances of a successful plan. • Ongoing report on the daily activity and implementation of the program • Initiating changes in the plan with the approval of the rehab basket team in the Ministry of health. • Participating in staff meetings, individual counseling and various training programs

33. Basic data on the service

34. Numbers of referrals to the service by the Rehabilitation Committees June 2009- Referrals 569 (63%) Active 526 (92%) Dec 2009- Referrals 862 (95%) Active 777 (90%) Feb 2010- Referrals 963 (107%) Active 843 (87%) *service data-Feb 2010.doc Gender males 613 (62%) females 363 (38%)

35. Individual Rehabilitation coordinated Plan (IRP) Focused on client’s wants and needs Integrative rehabilitation plan for each client- plan per service vs. plan per person Review of the plan every 3 months The plan is computerized IRP Template *Format for Individual Rehabilitation Plan-Feb 2010.doc

36. Impact of Service on Rehabilitation System in Israel Enhance Recovery values into the way services are giving to consumers. Enhancing clients’ rights to choose services and plans. More Focus on the Person instead of Service

37. Study Goals Primary: To assess the effectiveness of the RPCS intervention for individuals suffering from severe mental illness compared to individuals receiving regular rehabilitation services (the control group) and compared to baseline. Secondary: To assess different subgroups relative to the efficiency of the service (age, gender, services used etc..).

38. Methodology Stratification and randomization: based upon a service-use and age stratification procedure. Wave 1 within the first 2 weeks or 4 meetings of service inception. Wave 2 after 20 month. Assessment based upon 3 sources: Structured face to face interviews Clinician ratings Ministry of Health database Two regions studied (Center North/South). Two control groups (Within & outside [Haifa]-of RPCS region)

39. 83% 86%

40. Data collection so far-Wave 1 Experimental & Control Group

41. Stratification Results for ‘Veteran’ Users: expected vs. final sample* *User status was primarily based upon the use of housing services (from intensive to slight use). If no housing facility was used, user status was based upon the use of vocational services (from intensive to slight use). Information for this classification was provided by the Ministry of Health. Results based upon experimental and control ‘Veteran’ sample. ‘New’ users didn’t use any services and were thus not part of the stratification procedure.

42. Interviews done since study inception: Overall Monthly

43. Primary findings: Characteristics of 925 participants New Veterans * Haifa North South Status Region 59% are study participants and 41% control group *Within the ‘New’ category there are between 15-25% veteran ‘Revolving door’ service receivers

44. Characterization of study and control groups Most participants are single and with only basic or lower education *p<.001

45. SCALE DOMAINS • Goals • Number & Kinds • Achievement • Barriers & Support • Quality of Life (subjective and objective functioning) • Physical Health • Leisure • Community Integration • Residence • Interpersonal/Social • Employment • Financial • Education • Satisfaction • Optimism • Psychiatric Symptoms