Mentally disordered offenders – The need for integration and smart design of services

1. Mentally disordered offenders – The need for integration and smart design of services Marianne Kristiansson, M.D., Ph.D., Ass Prof Head and Medical Director Dept of Forensic Psychiatry in Stockholm National Board of Forensic Medicine and Karolinska institutet, Stockholm, Sweden e-mail: marianne.kristiansson@rmv.se June 2008/Kristiansson

2. VIOLENCE -a universal challenge THE PUBLIC HEALTH APPROACH WHO - 2002 June 2008/Kristiansson

3. Several cases of unprovocedLethal ViolenceSweden, 2003 The Minister for Foreign Affairs June 2008/Kristiansson

4. Psychiatric ServicesForensic Psychiatry Crisis? June 2008/Kristiansson

5. Need for a better way?Wolff N. (New) public management of mentally disordered offenders.Int J Law and Psychiatry 2002;25:427-444. • Systems-level dysfunction • Mismatch between individual needs and system capacities • Services-level dysfunction • Mismatch between individual needs and services due to management barriers • Lack of integration of various services June 2008/Kristiansson

6. New mental models –investment in innovation! Building cross-system and intraservice partnerships June 2008/Kristiansson

7. Lien L.Economic factors influencing the implementation of community care for severely ill schizofrenic patients.World Hospitals and Health Services2005;41:1:21-24 • A balance between hospital and community care • Incentives that serve the need of the patients • Economic incentives • Demand for mental health care • Different as compared to somatic care • Demander: society, relatives • Lack of information on what is good quality care • Price elasticity • Higher as compared to somatic care June 2008/Kristiansson

8. Lien 2005What works? • Multidisciplinary teams • Continuous responsibility • High staff-to-client ratio • Brief frequent contacts • Collaboration with other parts of the patient’s support system • Costs and Benefits? June 2008/Kristiansson

9. Organizations - Complexityvarious parts are integrated into an adaptive function – how to apply in mental health care? Anderson and McDaniel Jr Managing Health Care Organizations: Professionalism meets Complexity Science Health Care Management Review 2000;25:83-92 June 2008/Kristiansson

10. Mentally disordered offenders Complex needs Many services Psychiatry, Substance abuse treatment, Housing, Daily activities June 2008/Kristiansson

11. Substance abuse*Do not comply to medicationNo housing** * Grann & Fazel, Br Medical Journal 2004;328:1233-1234 **Tsemberis et al, Am J Public Health 2004;94:651-656 June 2008/Kristiansson

12. The Swedish designthe Swedish Penal Code, • ”a person who has committed a crime under the influence of a severe mental disorder must not be sentenced to prison” • Sentence to compulsory forensic psychiatric care • with or without special court assessment before discharge June 2008/Kristiansson

13. Compulsory forensic psychiatric care Not limited in time June 2008/Kristiansson

14. however There is a lack of specialised housing environments for mentally disordered offenders and need for integration of forensic psychiatric and social services. June 2008/Kristiansson

15. National Board of Health and Social Welfare 2006 – launched a national project Intermediate treatment Three models June 2008/Kristiansson

16. Aim of the project Design models that facilitate patients’ re-entry into community – Beneficial for patients and also for society June 2008/Kristiansson

17. Half-way house –located just near the hospital • Run by Mental Health Care • Forensic Psychiatric Care • Four small apartments • Short to medium term transitory phase from inpatient care to outpatient care • Assessment with regard to social skills and compliance • 6 – 12 months June 2008/Kristiansson

18. Forensic Psychiatric outpatient residential facility– home-designlocated in community • Run by forensic psyhiatry (75 %) in close collaboration with staff from social services (25 %) • Four to six small apartmens • Intensive rehabilitation services June 2008/Kristiansson

19. Accommodation Case manager Occupational therapy Social skills training Vocational training Physical exercise Relaxation centre Forensic psychiatric outpatient services Probation services Social services Outpatient substance abuse treatment Primary somatic care Work related activities Unit for information Media Public Outpatient forensic psychiatric residential facility June 2008/Kristiansson

20. Group living –located in community • 6 – 8 apartments • Run by social services (75 %) but with staff from forensic psychiatry (25 %) • Always possible to provide short periods of inpatient care June 2008/Kristiansson

21. Cost – Benefit Analysisfrom hospital to Facilities in community ??????????????? June 2008/Kristiansson

22. Financial aspectsthe three modelscosts per patient/year • Inpatient care 170 000 – 180 000 euro • Half-way house 110 000 euro • Forensic psychiatric outpatient residential facility – 140 000 euro • Group living with expert forensic psychiatric services – 120 000 – 100 000 euro June 2008/Kristiansson

23. Forensic Psychiatric Management(leadership, organization, innovation) A new concept We cannot change the patients but we can change June 2008/Kristiansson