THE MEETING OF ALL PARTICIPANTS OF "FOREIGN INTERNSHIPS" PROJECT 23RD - 24TH NOVEMBER 2009 PRAGUE

1. THE MEETING OF ALL PARTICIPANTS OF "FOREIGN INTERNSHIPS" PROJECT 23RD - 24TH NOVEMBER 2009PRAGUE Mauno SaariM.D., Ph.D. Family therapist Director of Health Services The Joint Authority of Kainuu Region,Finland

2. Kainuu in Europe 2 2 Prague 23-24.11.2009

3. KAINUU IN FINLAND 3 IVALO 625 km KAINUU Suomussalmi Puolanka OULU KAJAANI Hyrynsalmi 181 km Vaala Ristijärvi Paltamo Kuhmo Vuolijoki Kajaani Sotkamo HELSINKI 568 km Prague 23-24.11.2009

4. Finland is divided into 19 regions + Åland: Regions 2006 4 • Åland is an autonomous demilitarised Swedish-speaking region of Finland • Regions: • General regional planning • Prepare and monitor implementationof regional development plans • EU co-financed projects 4 Prague 23-24.11.2009

5. The most important statutory functions performed by local authorities are: Educational and cultural services Health care services Social welfare services Planning and building Fire and rescue services 332 Municipalities in 2009 5 5 Prague 23-24.11.2009

6. Social welfare and health services in Finland 2009 • Municipalities 332 • Municipality is responsible of services 130 muncipalities, • 69 % of the population (BLU E AREA) • Regional co-operation areas (64), 202 municipalities, • 31 % of the population • Joint Municipal Authoroties (GREEN AREA) 38, • municipalities 130 • One of municipalties (”the master municipality”) has • the primary responsibility (RED AREA) 26, municipalities 72 • Health centers 194 • Municipalities 130 • Joint Municipal Authotities 38 • One of municipalties has • the primary responsibility 26 • Health centers • Less than 20 000 inhabitants 122 • More than 20 000 inhabitants 72 6

7. Plan for mental health and substance abuse work. Proposals of the Mieli 2009 workinggroup to develop mental health and substance abuse work until 2015. The national plan for mental health and substance abuse work Defines the core principles and priorities for the future of mental health and substance abuse work until 2015. Starts from the premises that mental health and substance abuse problems have great significance for the public health. For the first time the plan outlines common national objectives for mental health and substance abuse work. The plan emphasises that the client’s status is reinforced, mental health and abstinence from alcohol and drugs are promoted, problems and alcohol and drug related harm are prevented and treated mental health and substance abuse services are organised for all age groups in a way that emphasises basic and outpatient services. New key policy definitions for developing the service system include the low-threshold principle of single entry point when a persons the establishment of outpatient units that combine mental health and services for substance abusers 7 Prague 23-24.11.2009

8. THE REGIONAL SELF-GOVERNMENTEXPERIMENT IN THE JOINT AUTHORITY OF KAINUU REGION, FINLAND

9. Reasons for the initiation of the self-government experiment: 9 • Decreasing population • Increase in the older age groups • Declining entrepreneurial activity and employment • Weakening municipal economy • Existing administrative and budgeting practices were not considered to provide sufficient support to the initiation of major, effective industry and business development projects in the region 9 Prague 23-24.11.2009

10. 10 • Provision of certain basic services at regional level • Responsibility for the specialized and primary health care, and most of social and educational services has been transferred from the municipalities to the region • Kainuu Region arranges upper secondary education, vocational education and vocational adult education • Responsibility for the financing remained with the municipalities 10 Prague 23-24.11.2009

11. ORGANISATION OF KAINUU REGIONAL AUTHORITY 11 REGIONAL COUNCIL AUDITING COMMITTEE REGIONAL BOARD Region Mayor MANAGEMENT GROUP PLANNING AND DEVELOPMENT COMITTEE FOR COMMITTEE FOR SOCIAL AFFAIRS AND HEALTH UPPER SECONDARY AND VOCATIONAL EDUCATION FINANCE ADMINISTRATION AND GENERAL SERVICES Prague 23-24.11.2009

12. SERVICES FOR HEALTH CARE AND SOCIAL WELLFARE (SOTE) Director of social welfare and health care services full- time in addition to one’s regular job Environmental health care Health services and treatment of illnesses Family services Services for the aged Mental health services for Adults and services for substance abuse General practice and health centre hospitals  Dental care Surgical care Conservative treatment Emergency duty services Health supervision Veterinary treatment Environmental health care laboratory Social- and family work Maternity- and child welfare clinic and family planning Health service for school children and students Services for the disabled Family counselling Gynaecology, maternity welfare and giving birth Specialized somatic care for children Child and Adolescent psychiatry Services supporting living at home Allowance for taking care of a relative Housing services Institutional care Joint services Medical services Occupational health care First aid, anaesthesia and intensive care Laboratory and pathology Radiology Pharmacy Equipment services Joint services Supporting services for management Clients’ advocate services 12 Prague 23-24.11.2009

13. Facts which make things difficult in Kainuu Sparsely populated, with only around 83,000 inhabitants The population is shrinking The inhabitants are older than in the rest of Finland More costs Less money Less workers in future (in 20 years the need for services is 50% more than now and we have 30% less workers to do it) The incidence of somatic and mental disorders is above the national average. A shortage of professionals in general health care and especially in mental health care 13 Prague 23-24.11.2009

14. The need of services for mental health and substance abuse 14 Prague 23-24.11.2009

15. Suicides in Finland 1979-2001/100.000 Prague 23-24.11.2009 15

16. Suicides in Finland 1980-2003 (Men-Total- Women) 16 Prague 23-24.11.2009

17. Suicides in Kainuu 17 Prague 23-24.11.2009

18. What did we have at the end of 1970s Local hospital beds over 170; plus in state hospitals about 20 beds Most of the patients had chronic schizophrenia or were mentally retarded No psychotherapists No psychiatrists No outpatient units No halfway houses No acute treatment There was a need for great reform that was conducted mostly in 1980-2000 and is still going on 18 Prague 23-24.11.2009

19. What do we have now 66 hospital beds in adult psychiatry 8 bed in child psychiatry 8 beds in adolescence psychiatry Outpatient units in all municipalities Halfway houses in almost every municipality Day-centres (Group houses) Occupational therapies as a part of the day-centres and halfway houses Several acute multiprofessional teams (later case specific teams) Home visits are a natural part of the work More than 100 psychotherapists Most of the workers have participated in some kind of psychotherapy or networks therapy training Everybody has a possibility to participate in supervision 19 Prague 23-24.11.2009

20. The only strategic objective in 1980s was To reduce the amount of hospital beds To prevent mental disorders from becoming chronic To develop methods for the early detection and intervention of mental disorders 20 Prague 23-24.11.2009

21. As a tool to do it we selected the Need-Adapted Treatment model That decision based on the following factors it was clear that in a region plagued by a persistent shortage of experts – general practitioners and specialists in particular – research, treatment and rehabilitation could not be implemented with a biological emphasis it was also clear that the need for hospital treatment could only be reduced by preventing mental disorders from becoming chronic. The above-mentioned objectives were supported by the immediate family- and network-oriented intervention performed in all cases in accordance with the Need-Adapted Treatment model, and by recommendations aiming at the continuity of treatment and the correct timing and integration of various forms of treatment. 21 Prague 23-24.11.2009

22. The basic principles of the need adapted treatment model are 22 1.The treatment activities are planned in such a way that they meet in the best possible way the real changing needs of the patient and his nearest environment. 2.Both examination and treatment are conducted with a flexible and comprehensive approach recognizing the process character of the treatment and avoiding restricting routines. 3.A psychotherapeutic attitude is dominant in the process of the treatment. 4.The therapies are carried out in mutual integration in such a way that they support, not counteract, each other Prague 23-24.11.2009

23. The basic principles of the need adapted treatment model are 23 4.The outcome and progress of the work must be followed up constantly. 5.Transactional thinking guides the application of the treatment. This means that the patient is regularly included in all situations concerning him, especially when the treatment plans are made. 6.Patients family and the significant others are also included from the intensive start of the examination and treatment. 7.The focus in the treatment is shifted from exclusively individual level to an analysis of the whole transactional system, including the treatment team itself. Prague 23-24.11.2009

24. MODE OF THERAPY COURSE OF THERAPY INDIVIDUAL THERAPY renewed therapy meetings THERAPY OF THE SECONDARY FAMILY THERAPY OF THE PRIMARY FAMILY PSYCHOTHERAPEUTIC COMMUNITY renewed therapy meetings FAMILY- AND ENVIRONMENT- CENTERED CRISIS INTERVENTION INITIAL INVESTIGATION IN THE FIRST THERAPY MEETINGS social situation, family situation,individual state of the patient

25. About the implementation Operational changes were first introduced at the psychiatric hospital and adjoining outpatient clinic. The changes were supported by long-term supervision the ward and outpatient clinic workgroups later extended to cover the day ward and outpatient wards 25 Prague 23-24.11.2009

26. About the implementation Investments were simultaneously made in increased psychotherapy training for the region’s mental health personnel, with a special focus on family therapy. 26 Prague 23-24.11.2009

27. The focus chosen in Kainuu for the development of the treatment model Primary phase assessment, examination and treatment; The first psychosis team was founded in the hospital district of Kainuu in 1991. The psychosis team should work not only with acutely psychotic patients but also with all other patients who were likely to be suffering from some other acute severe mental disorder 27 Prague 23-24.11.2009

28. The team set the following goals for its work: All new psychoses of schizophrenia-type and other types in the hospital district of Kainuu should be examined and treated by the team. The team should participate in the examination and treatment of every patient in apparent need of first-time psychiatric hospitalization, regardless of the diagnosis. The team can be contacted between 8 am. and 4 pm. Monday through Friday. The examination of severe mental disorders shall begin within the first 24 hours from the first contact. All parties involved in the examination and treatment of acute severe mental disorders should support and not counteract each other. The contents and effectiveness of the work of the psychosis team shall be examined. 28 Prague 23-24.11.2009

29. the clinical observations a single psychosis team is not enough, especially if the team’s operations covered other severe mental disorders besides psychoses. the transfer of treatment responsibility from the psychosis team to other outpatient care teams was often problematic and could lead to treatment being interrupted and to the deterioration of the mental condition of the patient In practical clinical work there appeared to be an extensive need for cooperation between personnel in mental health work, substance abuse work, social welfare and education, and somatic health care as well as for the sharing of treatment responsibility on a continuous basis These observations combined with the recommendations of the national Integrated Treatment of Acute Psychoses project led to the objective being set as the development of The Need-Adapted Treatment model towards case-specific work-groups 29 Prague 23-24.11.2009

30. C A S T E E S A P M E S S I F I C INITIALINVESTIGATION IN THE FIRST THERAPY MEETINGS N O T R E A T M E N T FAMILY- AND ENVIRONMENT- CENTERED CRISIS INTERVENTION renewed therapy meetings in open wards, homes etc. Hospital ward renewed therapy meetings Personal nurse Occupational therapy Psychotherapies Familytherapy, Couplestherapy, Individual psychoterapies, Grouptherapy Needadapted treatment model (according to Alanen 1993, Saari 2003) 30 Prague 23-24.11.2009

31. What is important as regards the regional implementation of a new working model? The regional implementation of any operating model requires personnel training and administrative support. On training. In Finland, basic vocational training in health care fails to provide sufficient skills in interactive relations management beyond those at the dyadic relationships. Training is based on a biological concept of man, and any psychological or psycho-therapeutic dimensions are generally based on psychoanalytical development theories. In short training programs with an approach differing from the above the operation of the work-group changes only temporarily for the duration of the training program, but will soon revert to its original course if the change is not backed by the unreserved support of management and a work-group committed to the new way of operating. training should be recurring and “non-stop” in nature. Training groups should be formed on the basis of actual cooperation needs and should transcend organizational boundaries. 31 Prague 23-24.11.2009

32. On training Since the 1990s Kainuu has trained a total of 75 special level and demanding special level psychotherapists. More than 100 employees of the region’s social welfare and health care sectors have participated in long-term training supporting work in multiprofessional case-specific work-groups. The training groups have been designed to support the regional needs of everyday operations. The participants have been selected from various branches of administration within the same municipality. In addition to the adoption of practical skills, one of the objectives has been that the workers learn to know each other and each others working methods during the training process. This allows them to establish a stronger sense of mutual trust, which is the single most important precondition for cooperation across organizational boundaries. The latest of the many training programs took place in 2006-2008, when 35 staff members from Kainuu were trained in family therapy, group therapy or psychodynamic individual therapy as an integrated part of the Need-Adapted Model. The training comprised sections on theory, which were common to all training groups, and clinical seminar days which focused particularly on the reconciliation of various therapy forms in clinical work. 32 Prague 23-24.11.2009

33. Organizational structure supporting the regional operating model An extensive organizational reform was carried out in social welfare and health care in Kainuu at the beginning of 2005 the administrative functions of the social welfare and health care sectors of the region’s eight municipalities were merged. Prior to the reform, the municipalities had been responsible for organizing basic services and the hospital district for organizing specialized services. Following the reform, it became possible to arrange the organization of mental health services to support the creation of case-specific work-groups. The support of administration is vital from the perspective of the implementation of the regional treatment model. However, in my opinion it is even more important that the overall operative service concept determines the method in which the organizational structure and management system is structured. 33 Prague 23-24.11.2009

34. SERVICES FOR HEALTH CARE AND SOCIAL WELLFARE (SOTE) Director of social welfare and health care services full- time in addition to one’s regular job Environmental health care Health services and treatment of illnesses Family services Services for the aged Mental health services for Adults and services for substance abuse General practice and health centre hospitals  Dental care Surgical care Conservative treatment Emergency duty services Health supervision Veterinary treatment Environmental health care laboratory Social- and family work Maternity- and child welfare clinic and family planning Health service for school children and students Services for the disabled Family counselling Gynaecology, maternity welfare and giving birth Specialized somatic care for children Child and Adolescent psychiatry Services supporting living at home Allowance for taking care of a relative Housing services Institutional care Joint services Medical services Occupational health care First aid, anaesthesia and intensive care Laboratory and pathology Radiology Pharmacy Equipment services Joint services Supporting services for management Clients’ advocate services 34 34 Prague 23-24.11.2009

35. Cordinating ward nurses More important than the support of top-level administration is the fact that the grass roots management in the various sectors has grasped the key objectives and content of the operating model to be implemented. In the clinical work of everyday reality it is ultimately the immediate supervisor who makes the decision on whether staff from the unit is authorized to participate in the work of case-specific teams or not. Outpatient and hospital services are placed under the same grass roots management, the so-called coordinating ward nurses Each coordinating ward nurse is in charge of the overall services for the sub-region, comprising both outpatient and hospital services. The coordinating ward nurses have a solid base in theoretical training and extensive clinical experience in the application of the need-adapted treatment model and case-specific work-groups. 35 Prague 23-24.11.2009

36. In conclusion The implementation as required extensive on the-job training for the entire personnel monitoring of effectiveness and changes in the organizational structure to support the implementation strengthening psychotherapeutic competence across a wide range of therapies special training programs were provided for the entire personnel (including, for example, nurses) in mental and social health care in order to increase cooperation. Safeguarding the continuity of the operating model in the future requires the regular implementation every few years of training and cooperation projects, an increase in the region’s own training resources organizing a new psychotherapist training (demanding special level ) that will be the key short-term development task in Kainuu 36 Prague 23-24.11.2009

37. Thank you..