1. The Organization of Mental Health Services in Ulss – 9 Treviso

2. The Organization of Local Health Areas in Veneto We call them: Az. Ulss Az = Azienda (Company: It is public company but it has a management like a private company) U = Unità (Unit) L = Locale (Local) S = Socio (Social: Municipalities have given Lhas the management of some social services) S = Sanitaria (Health ) In other Regions: LHAs are not also “social” but only “health”

3. Az.Ulss in Veneto Region

5. The Organization of LHAs : the Districts

6. The Organization of Mental Health Services in LHA There is one Mental Health Department for each of 21 Veneto Region LHAs Every Mental Health Department has one or more Mental Health Units In Az.Ulss 9 every District has one Mental Health Unit (4 Districts = 4 MHU) Every Mental Health Unit organizes many facilities

7. Mental Health Department In Italian language: DSM (Dipartimento/Department – Salute/Health – Mentale/Mental) Responsible for planning and coordinating all mental health services in a specific area Run by a Director, supported by a Board of Directors (of the units), a Broad Committee, and an Assembly

8. Mental Health Department It plans and work in cooperation with NPOs, Patients and Families Associations DSM coordinates the “Mental Health Area” that agree with Municipalities the “Piano di Zona” (Zone Planning Act) The Zone Planning Act describes the social activities shared by Municipalities and DSM, the way of building them, the financial resources

9. The Organization: Mental Health Unit Hospital Services National Planning: 1 bed per 10.000 population – In Az. Ulss 9: 1 Hospital Unit in Treviso General Hospital 1 Hospital Unit in Oderzo General Hospital We need 1 more Hospital Unit in Treviso General Hospital (2012?) – Now: 1 bed /17.000 inhabitants Community-based services

10. – 1 CSM (Mental Health Center) : the core for activities It is out of hospital Psychiatric and Psychological activities for outpatients Psychoeducational activities Group Therapy Home support Social support

11. Community-based services Partial Time treatments = Day Patients Patients live in their houses and come to facilities for 4-6 hours of treatment – Centro Diurno (Day Rehabilitation Service): Psycho education activities Group Therapy Occupational activities – Day Hospital (Day Treatment Service) Group Therapy Psychopharmacological Therapy

12. Community-based services Full Time treatments: patients live in community – Residential Facilities CTRP (Sheltered therapeutic Rehabilitation Community) CA (Sheltered House community) GAP (Sheltered group house) – Selection is based on : illness severity / disability / needs for intensive treatment / day care time – A way from high disability and severe disease to better health and skills

13. Sheltered Residential Facilities CTRP (Sheltered therapeutic Rehabilitation Community) – 8 – 14 inpatients – Highest intensity of treatment – Lowest social skills – Staff: 24/24 hours CA (Sheltered house community) – 6 – 8 inpatients – Medium intensity of treatment – Better social skills – Staff: 12/24 hours GAP (Sheltered house) – 4 inpatients – Low intensity of treatment – Low disability – Staff: 4 hours/day

14. Community based Facilities In Az. Ulss 9 we are modifying and completing the network of facilities – Modifying: some facility were organized for patients discharged 30 years ago from Psychiatric Hospitals. Their needs are changed – Completing: we need facilities more suitable for young people and early psychosis We now manage directly some facilities, and indirectly some others, managed directly by NPOs – Italian Financial Laws limit the engagement of new staff – LHAs must buy services from private organizations – NGOs are the best reference, owing to costs and the possibility of creating a good collaboration In Az.Ulss 9 the new planning will spend more than 10 million euro / year for sheltered residential facilities managed by NPOs

15. What we know: the Data In Az. Ulss 9 we have two flows of data – Hospital Discharging data: » patient (sex, date of birth, where he lives, job, … ) » admission (planned, emergency, compulsory) » disease (diagnosis, therapy) » length of hospital stay – Outpatients data » patient (sex, date of birth, where he lives, job, ….) » how the patient arrived to services » disease (diagnosis) » what we do (psychiatric or psychological examination, psychotherapy, rehabilitation activities, admission to residential or day/residential facilities, and so on) In Veneto Region we have the same two flows for all LHAs

16. Veneto Data Base: Hospital

17. Veneto Data Base: Mental Health Communiy based Services

18. DSM Computerized Medical Folder

19. Mental Health Year Report Veneto Region

20. How many patients? Rate per 1000 population - 2008

21. Admissions of psychiatric patients (all hospital units) – Public vs private unit

22. Admission of psychiatric patients (all hospital units)

23. Admissions of psychiatric patients (all hospital units) rate per thousand population 2008

24. Admissions to Public Psychiatric units in Veneto Rate per thousand population 2008

25. Admissions to Private Psychiatric units in Veneto per thousand population 2008

26. Compulsory Admissions to Psychiatric Public units

27. Compulsory Admissions to Psychiatric Public units - Rate per thousand population 2008

28. Community Based Services DSM 9 vs Regione Incidence – Prevalence - 2011

29. Prevalence rate per 1000 population 2012 by Unit

30. Incidence rate per 1000 population 2012 by Unit

31. Prevalence by age and sex 2009

32. Prevalence per 1000 population by age Males 2009 – Az.Ulss 9 / vs Veneto

33. Prevalence per 1000 population by age Females 2009 – Az.Ulss 9 / vs Veneto

34. Prevalence by diagnosis - 2012

35. Incidence by diagnosis - 2012

36. Incidence by diagnosis - rate per 10000 population 2008 – Ulss 9 vs Veneto

37. Activities 2012

38. Social therapeutic and rehabilitation activities  Employment  Sheltered jobs (together with “Provincia”)  Law “68”: companies have to employ some people from a list of patients with disabilities  SIL (Service for job integration):  training employment (a few hours, little earnings)  No profit work companies  We are now starting Supported Employment  Individual placement and support of people without training in competitive jobs  Help for House  Agreement Acts with Municipalities for houses for psychiatric people

39. Mental Health Promotion  A specific staff that promote groups to explain mental health organization and to inform about mental health diseases  In schools  In Municipalities  Every year there is the “mental health day”, to encounter population

40. Residential activities Patients admitted 2012 = 140 – Patients discarged from psychiatric hospital = 61 – Patients without history of psychiatric hospital = 79 Facilities = 18

41. Staff EmployedConsultantNPOsSumReal Staff Psychiatrists26202827,39 Psychologists544137,97 Nurses10907116105,66 Social Workers60066 Education Staff110 2215,84 Care Technical Staff4108812997,57 Administrative Staff60065,67 Others56132413,04 SUM20912123344279,14 Staff/population: 1,2 per 1000 population

42. Staff by facilities UOA 1 Profilo professionaleCSMCtrpCDSPDC Psychiatrists62 Psychologists21 Nurses166715 Social Workers1 Education Staff1113 Care Technical Staff 2676 Administrative Staff1

43. How much does it cost (2010)? Totale Community Based ServicesHospital Buying Assets1.276.012,821.230.012,8146.000,01 Staff9.449.987,777.475.855,221.974.132,55 Administration297.702,10289.117,758.584,35 Not Sanitary Services1.599.544,371.413.441,43186.102,94 Other Sanitary Services196937,29136094,1660843,13 Buying Services6.689.884,60 0,00 OVERALL COST19.510.068,9517.234.405,972.275.662,98 Financial Resources of Az.Ulss 9€ 552.650.811,00€ 283.210.811,00€ 239.118.000,00 % 3,536,090,95

44. A few data on the implementation of the Mental Health Reform in the Veneto Region 805 beds for acute psychiatric emergencies in 40 general hospitals 337 community-based services, 111 of which are residential ¾ of community-based services are run by LHA’s 3.000 staff (80% work for LHA’s): 47% nurses, 24% care givers, 13% psychiatrists, 6% educators, 3% psychologists, 3% social workers (ie. 1 : 1500 inhabitants)

45. 64.700 ( 16,3 per 1.000 inhabitants ) mentally ill people treated in 2007, of whom 11.680 ( 3,0 /000 ) admitted to general hospitals and 59.800 ( 15,1 /000 ) in community- based services Note: estimated prevalence of mental illness in Italian population: 8% → 368.000 in Veneto region (ie. most treated by G.P.’s) Overall costs: € 250 million (ie. 3,5% of LHA’s budget) Note: the objective is 5%

46. Admissions to Public Psychiatric Unit by diagnosis – rate per 10.000 population – AzUlss 9 vs Veneto