It’s Possible to prevent social exclusion among mentally ill?: IPSE Project, " Clinical Case Management " in Schizophrenic Patients in two catchment areas in Madrid (Spain) MARIA FE BRAVO ORTIZ Psychiatrist, M.D., Ph.D., Head of Psychiatric Department. Hospital Universitario La Paz (Area 5, Madrid). Professor, Autonoma University. Principal Research, Project IPSE

MAIN OBJECTIVE A reflection about the impact of a clinical case management program in the clinical and social outcome of schizophrenic patients, and its possibilities of prevent exclusion in these people. In this reflection I will analyse the results of the IPSE Project. A reflection about the impact of a clinical case management program in the clinical and social outcome of schizophrenic patients, and its possibilities of prevent exclusion in these people. In this reflection I will analyse the results of the IPSE Project.

PROJECT IPSE The Project that is presented comes framed inside the evaluation studies of "Case Management" programs and its impact in the treatment of people with schizophrenic disorders. The Project that is presented comes framed inside the evaluation studies of "Case Management" programs and its impact in the treatment of people with schizophrenic disorders. In our country the incorporation of these programs has been later and they have not still been carried out studies of effectiveness. In our country the incorporation of these programs has been later and they have not still been carried out studies of effectiveness. Results about clinical features, and use of inpatient (emergencies, admissions and stays) and outpatient (Psichiatric and Care Coordinator consultationa, and use of specific rehabilitation centers) services of schizophrenia patients referred to Case Management Programs (CMP) from three Madrid Community Mental Health Centers (corresponding to a population of inhabitants ) are shown. Results about clinical features, and use of inpatient (emergencies, admissions and stays) and outpatient (Psichiatric and Care Coordinator consultationa, and use of specific rehabilitation centers) services of schizophrenia patients referred to Case Management Programs (CMP) from three Madrid Community Mental Health Centers (corresponding to a population of inhabitants ) are shown.

WHAT ARE THE FEATURES OF CASE MANAGEMENT PROGRAMS? It organizes and coordinates the whole attention and care for people with more admissions and difficulties to use the community and mental health resources. It organizes and coordinates the whole attention and care for people with more admissions and difficulties to use the community and mental health resources. Keyworker assignmet Keyworker assignmet Written individualized plan Written individualized plan Clinical Case Management Clinical Case Management

IPSE PROJECT OBJECTIVES To evaluate the effectiveness of Case Management Programs (CMP) in the improvement of the outcome of people with schizophrenic disorders in three Madrid Community Mental Health Centers of Madrid after two years of follow-up. To evaluate the effectiveness of Case Management Programs (CMP) in the improvement of the outcome of people with schizophrenic disorders in three Madrid Community Mental Health Centers of Madrid after two years of follow-up. To identify the features that these CMP defines in each one of the studied Community Services of Mental Health and that they have a bigger impact in the results in the clinical, social state and of use of resources. To identify the features that these CMP defines in each one of the studied Community Services of Mental Health and that they have a bigger impact in the results in the clinical, social state and of use of resources.

SAMPLE: N= 267 SCHIZOPHRENIA PATIENTS ATTENDED IN 3 COMMUNITY MENTAL HEALTH CENTERS Psychiatric Case Register data since 1985 (Emergencies, Admissions, Stays, Outpatient contacts) SCHIZOPHRENIA PATIENTS ATTENDED IN THESE 3 COMMUNITY MENTAL HEALTH CENTERS (CMHC) DURING 2002 (N=744) P.C. Register Data + Psyquiatric Questionnaire SCHIZOPHRENIA PATIENTS ATTENDED IN THESE 3 CMHC DURING 2002AND INCLUDED IN CARE PROGRAMME (N=267) SCHIZOPHRENIA PATIENTS ATTENDED IN THESE 3 CMHC DURING 2002 AND INCLUDED IN CARE PROGRAMME (N=267) P.C. Register data + Psychiatric Questionnaire + Interview + Keyworker Questionnaire

INSTRUMENTS Demographic Data: Demographic Data: Gender, Age, Marital Status, Way of Living, Educative Level, Current Employment Situation Gender, Age, Marital Status, Way of Living, Educative Level, Current Employment Situation Clinical Features: Clinical Features: Positive and Negative Syndrome Scale (PANSS) (Kay SR, Opler LA, Lindenmayer JP., 1989); Positive and Negative Syndrome Scale (PANSS) (Kay SR, Opler LA, Lindenmayer JP., 1989); Disability Assessment Schedule (World Health Organization) (DAS); Disability Assessment Schedule (World Health Organization) (DAS); Global Assessment of Functioning Scale (DSM-IV) (GAF) Global Assessment of Functioning Scale (DSM-IV) (GAF) Schizom Subscales (Fisher, Cuffel, Owen et al., 1996) Schizom Subscales (Fisher, Cuffel, Owen et al., 1996) Use of Inpatient and outpatient Services Use of Inpatient and outpatient Services Data of Psychiatric Case Register (PCR) since 1985: Emergencies, Admissions and Stays, CRPS Register Data of Psychiatric Case Register (PCR) since 1985: Emergencies, Admissions and Stays, CRPS Register

DEMOGRAPHIC DATA WAY OF LIVING MARITAL STATUS EDUCATIVE LEVEL CURRENT EMPLOYMENT SITUATION GENDER

YEARS INCLUDED IN CASE MANAGEMENT PROGRAMME AGE OF ILLNESS BEGINNING

SOCIODEMOGRAPHIC DESCRIPTION SOCIODEMOGRAPHIC DESCRIPTION : Single men, with a mean of ages of 42,73 years that reside with their parents. Their educational level is Primary or Secondary School. They receive a a social benefit or permanent disability pension. Single men, with a mean of ages of 42,73 years that reside with their parents. Their educational level is Primary or Secondary School. They receive a a social benefit or permanent disability pension. The disorder began between the 19 and 25 years, with an average evolution of the disease of more than 15 years. The disorder began between the 19 and 25 years, with an average evolution of the disease of more than 15 years. 44 % of the studied patients are between 5 and 10 years in the program, and 24 % of them more than 10 years. 44 % of the studied patients are between 5 and 10 years in the program, and 24 % of them more than 10 years.

CLINICAL FEATURES SCHIZOM: SUICIDE RISK DAS ILLNESS AWARENESS EEFG SCHIZOM: SUBSTANCE ABUSE SCHIZOM: CURRENT SYMPTOMS PANSS TREATMENT ADHERENCE DAS

CLINICAL CURRENT SITUATION: They have not presented clinical relevant symptomatology recently; showing minimal or light levels of positive, negative and general symptomatology. They have not presented clinical relevant symptomatology recently; showing minimal or light levels of positive, negative and general symptomatology. In the main, they do not present problems of substance abuse. In the main, they do not present problems of substance abuse. Low levels of risk of suicide. Low levels of risk of suicide. More than the half of them they have high adherence to the treatment. More than the half of them they have high adherence to the treatment. The illness awareness is very poor, in general. The illness awareness is very poor, in general. They present major levels of disability, needing more help, in the occupational functioning and in the social wide context. They present major levels of disability, needing more help, in the occupational functioning and in the social wide context. With regard to their global functioning, in the main, they present difficulties of mild to moderated. With regard to their global functioning, in the main, they present difficulties of mild to moderated.

USE OF INPATIENT SERVICES YEAR OF INCLUSION IN CASE MANAGEMENT PROGRAM

USE OF OUTPATIENT SERVICES PATIENTS INCLUDED IN SPECIFIC REHABILITATION CENTER NUMBER OF CONSULTATIONS IN 2002

USE OF INPATIENT AND OUTPATIENT SERVICES: A significant reduction exists in the use of resources of hospitalization in those patients who are included in CMP from the moment of their incorporation. A significant reduction exists in the use of resources of hospitalization in those patients who are included in CMP from the moment of their incorporation. They diminish both the emergencies, and the admissions and the stays, as well as the number of subjects that have been admitted. They diminish both the emergencies, and the admissions and the stays, as well as the number of subjects that have been admitted. This reduction is kept throughout the years This reduction is kept throughout the years 48% of patients are using specific rehabilitation programs. 48% of patients are using specific rehabilitation programs. The average number of psychiatric consultations is 1 every 2 months, and of care coordinator 1 every 15 days The average number of psychiatric consultations is 1 every 2 months, and of care coordinator 1 every 15 days

CONCLUSIONS Clinical Case Management programme reduces significantly the use of inpatients and emergencies services, contributing to the clinical stabilization of the schizophrenic patients Clinical Case Management programme reduces significantly the use of inpatients and emergencies services, contributing to the clinical stabilization of the schizophrenic patients CCM contribute also to social stabilization and prevent exclusion among schizophrenic patients CCM contribute also to social stabilization and prevent exclusion among schizophrenic patients