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June 2008/Kristiansson Mentally disordered offenders – The need for integration and smart design of services Marianne Kristiansson, M.D., Ph.D., Ass Prof.

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Presentation on theme: "June 2008/Kristiansson Mentally disordered offenders – The need for integration and smart design of services Marianne Kristiansson, M.D., Ph.D., Ass Prof."— Presentation transcript:

1 June 2008/Kristiansson 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

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

3 June 2008/Kristiansson Several cases of unprovoced Lethal Violence Sweden, 2003 The Minister for Foreign Affairs

4 June 2008/Kristiansson Psychiatric Services Forensic Psychiatry Crisis?

5 June 2008/Kristiansson 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

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

7 June 2008/Kristiansson Lien L. Economic factors influencing the implementation of community care for severely ill schizofrenic patients. World Hospitals and Health Services 2005;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

8 June 2008/Kristiansson Lien 2005 What 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?

9 June 2008/Kristiansson Organizations - Complexity various 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

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

11 June 2008/Kristiansson Substance abuse* Do not comply to medication No housing** * Grann & Fazel, Br Medical Journal 2004;328:1233-1234 **Tsemberis et al, Am J Public Health 2004;94:651-656

12 June 2008/Kristiansson The Swedish design the 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

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

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

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

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

17 June 2008/Kristiansson 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

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

19 June 2008/Kristiansson Outpatient forensic psychiatric residential facility 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

20 June 2008/Kristiansson 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

21 June 2008/Kristiansson Cost – Benefit Analysis from hospital to  Facilities in community ???????????????

22 June 2008/Kristiansson Financial aspects the three models costs 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

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


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