The care and management of chronic patients present complex management problems for all of medecine. They incorporate the attention to medical management of the disease or disorder, the attention to support systems of living, movement within the community and relationships to the care-givers. However, the management of chronic mental patients is infinitely more complex. The treatment approaches, both psychotherapeutic as well as pharmacological, require a system of monitoring the symptoms, patient compliance and the daily adjustments to living within the community.
Frequently, relatives have died of having moved from the home areas leaving the system to provide surrogate attentive care-givers. The care of the chronic severely disordered individuals incorporates the protection by the courts adjudicating their rights and privileges under the law.
Programs for the chronically ill in the last decade have moved more and more into community-based organizations. However, the coordination and integration between the necessary elements have been fragmented and often absent. The premise of restructuring the system of care formerly centered in large state mental hospitals requires a more effective definition of the use of mental hospitals. Furthermore, economically driven decisions to limit and cost-manage admissions have often created a revolving door of ineffective treatment episodes.
In general, hospital episodes can be limited to:
1. Imminently suicidal or homicidal patients 2. Patients requiring medication adjustments or requiring high doses of medication 3. Those requiring a highly structured environment for a period of time.
Other chronic patients should be attempted to be managed in the community, utilizing comprehensive resources to effect the maximal adjustment within the joint capacities of both the system and the patient.
The program is designed to respond to a particular group of patients who have been committed for care in state hospitals by the courts. In a program planned to use community commitment in place of hospital commitment, the program projected a working system alliance between the State Mental Health Program, the courts of jurisdiction, the agencies which deliver community mental health services and the social service system which arranges for housing, food and rehabilitative services. All the members of the alliance are committed to a training program for their staffs of the roles and services they are to provide. The entire system is connected through a common computer based system which monitors, audits, and evaluates the system. Patients may be admitted to a hospital for a brief period, to stabilize an acute exacerbation or to adjust the medication routine.
Components of a community-based chronic illness support system ->
H.M. Visotsky, Prof., MD
Department of Psychiatry
Northwestern University Medical School, Chicago