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The evaluation cost-benefit for the community: to the services for user, at user as resource


Slides 1

First we’d like to show you how so called “emergency treatment” aimed at a single person doesn’t make the problem go away but instead maintains the “emergency” and so the cost remains high for the whole health care system. Then we’d like to describe how an emergency treatment not aimed only at a single person but also at his environment will bring benefits for the whole community and lower the overall costs.

Slides 2

Traditional psychiatric management means taking the person into a therapeutic-rehabilitating care. Keeping the person in these type of structures is expensive for the whole healthcare system and the cost doesn’t go down when the person leaves the “emergency treatment”. As we all know after hospitalization the return back to the normal life is critical (family, school, friends). People around him will still see a “sick person” and will relate to him according to views they have about his problem. So the person will find himself in a “catch 22” situation so that he can’t feel “normal” even after leaving the treatment so he finds it difficult to communicate with other people. The healthcare system doesn’t consider or even see this difficult passage from a hospital to normal life and so the person will find himself in the “emergency situation” again and even regress further. This means reactivating the healthcare system again when also the cost will be higher.

If every link in this chain instead of maintaining the “catch 22” situation, would create a so called “virtual circle” where the people around him would treat the person not as a sick person but as a person with his own identity. In this way people around the person leaving a traditional structure could help him to create a new beginning and help him to re-establish his identity. This type of management would have to involve the whole community and would bring benefits to the user and healthcare system as we can see later on


Slides 3

As we have seen above, nowadays the aim of those conditions defined as “psychiatric emergency” and managed by the national health service, is to modify – even pharmacologically – the behaviour that has led to reporting, thus involving the person being taken care of as a “passive” user. Behaviour modification, however, does not imply giving up the “rhetoric of the problem”, which continues to be used both by the person for whom the alert has been issued to describe themselves and by the context (family, friends, services) to describe him/her. By way of example, the drug addict continues being considered an ex-drug addict even after the scheduled treatment period is over, i.e. the bearer of a label. Such an operations practice, therefore, results in strengthening the “service user” identity. This leads to recurrent reporting and subsequent increase of costs over time with knock-on effects on the whole community. This process of managing emergency that maintains the status quo of the critical situation that originally called for intervention also leads to increasingly more congestion, as well as involving continuous financial and organizational costs. A tangible example of what this situation might give rise to is the activation of the T.S.O. (compulsory health treatment), which involves high economic and social costs – primarily the economic cost of mobilizing the health service, the police force and the mayor. Such interventions, moreover, do not solve exhaustively the issue; on the contrary they open new intervention scenarios and generally lead to institutionalisation, which contributes to cronicizing the existing situation. The benefits deriving from such a practice, as a matter of fact, are limited to managing the situation defined as “emergency” and consist in marginalising the user within a specific and protected structure, i.e. the mental health service. The benefits of such management methods are limited to preventing in the hic et nunc any possible physical damage to the users themselves or the community. Such practices also imply a strong stigma on the user's case history, as we have seen, as well as cronicizing and increasing the occurrence of the emergency situation.

Slides 4

What we have described above allows us to calculate the costs that affect the national economic system, based on the duration of the “social and health service user” status. This configuration in fact involves constant activation of the regional network as well as the services, which leads to perceiving the problem as unsolvable. Clearly, in order to manage the situation described as “problematic and unmanageable” and to stop the “psychiatric emergency” alert, it is necessary to shift the intervention focus from the aim of containing/stopping the behaviour that led to reporting to the aim of changing the mode of constructing the reality it described.

Slides 5

Implementing a management modality based on the Dialogic Model involves reconfiguring the roles played by the figures constructing the reality that leads to reporting. The context should be considered as a resource in the process of building a reality of “non reporting”, able to reconfigure reality from a “problem” into a “critical situation”, i.e. non problematic by definition, but manageable. The aim therefore will be to build these resources' competencies in managing the situations that led to reporting. Furthermore, this management mode promotes cooperation between the national health and social services and the private social services in the context of a team-work approach to the objectives of the intervention. In this way an informal service network is established, on one hand aimed at managing the here and now of the elements that led to reporting, on the other at promoting a different user identity: no longer a “service user”, i.e. an identity that cannot be described as “at risk of psychiatric emergency”. Such a process calls for the community to trigger a process of health promotion of the whole country as a system, by acquiring managing competencies, as well as team-work skills, with consequent benefits both to the single individual and the whole community.


Slides 6

The results in terms of achieving the intervention aims and, as stated before, in terms of benefits for the whole community, are attested by means of effectiveness assessment. If it is applied in itinere, this methodology represents a monitoring tool, as well as attesting the quantum of reached objectives. It allows to analyse the intervention “direction”, offering useful elements for the analysis of the strategies deployed to reach the objective of the intervention, in order to modify the intervention itself while it is in progress.

Consequently, higher benefits can be obtained in the long term for the whole national system by using the context as a player in the process of health construction, compared to the costs of activating the intervention itself. Such costs turn out – in perspective – to be lower in the absolute sense, since the “case history” configuration no longer leads to a third dimension. Institutionalization is not included, hence bringing down the costs connected with maintaining a “service user history”. The immediate costs related to institutionalization in public or private structures and the social costs arising from the impact that crystallizing the “user's history” has on the community are brought down. Additionally, training operators in strategic context management according to the assumptions of the dialogic model amounts to an investment for the whole national system. The operators working for change, as a matter of fact, intervene directly on the community by networking the services – both formal and informal – that interact with the user, and transfer competencies in managing the relationship and the here and now to the whole context involved by the emergency situation, with immediate beneficial effects for the community itself.

In this connection public health is considered a shared responsibility in terms of taking care of the needs arising from the same national system that is the final recipient and user of the intervention.