Le case management de transition: une intervention à court terme dans la communauté après une hospitalisation psychiatrique

Abstract

Outpatient care became more important and community psychiatry developed in industrialised countries. Through this community shift, the burden of mental health problems increased also for many citizens such as relatives, carers, neighbours, police, etc. Psychiatric hospitalisations became more easily accessible for a greater number of patients but for shorter durations leaving less time to carefully prepare discharge. Weeks following discharge were found at risk for resurgence of symptoms, readmission, and even suicide. The sector model in France and case management in the Anglo-Saxon countries were developed to meet the needs for care continuity of severe and persistent disorders, after long-term hospitalisation and for heavy users of acute psychiatric care. However, not enough attention has been drawn on transitions after short-term hospitalisations and in earlier phases of psychiatric disorders, although linking with community care remains notoriously difficult in these cases. This article aims to describe the practice of a transitional case management (TCM), a short-term intervention designed for people returning home after psychiatric hospitalisation without specialised outpatient psychiatric care. Method: The study is descriptive, with quantitative and qualitative data and clinical vignettes. TCM begins during hospitalisation and continues by one month follow-up at home after discharge. It aims to promote recovery, to manage stress associated with returning home, to foster links with the network of carers and to prevent the risk of early relapse and readmission. Results: Patients returning home without outpatient psychiatric care represented between 20% (schizophrenia unit) to 70% (admission unit) of patients. Subjects concerned by this intervention were mostly middle-aged (m = 40 years) women (65%) with a diagnosis of anxiety or mood disorder (65%). The level of functioning was disturbed with a GAF score of 45. The mean length of stay was 27 days. Subjects at risk were not identified a priori during hospitalisation: difficulties arose while they actually returned home. The primary (relatives) and secondary (caregivers) networks were often not clearly identified during hospitalisation, while psychiatric team remained mainly focused on symptoms. Being back home after psychiatric hospitalisation was a major stress that often exceeded the capacity of patients' community carers, although situations appeared simple and easy to manage during hospitalisation. TCM intervention was well accepted and appreciated by patients, relatives and caregivers. Discussion: Target population for transitional case management includes a majority of women with mood disorders, which are most at risk of suicide within days following discharge from psychiatric hospitalisation. The needs of these people remained underestimated during hospitalisation, where they were not identified as problematic patients. In addition, tools to identify patient's social network should be implemented in hospital care units, allowing linking between hospital care and community upon admission. TCM gave support to the patient and her/his social network after discharge. The week following discharge was often experienced as a crisis with symptoms' relapse, and often misunderstood by caregivers in the community while patient should be cured by hospitalisation. This crisis gave the opportunity for the case manager to identify stressors and to implement advanced directives in connexion with carers in the community. Patients were satisfied with home visits, concrete help for daily problems and linking with their relatives and caregivers. A randomised study is ongoing to prove efficacy of TCM.