Transdisciplinary assessment frame as leverage for integrated care

Abstract

In patients with severe, complex, and long-lasting psychiatric problems, psychopathology becomes intrinsically intertwined with personality, biological, social, and existential well-being. Consequently, the share of experience of general well-being becomes more critical. Therefore, apart from standard evidence-based treatment, added guidelines and good practices concerning suicidality, lifestyle, family impact and resource, human custodial measures, collaboration with patients and their expertise, and spiritual and existential guidance, complement standard guidelines. Unfortunately, these extra guidelines are used only as an add-on with traditional treatments or separated in a recovery approach where treatment would no longer be the focus. Because of the lasting need for integrated and precision care in these patients, UPC Duffel Belgium started an integrated plan for precision care. The first step in this plan was the development of a three-level assessment frame, a 'general treatment' backbone as leverage for uniting the different specializations, and a frame in which all interdisciplinary and transdisciplinary activities find their place. The next step is the collaborative use of the system and implementation of the associated skills and attitudes for all participants.
 The first person-centered level is the individual psychotherapeutic level at which criteria for treatment indication are evaluated in an overview that prioritizes with the patients’ different problems, systematically organized in four axes. Axis I, of distant fixed factors of nature and nurture is associated with the latent intrapersonal or permanent contextual or cultural factors (Axis II). The outcome behavior Axis III shows problem behaviors as a flip side of their associated therapeutic goals, followed by Axis IV with direct behavior-triggering and factual temporary, environmental, and relational/contextual factors. This case conceptualization is feasibly visualized and translated into a short explanation and hope inspiring narrative with the patient. 
 The second interdisciplinary level is the team level, at which treatment criteria are evaluated in the context of the treatment history. The staff and the patient check ten points: identification of the patient, triggering events for admission, previous treatments with successes and failures, important influences of personality, contextual or cultural factors as far as conditional for the present treatment, preferences of the patient, short term risks, long term risks, treatment priorities, ultimate goal and deselected treatment targets, criteria for dismission and contextual points of attention. Experience experts coach patients, using these points as a guide, to emancipate these patients to equality and to informed negotiator in their treatment, thus obliging the teams to prepare for a transparent discussion. 
 The third transdisciplinary level is the hospital level which automatically and repeatedly evaluates the stay's effect by Routine Outcome Monitoring in all domains of functioning as in the International Classification of Functioning model (ICF). This model provides an overview of functioning, activity, and participation problems and resources and indicates the right places for engaging in transdisciplinary actions and collaboration beyond the restricted cure field of psychiatry. The functioning chart is a hinge that connects the psychopathology frame and the complementary positive health domains as both map on the same ICF scheme.