Evaluation of the rehabilitation process in Greek Community Residential homes:
resettlement from Greek Psychiatric Hospitals


Stelios F. Stylianidis (corresponding author)
Professor of Social Psychiatry, Panteion University of Social and Political Sciences, Athens, Greece
Scientific Director of EPAPSY (Scientific Association for the Regional Development and Mental Health- N.G.O.)

Stella M. Pantelidou
Scientist Responsible of Mental Health Mobile Unit of NE Cyclades Islands
Psychologist MSc

Panagiotis C. Chondros
President of EPAPSY (Scientific Association for the Regional Development and Mental Health- N.G.O.)
Psychologist MSc


Citation
Stylianidis SF, Pantelidou SM, & Chondros  PC. (2008). Evaluation of the rehabilitation process in Greek Community
 Residential homes: resettlement from Greek Psychiatric Hospitals.   International Journal of Psychosocial Rehabilitation. 13(1), 31-38

EPAPSY
Grammou 61-63 Marousi, 15124 Athens, Greece
 e-mail:epapsy@otenet.gr

---

Abstract
Objective The aim of the study is to evaluate the impact of transfer of care from the psychiatric hospital to community residential homes on the patients’ level of social functioning, one year after discharge. Method A repeated measures design was employed in order to compare 73 patient’s level of functioning one week before the transfer to the psychiatric hospital and one year later in community residential homes. A Personal data and psychiatric history form was used as well as the Scale of Rehabilitation Evaluation of Baker and Hall (1984). Descriptive statistics and One-Way ANOVA were used to analyze the data.Results A statistically significant improvement was noted in the rehabilitation and social functioning status of the patients (p<0.01). Conclusions Specific interventions developed in the community residential homes seems to have positive impact in many domains of social function of chronic psychiatric patients.

Keywords psychosocial rehabilitation, social functioning, Greek psychiatric reform, community residential homes

---

Introduction
Till the beginning of the psychiatric reform, the mental health system in Greece was highly centralized, lacking primary care and rehabilitation facilities. The operation of the psychiatric hospitals was anachronistic and failed to serve the needs of the population. Psychiatric care was provided mainly in 9 state psychiatric hospitals (some were commonly called  “warehouses of chronic psychiatric patients”) and 40 private hospitals. The Greek psychiatric reform began in 1983 with the introduction of the National Health System and the membership of Greece in European Community. A five year plan was then constructed aiming at developing sectorization, deinstitutionalization of chronic psychiatric patients, implementation of psychiatric clinics in General Hospitals, development of community mental health facilities within the sectors and programs of prevocational and vocational rehabilitation. The implementation of the plan was extended till 1995. In 1997 a new program titled ‘Psychargos’ was developed with the same aims concerning deinstitutionalization and development of community services (Α’ phase 2000-2001, Β’ phase 2001-2007) (Madianos et al., 1999; Karastergiou et al., 2005). The number of long stay psychiatric patients will be, by the end of 2006, near to zero in the mental hospitals, whereas in 1984 there were 7795 chronic patients in the eight psychiatric hospitals of Greece (Brown et al., 1984). Two mental hospitals (Petra Olympou and Chania) have already closed (the first in January 2004 and the second in February 2006) and their staff moved to the community mental health facilities while three more (Attica Mental Health Hospital for Children, Corfu, and Tripoli mental hospitals) are planned to close by the end of 2006. It is anticipated that by the year 2015 the final closure of the rest of the mental hospitals (Attica, ‘‘Dromokaiteio’’ and Thessalonica mental hospitals) will have been achieved (Spyraki, 2001). Until then the objective is to reduce dramatically the acute beds in the remaining mental hospitals.

In a survey that has been carried out by the Psychargos Phase II Monitoring and Support Unit (not yet published) it was found out that on December 31st 2005 there were 377 residential facilities all over Greece, created since 1988, 28.6% of which run by NGOs (there are 33 NGOs involved in Psychargos Phase II programme) and 71.4% by state mental or general hospitals. In these facilities (boarding homes, hostels and apartments) there were, by that day, 2695 patients (total number of beds: 2961, 2.71 beds every 10000 inhabitants). Male patients constitute 62.63% and female patients 37.36% of the residents’ total number. Their average age was 54.67 years. Quite all residents are former mental hospital inpatients. 1288 of them have been settled during Psychargos Phase II

This change in the way psychiatric care is provided for chronic patients has created new needs for the organization and evaluation of the new services developed. However, evaluation in mental health services in Greece is still at its infancy. There is also no systematic process of evaluation according to certain criteria common for all services of the same kind. The attitude of the staff towards evaluation seems also to be negative, as evaluation generally is not part of the philosophy of any service in the field of mental health care.

 A few studies have been conducted in the Greek context concerning the evaluation of deinstitutionalization and rehabilitation pilot intervention projects implemented at Leros (Stylianidis and Gkionakis., 1997; Stylianidis, 1992; Tsiantis et al., 2000) as well as the evaluation of specific rehabilitation programs (Tomaras et al., 1992). Generally, these studies have shown significant improvements in different domains such as communication between staff and families, change in negative attitudes of the staff towards patients, better living conditions and increased sensitization of the local communities, decrease of duration of hospitalization in the follow-up period. Specifically, concerning evaluation of rehabilitation programs related to deinstitutionalization, Zissi & Barry (1997) assessed the level of functioning and quality of life for 99 hostel residents discharged from Leros asylum. Results have shown that most residents were satisfied with their new living situation, finding a positive change in most domains of their life. The residents’ functioning status indicated different levels of abilities. Results on this direction were also found by Paxinos (2005) for 95 patients living in community apartments in Leros (discharged from Leros asylum). However, as there was no assessment done in the psychiatric hospital, before the discharge, no comparisons could be made on level of functioning. A repeated-measures design could be effective in this case in order to examine the impact of transfer of care in the community for those patients.  Such designs have been implemented successfully in countries were deinstitutionalization movement had began earlier than Greece (Harding et al., 1987; Salokangas, 1994; Crosby & Barry, 1995; Leff, 1997; Trieman et al., 1998; Trieman et al., 1999; Kaiser et al., 2001; Priebe et al., 2002  etc). These studies have shown a positive effect of deinstitutionalization on patient’s functioning status and quality of life.

Objectives
This study is a part of a wider evaluation project of all services provided by the Scientific Association for Regional Development and Mental Health (EPAPSY-the initials of the words in Greek). EPAPSY is a Non-Govermental Organisation established in 1988 with an aim to develop services in the field of psychiatric rehabilitation (community residential homes, hostels, day-centers, and vocational rehabilitation projects), primary and secondary care services (mental health mobile units), research and training of mental health professionals. The development and implementation of services and projects is financed by the European Union and the Greek Ministry of Health. The first hostel managed by EPAPSY was established in 1990 as part of the Program of Deinstitutionalisation of Leros. Till 2000 there was only qualitative evaluation of quality of care provided in that hostel (Stylianidis, 1992; Gkionakis et al., 1996). The establishment of new services since then created the need of systematic evaluation of rehabilitation process and quality of care.    

The aim of the present study is to evaluate the rehabilitation process and specifically the impact of transfer of care from the psychiatric hospital to community residential homes on the patients’ level of social functioning. A secondary aim is to sensitize the professionals on the philosophy and method of evaluation, as a tool of recognizing needs and taking actions in order to achieve improvements in the related domains. 

Briefly, the procedure followed concerning the deinstitutionalization process, and specifically the transfer of care from psychiatric hospitals to residential homes was the following: First, a period of preparation of the patient in the psychiatric hospital (with a mean duration of 6 months) takes place. The patient is prepared for the transfer and psychosocial interventions are developed. Place of birth, psychopathology, level of functioning are some of the selection criteria. However, there is much debate concerning the way these criteria were followed, resulting usually in conflicts between the staff of the psychiatric hospitals and the team of professionals preparing the patients for transfer.

The community residential home provides 24 hour care to about 15 patients with a staff to patient ratio being 1:4. The therapeutic team is multidisciplinary and consists of a part-time psychiatrist, a psychologist, a social worker, nursing and care staff. The team leader is a mental health professional, usually a psychologist. Emphasis is given on basic self-care training, development of domestic and social skills, vocational rehabilitation (in case where there is such a potential), increase of social support provided in the community, contact and work with the families of the patients, increase in the use of community resources and facilities, with an aim to achieve a more independent way of living.  

Methods
Design
A repeated measures design was employed in order to compare the patient’s level of functioning one week before the transfer to the psychiatric hospital and one year later in the community residential home.
Sample
The sample consisted of seventy-three patients discharged from Greek Psychiatric Hospitals (Psychiatric Hospital of Athens Dafni, Dromokaiteio, Psychiatric Hospital of Petra Olympou) living in 6 community residential homes (in Attica, Evia, Voiotia, Fthiotida, Thessalia) managed by EPAPSY.

Measures
A) A Personal data and psychiatric history form was used in order to collect information on socio-demographic characteristics and psychiatric history. This form was completed by the manager (psychologist) of each residential home in collaboration with the social worker.

B) The Scale of Rehabilitation Evaluation of Baker and Hall (1984) was used in order to assess the patient’s rehabilitation and social functioning status. It consists of two sub-scales: Deviant Behavior Subscale (socially unacceptable behavior) and General Behavior subscale which constitutes five areas of basic life skills: social activity, speech skills, speech disturbance, self-care skills and community skills. The Total General Behavior score has been suggested as the best and valid single dimension indicator of the patient’s level of dependency and functioning. The scale was adjusted and standardized in the Greek context by Zissi and Barry (1997). Internal consistency reliability measures were computed for the Greek version of REHAB and satisfactory Cronbach’s estimates were obtained (Total General Behavior subscale coefficient alpha=0.93 and Total Deviant Behaviour sub-scale coefficient alpha=0.54, Zissi and Barry, 1997). For the items of Deviant Behavior sub-scale a score from 0 to 2 can be given, with the lower scores indicating less frequent problems of deviant behavior (i.e. incontinence, physical violence, verbal aggression). The other sub-scales contain items that can be scored from 0 to 9 (higher scores indicate greater level of dependency, lower level of social functioning and basic social skills). It was completed by the manager (psychologist) of each residential home in collaboration with the nursing staff.

Analysis
Descriptive statistics and One-Way ANOVA were used to analyze the data.

Results
1.    Sociodemographic characteristics and psychiatric status
Seventy-three patients were assessed one week before the discharge from the psychiatric hospital. The main sociodemographic characteristics are presented in Table 1. Furthermore, the age ranged from 22 to 88 years old, with a mean age of 65. Characteristics of the psychiatric status are shown in Table 2 and Table 3.

Table 2. Psychiatric Diagnosis

 
Table 3. Psychiatric status

2. Rehabilitation status
The Rehab scale was completed again in the residential home, one year after the discharge for 72 out of 73 initial patients (one had passed away). A significant improvement was noted concerning the rehabilitation and social functioning status of the patients (Table 4). There was a statistically significant decrease (p<0.01) in the mean scores for total general behavior in the second assessment, one year after discharge (T1). The total scores in social activity were also significantly decreased (p<0.01). Furthermore, statistically significant lower mean scores in the second assessment were noted for total speech skills and speech disturbance (p<0.01), indicating important improvement in these domains. Moreover, there was a significant reduction in the mean scores for total self-care skills and community skills (p<0.01) in the residential home in comparison with the first assessment in the psychiatric hospital. Finally, there was an increase in the mean score of deviant behavior one year after the discharge (p<0.01).

Discussion
Although the evaluation project implemented had some methodological limitations, such as the lack of control group staying for the same period of time in the psychiatric hospital, the small sample related to the great number of patients discharged from psychiatric hospitals and the lack of external evaluation by a team of independent researchers, it has important implications concerning the new way of care provision in the community. It seems that the specific interventions developed in the community residential homes (focused on social skills training, psychosocial rehabilitation and achievement of a more independent way of living) have positive impact in many domains of social function, even for chronic psychiatric patients, who have spent a significant part of their lives into a psychiatric hospital. The results are in accordance with other studies conducted in the domain (Salokangas, 1994; Crosby & Barry, 1995; Leff, 1997; Trieman et al., 1998). Although, in many cases the expectations of the staff seemed to be low from the beginning of the intervention and there were resistances, it seems that the significant improvements in the rehabilitation status of the patients provided important positive feedback for the staff.

Preliminary results found on a pilot study done by the same organization (EPAPSY) on 51 patients six months after discharge have shown significant improvements in social activities and development of social skills even from that period, but a deterioration in some domains of deviant behavior (increase of verbal aggression and sexually insulting behavior) in comparison with the period staying in the hospital. Problems related to deviant behavior maybe are related to the period of adjustment in the new environment and have also been found by other studies too, one year after discharge (Crosby & Barry, 1995). This increase in deviant behavior remains even one year after discharge, which should be investigated further and must be taken into consideration in the care plan development.

 In the current context of psychiatric reform in Greece, the establishment of standard evaluation criteria, common for all the community psychiatric services developed is a need in order to assure quality of care provided, especially after the significant reduction of funding by the Ministry of Health and Social Solidarity which has affected the function of mental health services developed in the context of psychiatric reform. Evaluation should refer to different domains concerning the patients (i.e care and social needs, recovery status, psychopathology, rehabilitation, quality of life, satisfaction by the services provided), their families (i.e. burden, satisfaction by the service), the staff (i.e. burn-out, training needs) as well as the quality of care provided (i.e. care process, administrative arrangements, interaction with families, physical environment).  

---

References

Baker, R. & Hall, J. (1984). Users Mannual for Rehabilitation Evaluation Hall and Baker. Aberdeen: Vine Publishing

Brown, I., Liaropoulos, L., Lorenzen, D., Losavio, T., Maynard, A., Skaropoulos, H., Tsiantis, I., & Katzourakis, G. (1984). Reform of public psychiatric care in
Greece. Brussels: EC Commission. [In Greek].

Crosby, C. & Barry, M., M. (Eds). (1995). Community Care: Evaluation of the Provision of Mental Health Services. Aldershot: Avebury Press.

Gkionakis, N., Stylianidis, S., Kapsali, A., Tziou, E., Frattura, I. & Saraceno, B. (1996). Medicina di base e Psichiatria: ricerca e pratica in Eubea, una regione rurale della Grecia. Rivista di Freniatria, 3, 475-491.

Harding, C., M., Brooks, G., W., Ashikaga, T., Strauss, J. & Breier, A. (1987). The Vermont longitudinal study of persons with mental illness. I. Methodology, study sample and overall status 32 years later. American Journal of Psychiatry, 144, 718-726.

Kaiser, W., Hoffmann, K., Isermann M. & Priebe, S. (2001). Long-term patients in supported housing after deinstitutionalisation--part V of the Berlin Deinstitutionalisation Study. Psychiatrische Praxis, 28 (5), 235-243.

Karastergiou, A., Mastrogianni, A., Georgiadou E., Kotrotsios, S. & Mauratzotou, K. (2005). The reform of the Greek mental health services. Journal of Mental Health, 14 (2), 197-203.

Leff, J. (1997). Care in the community: Illusion or Reality? London: Wiley.

Madianos, M., Tsiantis, J. & Zacharakis, C. (1999). Changing patterns of mental health care in Greece (1984-1996). European Psychiatry, 14, 462-467

Paxinos, I. (2005). Perceptions of quality of life among residents of community residential units of Leros Hospital. Tetradia Psychiatrikis, 90, 47-55.

Priebe, S., Hoffmann, K., Isermann, M. & Kaiser W. (2002). Do long-term hospitalised patients benefit from discharge into the community? Social Psychiatry and Psychiatric Epidemiology, 37 (8), 387-392.

Salokangas, R. (1994). Community care and need for treatment of schizophrenic patients in Finland. British Journal of Psychiatry, 164 (suppl 23), 115-120.

Stylianidis, S. & Gkionakis N. (1997). La situazione in Grecia ed il caso Leros. Le cronicità ed I loro bisogni (p.p. 51-58), Bergamo: CIC Edizioni Internazionali.

Stylianidis, S. (1992). The experiment of Evia. An attempt between understanding and action. Tetradia Psychiatrikis, 40, 108-118.

Tomaras, V., Ioannovich, I., Madianos, M. & Capsali, A. (1992). Psychiatric rehabilitation: Evaluation of outcome. Psychiatriki, 3 (1-2), 67-76.

Trieman, Ν., Hugues, J. & Leff, J. (1998). The TAPS Project 42: The last to leave hospital. A profile of residual long-stay population populations and plans for their resettlement. Acta Psychiatrica Scandinavica, 98, 354-359.  

Trieman, N., Leff, J. & Glover, G. (1999). Outcome of long stay psychiatric patients ressetled in the community: prospective cohort study. British Medical Journal, 319, 13-16

Tsiantis, J., Diareme, S & Kolaitis, G. (2000). The Leros PIKPA asylum deinstitutionalization and rehabilitation project: A follow-up study on care staff fears and attitudes. Journal of Learning Disabilities, 44, 281-292.

Zissi, A. & Barry, M., M. (1997). From Leros Asylum to community-based facilities: Levels of functioning and quality of life among hostel residents in Greece. International Journal of Social Psychiatry, 43, 104-115.