|Year : 2021 | Volume
| Issue : 4 | Page : 343-345
Home-based care in the community
Shikha Tyagi1, Akshit Katoch1, Subhash Das1, Nitin Gupta2
1 Department of Psychiatry, Government, Medical College and Hospital, Chandigarh, India
2 Gupta Mind Healing and Counselling Centre, Chandigarh, India
|Date of Submission||11-Nov-2021|
|Date of Acceptance||11-Nov-2021|
|Date of Web Publication||25-Nov-2021|
Ms. Shikha Tyagi
Department of Psychiatry, Government, Medical College and Hospital, Chandigarh
Source of Support: None, Conflict of Interest: None
Treatment gap in mental health is vast and continues to remain a grim reality. Amongst community mental health care, one approach available is home based care (HBC). However, HBC services are almost lacking in India. Nevertheless, the limited evidence points towards a successful utility of HBC till date. In this article, the Chandigarh experience of HBC is presented and discussed in detail in order to demonstrate its utility and effectiveness. Lastly, recommendations are provided for the future of HBC.
Keywords: Community Care, Home Based care, Community, Mental Health
|How to cite this article:|
Tyagi S, Katoch A, Das S, Gupta N. Home-based care in the community. Indian J Soc Psychiatry 2021;37:343-5
| Introduction|| |
Treatment gap in mental health continues to remain a grim reality, ranging from 83% to 96%. Majority of these patients are left to themselves or to their families, as there is no mechanism to provide services to such patients suffering with treatable mental disorders. The World Health Report of 2001 has described the community-based mental health service approach as comprising services which are close to home including general hospital care for acute admissions, long-term residential facilities in the community; interventions related to disabilities as well as symptoms; treatment and care specific to the diagnosis and needs of each individual; a wide range of services which address the needs of people with mental and behavioural disorders; services which are coordinated between mental health professionals and community agencies; ambulatory rather than static services including those which can offer home treatment; partnership with carers and meeting their needs; and legislation to support the above aspects of care. Community mental health services are deemed to be very crucial in promotion of mental health awareness, reduction of stigma and discrimination, supporting recovery and social inclusion, and prevention of mental disorders.
| Community Mental Health Care|| |
Community Mental Health Care in the West began in 2nd half of 20th century in the form of balanced care that included provision of treatment and community-based services at home or close to home. These were delivered through multidisciplinary Community Mental Health Teams (CMHTs) that existed in different forms and had been going through different phases of evolution. The teams delivering such services were CMHTs, Assertive Community Teams, Crisis Resolution Teams, Home Based Treatment Teams, and Crisis Resolution and Home Treatment Teams (CRHTs).
On the other hand, in India, community mental health developed as “the service” and not as an “alternative” to “institutionalized care.” However, despite cultural and resource-based differences, models from the developed world can still be adopted to suit local Indian culture subject to testing for appropriateness. Although home-based services are almost lacking in India, such type of services have consistently been found to be effective in improving quality of life and social behavior in the Western countries. There are studies from the early 1980s and somewhat recently from the Department of Psychiatry, GMCH, Chandigarh that have shown that if the treating team goes to the patient's home to provide treatment, then it is successful.,, Although hospital-based services may be qualitatively better, it is not feasible to bring everybody into treatment due to multiple barriers. However, patients who are unable to seek treatment from hospital-based services have a right to get minimum mental health facilities in order to assist them to live as independently as possible in their chosen environment. In order to implement home-based care (HBC) in India, logistics need to be worked out in view of scarcity of mental health professionals.
| Home-Based Care: The Chandigarh Experience|| |
HBC is aimed at development, and delivery, of services in collaboration with various stakeholders, namely, people with mental illness (PMI), caregivers, and mental health professionals. This may include provision of or linking PMI and families with services depending on their respective needs. In India, there might have been small efforts by certain individuals to provide community outreach services out of personal choice.
Providing comprehensive mental health services in the city of Chandigarh was a dream very close to the heart of Dr. BS Chavan. Ever since he joined GMCH-32, Chandigarh in the capacity of Head of Department, Dr. BS Chavan laid a great deal of emphasis on community psychiatry. The journey of community psychiatry in GMCH-32, Chandigarh, started with him initiating a clinic under the shade of tree along with colleagues at Palsora in the year 1996. That “under the tree” clinic not only prescribed medicines but also focused and extended itself more on listening to the multiple problems and stories that the people living in that area had to share. This nonjudgmental attitude gradually built a relationship of trust with the community; and the department ever since has been running community outreach clinics at four different centres since then on a regular basis. The zeal to do more and reach out to people never got satiated in Dr. Chavan, and this led onto the department to start running deaddiction camps in the community; an innovative step which took community psychiatry nearer to the homes of the people. It will be pertinent to highlight here that most of the innovations led and conceived by Dr. Chavan had their roots from his intense and informal interaction with patients and caregivers.
In Chandigarh, the treatment facilities for persons with mental illness have traditionally been available in both public and private sector. However, the major difficulty faced by the families/caregivers would begin when the patient, despite having major mental illness, refuse to seek treatment from hospital-based facilities. In addition to refusal for treatment, persons with mental illness would sometimes become violent, thereby posing a risk to self and others. Quite frequently family members approached the psychiatrist for prescribing medicines to their relative/ward without any assessment. Continuing with his streak for innovations and for improving mental health services in Chandigarh, Dr. Chavan started giving shape to his long-cherished dream of starting Crisis Resolution and Home-Based Treatment Services and formally began it in April, 2013. The initial setup and running of the service proved to be a challenge as initially the services were started using the resources available within the department. However, the service continued with all the inherent constraints as Dr. Chavan strongly believed that merely sitting within hospitals cannot solve the myriad difficulties faced by the caregivers in bringing patients for treatment, and it was essential for mental health professionals to move out of their comfort zone to cater to vast majority of the population who does not want to seek treatment. Hence, despite challenges and the teething issues that continued for a long time the efforts to develop a sustainable model for providing HBC in the community were continued. Few IEC activities were carried out and within 3 months of initiating these services, it was realized that requests started pouring in especially from caregivers of persons with SMI and also the dissatisfaction with the service as the waiting time for them used to be long. Gradually, a Public Private Partnership (PPP) model was worked out along with a Nongovernmental organization (NGO) (Parivartan), for delivery of HBC services. Under the PPP model, resources were shared between the NGO (Parivartan) and Department of Psychiatry, GMCH, Chandigarh. The personnel came from Department of Psychiatry, namely, one full time Psychiatric Social Worker, one full time nursing staff, one full time security guard, and a psychiatrist for periodical input. Other essential resources such as one full time driver, mobile, van, medical equipment, and salary of driver came from the NGO “Parivartan.” The service was made available 6 days a week; 9 am–5 pm (Mon-Fri) and 9 am–1 pm (Sat) to residents of Tricity of Chandigarh/Panchkula/Mohali with mental health difficulties or who were in crisis. This division of resources reduced waiting time for families, thus improving utilization of service. The Department of Psychiatry, GMCH, Chandigarh, has been running these services for the past 8 years and have catered to around 450 families till now. This kind of innovative approach can be utilized in other parts of India too to determine the plausibility of implementing the model throughout India. It is important to note that the services must be simple in terms of accessibility and approachability, and be additionally sustainable, replicable, and cost effective.
| Home-Based Care and Mental Health Care Act, 2017|| |
The Mental Health Care Act (MHCA), 2017 for the first time envisaged that the government should take sufficient measures to provide a range of services for persons with mental illness that shall include home-based facilities. This laudable initiative is part of right to comprehensive mental health facilities to be created in the public sector.
| Home-Based Care in Chandigarh|| |
As mentioned earlier CRHT services in Chandigarh started in April, 2013, when Mental Health Act, 1987 was in force; hence warranted changes in delivery of services after the MHCA, 2017 got implemented. Accordingly, the standard operating procedure of CRHT services was revised. Major changes had to be incorporated, especially for attending a case requiring emergency services. For instance, Section 100 of MHCA, 2017 was used each time a crisis case had to be admitted, capacity assessment by two mental health professionals was made mandatory in the first visit for every case required to be seen for the first time, etc. Even for cases requiring regular HBC, the visits were stopped if patient had capacity and refused to give written informed consent for them despite the family members insisting the team to visit. After implementation of MHCA, 2017 the CRHT team primarily focused on building a strong therapeutic alliance with the patient to bring about desired changes in their behavior. For every patient enrolled under CRHT services, the management plan is made in keeping with aspirations of the patient.
HBC as envisaged by MHCA, 2017 also has potential to decrease the stigma attached to hospital admission, provide service that is accessible and affordable (in keeping with National Mental Health Programme), reduce the burden of family members, reach the unreached, reduce burden on hospital beds, and in reducing the treatment gap.
| Conclusions|| |
There is a need for continuation and development of the HBC service, its assessment using the “service evaluation” model, and to demonstrate fidelity and consistency for replication at other centers in India along with a need for putting forth recommendations for appropriate and uniform implementation.
There is also a need to develop modules to promote self-care skills of the persons with mental disorders and their family members. Such transfer of skills will go a long way to address the limitations of manpower, fight stigma, increase acceptance of care, and most importantly build care program on the local community resources.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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