RSS-Feed abonnieren
DOI: 10.1055/s-0034-1390424
Home Treatment – aufsuchende Behandlung im Hamburger Modell der Integrierten Versorgung
Home Treatment – A Treatment Model of Integrated Care in HamburgPublikationsverlauf
eingereicht 04. April 2014
akzeptiert 09. September 2014
Publikationsdatum:
08. Dezember 2014 (online)
![](https://www.thieme-connect.de/media/ppmp/20150304/lookinside/thumbnails/10.1055-s-0034-1390424-1.jpg)
Zusammenfassung
Aufsuchende Behandlungsformen, wie das „Crisis Resolution and Home Treatment (CRHT)“ oder „Assertive Community Treatment“ (ACT), haben sich als effektive und die Behandlungsqualität verbessernde Modelle zur Behandlung von Menschen mit schweren psychischen Erkrankungen erwiesen. In Deutschland sind diese noch wenig implementiert, als Bestandteil einer sektorenübergreifenden Integrierten Versorgung jedoch vereinzelt vorhanden. Anhand des Hamburger Modells wird dargestellt, wie die Umsetzung einer solchen Behandlung durch ein ACT-Team als Teil der Integrierten Versorgung (IV) aussehen kann und anhand der Ergebnisse des 3-Jahres-Verlaufs diskutiert. Das Hamburger Modell bezeichnet ein IV-Modell für schwer erkrankte Psychose-Patienten. Das Modell wird seit 2007 als Managed Care „Capitation-Modell“ über den §140 SGB V als Jahrespauschale von verschiedenen Krankenkassen finanziert und kontinuierlich bezüglich der Effektivität und Effizienz untersucht. In Vorstudien zu diesem Modell zeigte sich bereits bei Kostenneutralität im Vergleich zur Standardbehandlung eine niedrige Gesamtbehandlungsabbruchrate sowie signifikante Verbesserungen hinsichtlich Psychopathologie, Funktionsstatus, Lebensqualität, Therapieadhärenz und Behandlungszufriedenheit. Auch die Rate von Zwangseinweisungen verringerte sich signifikant auf 10% im Vergleich zu den Vorjahren. 2011 wurde das Modell im Rahmen einer vom Bundesministerium für Bildung und Forschung (BMBF) geförderten Studie (Integrated Care in Early Psychosis, ICEP-Studie) auf die Indikation „ersterkrankte Jugendliche und junge Erwachsene im Alter von 12 bis 29 Jahren“ spezifiziert. Diesbezüglich wurde ein fachübergreifendes Team implementiert. Dieses Projekt wird seit 2012 von den beteiligten Krankenkassen gemäß einer Erweiterung des §140 SGB V finanziert.
Abstract
Treatment models like “Crisis Resolution and Hometreatment (CRHT)” or “Assertive Community Treatment” (ACT), were found to be effective, enhancing the qualitative level of treatment for patients with severe mental disorders. In Germany, these are implemented only sporadically until today, often as part of a cross-sectoral Integrated Care (IC) treatment system. We will present the implementation of an “Assertive Community Treatment” embedded into an IC-treatment model in Hamburg and discuss the 3-year-outcomes. The IC-treatment model has been designed for severe mentally ill patients with psychotic disorders. Since May 2007 the model is financed by different health insurances as a managed-care “capitation-model” and its effectiveness gets continuously evaluated. The model proved to be effective in earlier studies were compared with standard care low rates of service disengagement were found as well as significantly improved psychopathology, psychosocial functioning, quality of life, satisfaction with care and adherence, while being cost effective. The rates of involuntary admissions declined to 10% in comparison to the years before. In 2011 the model was specified to the indication “first-episode adolescents and young adults in the age of 12–29” in a government-funded study “Integrated Care in Early Psychosis, ICEP Study”. In this study an interdisciplinary team of child, adolescent and adult psychiatrists was implemented and since 2012 it is financed by the involved health insurances throughout an expansion of the §140 SGB V agreement.
-
Literatur
- 1 Riedel-Heller SG, Gühne U, Weinmann S et al. German Society for Psychiatry, Psychotherapy and Neurology. Psychosocial therapies in severe mental illness: DGPPN-S3-guideline: evidence, recommendations and challenges for mental health service research. Psychother Psychosom Med Psychol 2012; 62: 425-428
- 2 Lambert M, Bock T, Naber D et al. Mental Health of Children, Adolescents and Young Adults – Part 1: Prevalence, Illness Persistence, Adversities, Service use, Treatment Delay and Consequences. Fortschr Neurol Psychiatr 2013; 81: 614-627
- 3 Karow A, Bock T, Naber D et al. Mental health of children, adolescents and young adults – part 2: burden of illness, deficits of the german health care system and efficacy and effectiveness of early intervention services. Fortschr Neurol Psychiatr 2013; 81: 628-638
- 4 Schimmelmann B, Conus P, Cotton S et al. Pre-treatment, baseline, and outcome differences between adolescent-onset and adult-onset psychosis in an epidemiological cohort of 636 first-episode patients. Schizophr Res 2007; 95: 1-9
- 5 Wang PS, Berglund P, Olfson M et al. Failure and delay in initial treatment contact after first onset of mental disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 2005; 62: 603-613
- 6 Robinson J, Cotton S, Conus P et al. Prevalence and predictors of suicide attempt in an incidence cohort of 661 young people with first-episode psychosis. Aust N Z J Psychiatry 2009; 43: 149-157
- 7 Marshall M, Lewis S, Lockwood A et al. Association between duration of untreated psychosis and outcome in cohorts of first-episode patients: a systematic review. Arch Gen Psychiatry 2005; 62: 975-983
- 8 Conus P, Lambert M, Cotton S et al. Rate and predictors of service disengagement in an epidemiological first-episode psychosis cohort. Schizophr Res 2010; 118: 256-263
- 9 Lambert M, Bock T, Meigel-Schleiff C et al. Integrierte Versorgung von Patienten mit psychotischen Erkrankungen nach dem Hamburger Modell: Rationalen, Behandlungsmodell und Ergebnisse der Vorstudie. Psychiatr Prax 2014; 41: 257-265
- 10 Karow A, Bock T, Meigel-Schleiff C et al. Integrierte Versorgung von Patienten mit psychotischen Erkrankungen nach dem Hamburger Modell Teil 2: Ergebnisse des 2 und 4 Jahres Langzeitverlaufs. Psychiatr Prax 2014; 41: 266-273
- 11 Delespaul PH, de consensusgroep EPA. Consensus regarding the definition of persons with severe mental illness and the number of such persons in the Netherlands. Tijdschr Psychiatr 2013; 55: 427-438
- 12 Kreyenbuhl J, Nossel IR, Dixon LB. Disengagement from mental health treatment among individuals with schizophrenia and strategies for facilitating connections to care: a review of the literature. Schizophr Bull 2009; 35: 696-703
- 13 Lambert M, Conus P, Cotton S et al. Prevalence, predictors, and consequences of long-term refusal of antipsychotic treatment in first-episode psychosis. J Clin Psychopharmacol 2010; 30: 565-572
- 14 Tiihonen J, Haukka J, Taylor M et al. A nationwide cohort study of oral and depot antipsychotics after first hospitalization for schizophrenia. Am J Psychiatry 2011; 168: 603-609
- 15 Velligan DI, Weiden PJ, Sajatovic M et al. The expert consensus guideline series: adherence problems in patients with serious and persistent mental illness. J Clin Psychiatry 2009; 70 (Suppl. 04) 1-46
- 16 Marshall M, Lockwood A. Assertive community treatment for people with severe mental disorders. Cochrane Database Syst Rev 2011; DOI: 10.1002/14651858.CD001089.pub2.
- 17 Nordén T, Malm U, Norlander T. Resource Group . Assertive Community Treatment (RACT) as a Tool of Empowerment for Clients with Severe Mental Illness: A Meta-Analysis. Clin Pract Epidemiol Ment Health 2012; 8: 144-151
- 18 Murphy S, Irving CB, Adams CE et al. Crisis intervention for people with severe mental illnesses. Cochrane Database Syst Rev 2012; DOI: 10.1002/14651858.CD001087.pub4.
- 19 Murphy S, Irving CB, Adams CE et al. Crisis intervention for people with severe mental illnesses. Schizophr Bull 2012; 38: 676-677
- 20 Dieterich M, Irving CB, Park B et al. Intensive case management for severe mental illness. Cochrane Database Syst Rev 2010; DOI: 10.1002/14651858.CD007906.pub2.
- 21 Malone D, Marriott S, Newton-Howes G et al. Community mental health teams for people with severe mental illnesses and disordered personality. Schizophr Bull 2009; 35: 13-14
- 22 Schöttle D, Karow A, Bock T et al. Integrated Care in patients with schizophrenia: results of trials published between 2011 and 2013 focusing on effectiveness and efficiency. Curr Opin Psychiatry 2013; 26: 384-408
- 23 Schöttle D, Bock T, Meigel-Schleiff C et al. Translating research into clinical practice: effectiveness of Integrated Care (IC) including therapeutic Assertive Community Treatment (ACT) in severe and persistent schizophrenia-spectrum and bipolar I disorders – a 24 months follow-up study (ACCESS II study). J Clin Psychiatry [in press]
- 24 Teague GB, Bond GR, Drake RE. Program fidelity in assertive community treatment: development and use of a measure. Am J Orthopsychiatry 1998; 68: 216-232
- 25 Guy W. Clinical global impression. In: Guy W. (ed.). ECDEU Assessment Manual for Psychopharmacology, revised. Rockville, MI: National Insitute of Mental Health; 1976: 217-222
- 26 Spearing MK, Post RM, Leverich GS et al. Modification of the Clinical Global Impression (CGI) scale for use in bipolar illness (BP): The CGI-BP. Psychiatry Research 1997; 73: 159-171
- 27 American Psychiatric Association . DI. American Psychiatric Association and Task Force on DSM IV. Diagnostic and Statistical Manual of Mental Disorders, DSM IV. 4 ed. Washington, DC: APA; 1994
- 28 Overall J, Gorham D. The brief psychiatric rating scale. Psychological Reports 1962; 10: 799-812
- 29 Tohen M, Hennen J, Zarate CM et al. Two-year syndromal and functional recovery in 219 cases of first-episode major affective disorder with psychotic features. Am J Psychiatry 2000; 157: 220-228
- 30 Ritsner M, Kurs R, Gibel A et al. Validity of an abbreviated quality of life enjoyment and satisfaction questionnaire (Q-LES-Q-18) for schizophrenia, schizoaffective, and mood disorder patients. Qual Life Res 2005; 14: 1693-1703
- 31 Nguyen TD, Attkisson CC, Stegner BL. Assessment of patient satisfaction: Development and refinement of a service evaluation questionnaire. Eval Program Plann 1983; 6: 299-314