Medium Stay Units for Males and Females

Operational Policy for the Male and Female Intermediate Rehabilitation Homes of National Institute of Mental Health, Sri Lanka (Medium Stay Mental Health Rehabilitation Units)

There shall be two Intermediate Rehabilitation Homes (IRH) respectively for males and females situated within the premises of National Institute of Mental Health (NIMH) which serve the purpose of providing temporary residence for the patients who are on rehabilitation programmes.

1. National mental health policy of Sri Lanka has elaborated on community based mental health services where accessible and affordable services will be provided to the mental wellbeing of all citizens. 2. For the people with mental illness a broad range of rehabilitation and psychosocial care services will be developed at district level close to the community to support ongoing rehabilitation, depending on identified levels of local need. 3. Focus of care is on activities of psychosocial rehabilitation to ensure growth and personal development of individuals by using recovery models and life skills training. 4. Attention will be paid on the person rather than the disease building trust and involving them in making choices, living in a place of his /her choice and emphasizing the need for personal support and intimacy 5. Family and community participation in the rehabilitation process is identified as vital and given significance in the policy.

(Adopted from Guidelines for Medium Stay Mental Health Rehabilitation units, Directorate of Mental Health. Ministry of Health)

Two Intermediate care homes at National Institute of Mental Health will be model homes for intermediate care rehabilitation for the trainees of all the disciplines of the health sector as well as other sectors with which we need close collaboration.

This intermediate rehabilitation centre is open for the whole country as the National Institute of mental health.

1. To work collaboratively with residents (affected by severe and enduring mental health illness) and family members to provide recovered focus care

2. To work in partnership with residents, using and building upon their own individual strengths and abilities and involving the significant people in their lives in all aspects of their care, where possible and where desired by the resident

3. To inspire hope in individual residents, so they can plan and achieve their wishes and goals for the future, lead meaningful and fulfilling lives and reach their full potential whilst learning to adapt and live with the changes that a mental illness may bring

4. To maximize social inclusion through working with residents, family and the local community

5. To identify and link with employment providers, social services, voluntary organizations and other relevant services/providers required to ensure residents gain defined activity based life roles and/or gain employment

6. To work towards supporting residents in mainstream settings rather than in segregated services

7. To provide intensive client centred care, negotiating meaningful and achievable goals with realistic and achievable time scales in order to enhance the personal growth and development of the residents and promote self-confidence within a safe resourceful and supportive environment

8. To safeguard and promote rights and autonomy of residents

9. To ensure a comprehensive and scientific approach to needs of the residents is maintained during their stay

10. 10. To respect the diversity of residents

11. To facilitate residents, the opportunity to perform their chosen religious or spiritual and cultural practices and rights

12. To provide opportunities for appropriate recreational activities

13. To promote safety whilst encouraging positive risk taking

14. To offer a system of regular reviews, in consultation with the multidisciplinary teams, residents and family/carers

15. To invest in a multi-disciplinary team by encouraging staff involvement and adapting open communication, respecting each other‘s diversity and prioritizing the training and development of all staff

16. To increase awareness and understanding of the role of a rehabilitation ethos both within service provision and the wider community

17. To optimize medication and facilitate recovery through empowering residents to take their own medicine specially by improving knowledge and understanding regarding their illness, medication

18. To work in partnership with government, social services, voluntary organizations, private sector and other relevant services towards sustaining a successful and supportive recovery

The process of social inclusion, community engagement will ultimately lead to alleviate the stigma and discrimination in the society

(Adopted from Guidelines for Medium Stay Mental Health Rehabilitation units, Directorate of mental health, Ministry of health)

1. To offer to those patients identified as ready for discharge for a period of supported living (six months) in a shared house out of the ward environment, to practice their independent living skills, conversational skills, social skills and work behaviour skills which are needed to move back into the community or to their families where possible 2. To improve their functioning in a role valued by society and selected by the individual and to attain their full potential through a holistic approach with the support of the multidisciplinary team

3. To boost the resident‘s self-image and self esteem 4. To build on their own identified strengths and capabilities whilst acquiring other life skills needed to move back into the community or to their families where possible with the support of the multidisciplinary team. 5. To give an opportunity for the multidisciplinary team to get hands on experience to practice SMART goal setting on individual clients

a. Specific b. Measurable c. Achievable d. Realistic e. Time frame

6. To give an opportunity for the members of multidisciplinary team to learn through long term follow up of clients 7. To provide an opportunity for the team to do research on rehabilitation specially on how rehabilitation helps to ensure compliance through trust worthy therapeutic relationships, prevent relapses and reduce readmissions

Male Intermediate Rehabilitation Home (IRH) of National Institute of Mental Health named ―Sumithuru Sewana‖

Structure-

1. Two adjoining buildings with separate entrances. Each Comprises of two double bedrooms, a living space, a kitchen space with small sink, and outdoor toilet and a shower.

2. The house is surrounded by land which could be cultivated as a home garden.

3. The building is situated adjacent to the 4-acre horticulture plot

A Male Supportive staff member who is selected by the Rehabilitation Committee of NIMH after calling for applications through open notice based on selection criteria as decided by the Rehabilitation Committee, shall live in the same plot in a separate house. He shall work as the ―house caretaker‖ who is available 24 hours for resident‘s needs.

Female Intermediate Rehabilitation Home (IRH) of National Institute of Mental Health named ―Pathum Piyasa‖

1. Female Intermediate Rehabilitation Home is part of a building with two bedrooms and two indoor bathrooms which is arranged to accommodate six female clients. 2. The building is furnished with basic facilities. 3. The home is surrounded by land which could be cultivated as a home garden.

A Female Supportive staff member, who is selected by the Rehabilitation Committee of NIMH after calling for applications through open notice based on selection criteria as decided by the Rehabilitation Committee,

shall live in the house in a separate part. She shall work as the ―house caretaker‖ who is available 24 hours for resident‘s needs.

1. Patient with a diagnosis of long-term mental illness recommended by a Consultant Psychiatrist and the multidisciplinary team, 2. Age limit of 18 to 55 years. 3. Admission is approved by the rehabilitation team headed by consultant psychiatrist rehabilitation

NIMH and Director – NIMH 4. The client should be assessed as having the potential and motivation to live outside the hospital (either for employment in community or to hold responsibilities within the family) 5. The client would benefit from the opportunity to regain or gain skills needed for independent living. 6. At the time of entrance to the IRH, the entire rehabilitation care plan and the discharge care plan from IRH should have been decided by the relevant multidisciplinary team, with the guidance of the rehabilitation team. 7. Informed written consent should be taken from the clients when they are in remission and of sound mind. 8. Concurrence should be taken from a next of kin if available. 9. Stay is voluntary and residents should be compliant with medication. 10. Risk assessment should be carried out by the relevant multidisciplinary team, and exclude high risk of suicide, self-harm, aggression, or risk to others or property. 11. Patients who are referred from District courts or long-term care taking homes are also accepted, provided the place/position in the relevant care taking place is reserved for the referring patient (in case the patient should be returned.) 12. Only males are included in the male intermediate rehabilitation home and only females are included in the female intermediate rehabilitation home.

1. Acute psychiatric patients 2. Severe personality disorder 3. Brain injury 4. Dementia 5. Severe Learning Disability 6. High risk of suicide, self-harm, aggression, or risk to others or property.

1. After 6 months of stay in IRH client should be discharged according to the pre-planned discharge care plan 2. If a client has completed six months stay but not achieved the expected outcome or for any other reason if the need arises rehabilitation team will decide on extension of the stay for not more than 2 months provided client is benefited by that otherwise client will be discharged to the Psychiatry Unit. 3. The individual is not receptive to the training and support offered and/ or wishes to return to the ward. 4. The individual presents with challenges or behaviours which are not acceptable to the other residents of the house.

There should be a steering committee hereinafter referred to as ―Rehabilitation team NIMH‖ who is responsible to the consultant psychiatrist in charge of the homes and ultimately to the Director NIMH to manage the overall functioning of the intermediate care home.

1. The steering committee will be made up of the consultant psychiatrist, medical officer rehabilitation, occupational therapist, psychiatric social worker, community psychiatric nurse, nursing officer from the rehabilitation centre and the house caretaker. 2. Steering committee tasks will include monitoring and evaluation of the service, providing a support mechanism for the staff working there and developing the service over time, making necessary adjustments and improvements based on shared experiences. 3. Potential residents will be educated about the structure and soft skills for being with others by an occupational therapist for a period of one week prior to the entry. If possible they will be admitted in one intermediate care ward for a week depending on the bed capacity during that time. 4. First two months there will a weekly close supervision on a fixed day by the rehabilitation team

NIMH 5. There will be a timetabled MDT meeting once a month with individual residents and attended by their family members where possible, to review progress. 6. Members from relevant area MDT/ referred team should participate this meeting 7. Minutes will be made of the meeting and a summary will be presented in the monthly rehabilitation meeting. 8. A special meeting in between those scheduled can be called if the need arises; for example, sudden availability of vacancies 9. Other interested people such as employers of the residents can be invited to these meetings should the need arise. 10. If a new client is selected by the steering committee residents who are already there will be given a chance to meet the new client before getting her admitted 11. Accommodation Cost including lodging, electricity, water, security and house maintenance costs will be borne by the National Institute of Mental Health. 12. If the client is employed the meals/food should be provided by themselves. If the patient is not able to bare the expenses of food that will be provided by the next of kin or through sponsoring or a fund 13. Surprise visits to employee workplaces should be made by the MDT 14. Each client should have a case file (preferably a Community File) with a recording of the progress. 15. Routine Medication needed for patients can be issued through registering in Clinic or through a

Community File number. 16. In an event when a client develops an acute psychiatric, medical or surgical emergency that requires urgent medical attention it will be the duty of the treating psychiatry team to attend via the NIMH

OPD. Such events shall be coordinated by any available member of the Rehabilitation Team, NIMH. 17. If Clients are to attend medical/ surgical clinics at other hospitals it will be the responsibility of the treating psychiatry team‘s CPN and PSW to arrange those with their team.

1. Custodianship of the Homes 2. Administrative supervision of all staff 3. If a resident does not have a next of kin to provide guardianship where necessary such as for employment purposes

1. To be the in-charge consultant psychiatrist with overall responsibility for the Service 2. To provide technical supervision to the members of the MDT with the intention of assisting staff to realize their full professional potential

1. To facilitate and coordinate the admissions, reviews and discharges 2. Risk assessments 3. To be vigilant on all types of clinic follow ups or any other clinical contacts and arrange the visits with the support of the community psychiatry nursing officer

1. To provide a lead for the rehabilitation program in collaboration with the MDT members 2. Development of individual care plans for the residents once their place has been confirmed 3. To conduct a specific training program for all residents on one afternoon a week. (NB. Residents on employment will need to be released from their work responsibilities with the permission from the employer) 4. To review progress and make necessary adjustments of the client within the rehabilitation program making necessary adjustments. 5. To submit a summary report of the progression to the MDT members at the monthly review meeting 6. To undertake home visits if appropriate together with the social worker. 7. To provide weekly supervision to the house warden and be the contactable person for any emergency at the residence 8. To report to higher authorities if any emergency situations take place 9. To arrange alternative measures for supervision if a client does not attend for work. Clients should not be allowed to stay alone at the residence at working hours

1. To act as the link with the ward regarding the medication regime for all the residents 2. To attend to any medical needs of the residents 3. To undertake home visits with another member of the MDT where necessary 4. To support the community psychiatric nursing officer to make arrangements with relevant area multidisciplinary teams for all types of clinic follow ups of residents

1. Be a part of the individual care plan development for the residents once their place has been confirmed 2. To ensure drug compliance 3. To coordinate and give support to the family where applicable 4. To coordinate psycho social support during reintegration of the client to the society 5. To undertake home visits if appropriate together with the social worker. 6. To make arrangements with relevant area multidisciplinary teams for all types of clinic follow ups

1. Be a part of the individual care plan development for the residents once their place has been confirmed 2. To coordinate support to the family where applicable both during admission, the stay, discharge and reintegration into the community and provide follow up.

3. To support the client in the social and legal service needs such as getting an identity card, bank account, getting the right to vote etc. 4. To coordinate the individual to obtain and maintain employment either in the hospital or in the community with the support of the other members of the MDT. 5. To set with the occupational therapist and nurse, individual care plans for the residents once their place has been confirmed 6. To undertake home visits when necessary together with the occupational therapist and community psychiatric nurse.

1. Supporting the residents on arrival at the house 2. Developing a therapeutic relationship with the residents 3. Acting as the person on site, contactable by residents or members of the MDT at any time of the day 4. Being available to the residents for two defined periods each day, morning and evening for training/ support purposes in activities of daily living, and to ensure the welfare of residents. 5. Check on the residents, medication intake at appropriate times. 6. Encourage the residents to participate in the general maintenance of the residence. 7. To check daily whether all the clients have attended for their duties if not to inform occupational therapist - IRH 8. Arrange cover up for absences and notifying the occupational therapist - IRH 9. Submitting a weekly written report to the occupational therapist in an agreed format

1. To train in and support the preparation of the meals ensuring that all the residents are involved. 2. This Support Staff Member should be a designated individual to ensure continuity of the service provided in a routine familiar manner 3. If needed to accompany the resident for clinical contacts if the area MDT is unable to carry it out due to practical reasons

1. There should be an understanding by members of the steering group to listen to the experiences and provide support whenever needed 2. Any complaints by the residents should be noted and taken before the MDT for resolution if possible and within the time frame of not more than 2 weeks 3. Any resident who feels they have been unfairly treated will be helped to speak out in the appropriate forum and be heard.

Each staff member with responsibilities in the Service to be given a clear ―Job description‖ to obviate role overlaps and poor communication.

These Homes are state property and are an investment by the state for the benefit of the patients, as such all effort should be taken to do the maximum for the patient within set departmental rules and guidelines.