System Flexibility in the Rehabilitation Process of Mentally Disabled Persons in a Hostel That Bridges between the Hospital and the Community/Discussion
Baloush-Kleinman, Vered, Schneidman, Michael, The Israel Journal of Psychiatry and Related Sciences
Abstract: Background: Deinstitutionalization and community mental health services have become the focus of mental health care in the United States, Italy and England, and now in Israel. Methods: Tirat Carmel MHC developed an intervention model of organizational change implemented in a rehabilitation hostel. It is an interim service based on graduated transition from maintenance care to a transitional Halfway House, followed by a Transitional Living Skills Center oriented for independent community living. Results: Of 205 rehabilitees who resided in the hostel since the beginning of the project, 138 were discharged to community residential settings: 67 patients were discharged to reinforced community hostels; 27 to sheltered housing and 23 to independent residential quarters; 7 patients were discharged to comprehensive hostels, 3 to old-age homes and 11 returned home to their families. In terms of employment, 79 were placed in sheltered employment facilities, 24 work in the open market and 3 returned to school; 22 work in therapeutic occupational settings and 10 patients discharged to comprehensive hostels and old-age homes are engaged in sheltered employment programs in those settings. Conclusion: The system flexibility model and the rehabilitation processes anchored in normalization supported the relocation of hospitalized psychiatric patients to community-based settings and enabled the rehabilitees to cope with readjustment to community life.
The trend of deinstitutionalization and development of community mental health services has developed over the last three decades in the United States, Italy and England (1). The community care approach was adopted in Israel in the 1970s (2-4), following the English model.
A review of the literature revealed that most studies deal with the implications of discharge from hospitalization for the mentally disabled and on extra-institutional factors that support their reintegration into the community (5, 6). To the best of our knowledge, information concerning the phase of restructuring and organizational changes in the various hospital settings necessary to prepare patients for integration into the community is lacking, except for reports on the TAPS project, that closed two psychiatric hospitals in London, and transferred the patient population to designated community-based settings (7).
This paper aims to shed light on the phase of implementation of the reform and the trend of deinstitutionalization in Israel using the model of comprehensive organizational reform, implemented in the hostel for mentally disabled in Tirat Carmel Mental Health Center, as part of the general process of reform at the Center that included large-scale discharge of long-term hospitalized patients to the community.
The permanent housing facility became a transitional halfway house which served as a transitional living skills center for the mentally disabled who needed a time-limited period to prepare for independent living in the community.
The change was a planned structured process with graduated transition from phase to phase correlating to the needs of the patient in the rehabilitation system, i.e., systemic flexibility.
The Tirat Carmel MHC hostel opened in 1989 in a building situated near, but outside the walls of the hospital, and served as a group home for 20 patients. Most residents had lived in psychiatric hospitals for many years, and a small proportion had been admitted for short-term hospitalizations and discharged through the revolving door due to a life of loneliness and estrangement in the community. The hostel provided permanent housing for the first five years of its establishment. In 1993 patients began to be discharged to the community, and of the 49 patients who had lived in the hostel during the first five years, 19 were discharged to the community (8). Noteworthy, these first discharges marked the beginning of the reform, whose motto was "the hospital is no longer a residential home for the mentally disturbed. …