CPG for Psychosocial Interventions in Severe Mental ... - GuíaSalud

B
B
B
C
A
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C
5.3. SERVICE LEVEL INTERVENTIONS
When people with SMI need to be readmitted several times into acute units, and/or
there is a past history of difficulties to engage with the services with the subsequent risk
of relapse or social crisis (as for example becoming a “homeless” person) it is advisable
to provide assertive community treatment teams.
The continuity of the treatment must be favoured via the integration and coordination
of the use of the different resources by the people with SMI, maintaining continuity of
care and interventions, and the psychotherapeutic relations established.
Care must be maintained from the perspective of the CMHC as a configuration of the
most commonly implemented services in our context,, based on teamwork, on service
integration and not losing the perspective of being able to integrate other ways of
configuring the services that might be developed.
When the needs of the people with SMI cannot be covered from the CMHC, continuity
of assistance must be given from units that provide day care, and whose activity is
organised around the principles of psychosocial rehabilitation, whatever the name of
the resource are (Day Centres, Psychosocial Rehabilitation Centres, etc.).
A certain level of care can be offered to people with SMI whose needs cannot be
satisfied by resources that provide day-care in rehabilitation orientated residential
resources whatever the name of the resource are (hospital rehabilitation units, medium
stay units, therapeutic communities, etc.)
5.4. INTERVENTIONS WITH SPECIFIC SUB-POPULATIONS
5.4.1. SMI with dual diagnosis
People with SMI with dual diagnosis must follow psychosocial intervention
programmes and drug-dependent treatment programmes, both integral and parallel.
The treatment programmes offered to people with SMI with dual diagnosis must have a
multi-component nature, be intensive and prolonged.
For people with SMI and dual diagnosis and in a homeless situation, the treatment
programmes should incorporate sheltered housing as a service.
When the care for people with SMI and dual diagnosis is provided in parallel, it is
necessary to guarantee continuity of care and coordination among the different health
and social levels.
5.4.2. Homeless SMI
For homeless people with SMI who require psychiatric care and psychosocial
intervention, it is advisable for both to be supplied together via integral programmes
where residential programme/housing is offered.
When there is no active substance abuse, it would be advisable to provide grouped
accomodation to homeless people with SMI included in integral intervention
programmes.
When it is not possible to use accommodation and support programmes in the integral
psychosocial intervention of homeless people with SMI, the intervention of assertive
community treatment team should be offered.
18 CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS