Provision of community-based mental health care, Latvia

Abstract Problem In Latvia, the move towards community-based mental health-care services has been slow. Approach The hospital managers of the only psychiatric hospital in Riga decided to establish two community-based clinics that were financially and administratively integrated with the hospital. The clinics were established using a step-wise approach by redistributing resources, including psychiatrists, nurses and beds, from the hospital to the new clinics. In 2005, the Veldre clinic started outpatient consultations and day care admissions. In 2009, Pardaugava clinic opened as an outpatient clinic. In 2012, an open-door inpatient ward with 30 beds was transferred from the psychiatric hospital to Veldre. In 2013, Pardaugava clinic opened a day care clinic and an open-door inpatient ward, transferring 26 beds from the psychiatric hospital. Local setting Latvians have worse mental health indicators than those of the average population in Europe. Mental care has traditionally focused on inpatient care. Relevant changes The clinics are now providing most of the outpatient services and the number of inpatients treated at the hospital has declined from 5696 patients in 2004 to 4957 patients in 2018. Patients are treated in a more open and patient-centred environment. Lessons learnt The administrative and financial integration of the new community-based clinics within the existing structures of the hospital is a successful approach. Transferring resources to the clinics seems to have improved the quality of care without requiring additional funding apart from the initial investment costs. Involving the staff members during the planning phase reduced resistance to the project.


Introduction
The World Health Organization (WHO) promotes the development of community-based mental health-care services as part of a balanced care model. 1,2 Nevertheless, policy-makers in many central and eastern European countries have struggled to develop adequate community mental health services, despite having national policies for such care provision in place. 1,3 Here we present the approach for establishing two community-based mental health clinics in Latvia.

Local setting
Latvia is a Baltic country with about 2 million inhabitants. Mental health indicators in Latvia are worse than that of other European populations. For example, the number of deaths per 100 000 people caused by suicide or intentional self-harm was 16.2 in 2015, compared with 9.8 overall in the WHO European Region. 4 Mental care has traditionally focused on inpatient care, and the move towards community-based mental health services has often taken place in response to pressures from international and human rights organizations. 5 For example, WHO and the health ministry found in 2005 an insufficient development of services outside of psychiatric hospitals. 6 Although the number of psychiatric hospital beds has decreased from 186 beds per 100 000 population in 2000, to 126 beds per 100 000 population in 2014, the number is higher than the European average of 68 beds per 100 000 population. 4 In the capital Riga, with about 641 000 inhabitants, one psychiatric hospital, the Riga Psychiatry and Narcology Centre, provided mental care. 4

Approach
To tailor service provision to patient needs and to enable greater continuity of care across outpatient and inpatient settings, the psychiatric hospital directors and chairman of the board decided in 2002 to establish a community-based clinic in Riga. Based on hospital statistics, the clinic should provide care for 4000 to 5000 patients living nearby the clinic, and therefore the location needed to be sufficiently populated. The location should also be accessible by public transport and be in a different administrative district than the hospital.
In 2005, the Veldre clinic started outpatient consultations and day care admissions after the hospital renovated an unused kindergarten building. To promote community integration and reduction of stigma, the clinic was located next to a school. Based on the example of the Veldre clinic, a second clinic, Pardaugava, opened in 2009 as an outpatient clinic after renovating a rehabilitation facility for substance abusers and constructing a new building. In 2012, an open-door inpatient ward with 30 beds was transferred from the psychiatric hospital to Veldre. Finally, in 2013, Pardaugava opened a day care clinic and an open-door inpatient ward, transferring 26 beds from the locked ward at the psychiatric hospital.
To set up the clinics, the hospital managers decided to redistribute resources, including psychiatrists, nurses and beds, from the hospital to the clinics. All relevant staff members were involved in the planning of the new clinics.
Hospital staff members would keep their jobs but would have to work at the new locations, full-or part-time. Eventually, the clinics employed more staff for outpatient care since the patient load increased. Part-time staff usually work at the psychiatric hospital for the rest of the week. To ensure continuity, an outpatient requiring inpatient care is treated by the same psychiatrist.

Maris Taube a & Wilm Quentin b
Problem In Latvia, the move towards community-based mental health-care services has been slow. Approach The hospital managers of the only psychiatric hospital in Riga decided to establish two community-based clinics that were financially and administratively integrated with the hospital. The clinics were established using a step-wise approach by redistributing resources, including psychiatrists, nurses and beds, from the hospital to the new clinics. Lessons learnt The administrative and financial integration of the new community-based clinics within the existing structures of the hospital is a successful approach. Transferring resources to the clinics seems to have improved the quality of care without requiring additional funding apart from the initial investment costs. Involving the staff members during the planning phase reduced resistance to the project.

Lessons from the field
Lessons from the field Community-based mental health care, Latvia Maris Taube & Wilm Quentin As special training courses in community-based mental health care were unavailable, most community-based practice skills had to be acquired on the job. However, continuing education activities were available. For example, six times a year the Latvian Psychiatric Association Conferences provided free lectures lasting 3-4 hours, covering topics such as psychiatric rehabilitation, multidisciplinary team work and role of art therapies. Furthermore, three to five senior staff had the opportunity to visit similar facilities in Finland and the United Kingdom of Great Britain and Northern Ireland.
Patients receive psychiatric outpatient consultations without a referral, from 8:00 to 18:00, and patients with more complex needs are admitted for day care or inpatient care at the clinics. Admitted patients receive a tailored rehabilitation and treatment programme, including cognitive behavioural therapy, pharmacotherapy, art therapy, ergotherapy and physiotherapy. The development of the programme was informed by the literature and programmes in other countries. The day care programme focuses on nonpharmacological treatment, while inpatient care, which is reserved for patients with highly complex needs, focuses on, for example, identifying medications for treatment. Treatment is free of charge.
The psychiatric hospital is legally and financially responsible for the clinics and the directors of the clinics report to the chairman of the hospital board. Strong incentives exist at the institutional level to develop outpatient and day care activities. The inpatient care is financed based on a global budget, and funding remains the same over time, while budgets for outpatient and day care are determined based on registered fee-for-service points. With increasing activity, the increasing outpatient and day care budget allowed to finance new positions. Inpatient service provision at the clinics did not require additional funding apart from the initial investments for construction and equipment of the new facilities, as the inpatient care budget was simply transferred from the hospital to the clinics. The total investment costs were 4.4 million euros (€), of which € 3.7 million was financial support from the European Union. Incentives for outpatient care provision exist also at the individual level as psychiatrists (since 2005) and therapists (since 2019) receive an additional €7 fee-for-service based remuneration for outpatient visits from the health insurance system.

Relevant changes
In 2019, each clinic had seven psychiatrists employed on full-time contracts and four to seven psychiatrists working six hours per week. Between 2005 and 2013, 43 staff members were transferred from the hospital to the clinics. In addition, the clinics have hired 12 psychiatrists, eight nurses and 27 therapeutic specialists, either full time or part-time.
The The types of disorders treated by inpatient care differ between the clinics and the hospital. At the hospital such care is focused on psychosis and other mental disorders, while the clinics attract mostly patients with affective disorders, including depression, anxiety and bipolar disorders (Table 1).
Limited data are available on the quality of mental care in Latvia and quality has not been systematically monitored. 8 However, psychiatrists in the clinics receive positive feedback from patients on the continuity of care. Furthermore, the care provided at the clinics is much more in line with international recommendations for a balanced care approach. 1 In addition, the clinics have piloted an adapted version of the Psychiatric Inpatient Patient Experience Questionnaire 8 and the results showed that patients were generally satisfied with the care they received in the clinics. 9

Lessons learnt
The two clinics have been able to implement the community-based balanced care approach, treating patients in a more open and patient-centred environment. Patients and their psychiatrists appreciate this approach and personal experience of treating psychiatrists suggests that managing patients in a day-care setting reduces hospitalizations. However, demonstrating the effect of less hospitalization is difficult due to limited data availability.
Personal motivation of the hospital managers at the psychiatric hospital played an important role in the development of the clinics. Hospital managers wanted to be progressive and replace inpatient care with day care and outpatient care. Furthermore, health-care financing principles in Latvia stimulate the development of outpatient and day care activity. 10 The idea of establishing community-based clinics initially met resistance from psychiatrists and nurses. Staff members were reluctant to adopt new practices as these required a different mindset and new skills, for example, suicide risk management and dealing with patients not attending day-care treatment. In addition, many staff members were reluctant to relocate because of longer commuting time.
However, hospital managers addressed staff resistance by involving staff members in the planning process, by incorporating their suggestions in designing and equipping the new facilities, and by allowing them to shape the organization of work. Some staff were easier to convince of the benefits of community-based practice. Financial incentives for the provision of outpatient care also helped. In addition, some psychiatrists and nurses already lived close to the new clinics. In 2007, the director of Pardaugava clinic was elected President of the Latvian Psychiatric Association, which contributed to acceptance of the clinics.
The Latvian experience holds several lessons for other countries wishing to move psychiatric service provision away from hospitals and towards community-based care (Box 1). First, external pressure and recommendations of international organizations, as well as external funding can contribute to developing community-based mental health services. 11 Second, the administrative and financial integration of the new clinics within the existing structures of the hospital and the involvement of clinical staff in the planning process created a sense of security for Lessons from the field Community-based mental health care, Latvia Maris Taube & Wilm Quentin the involved personnel and encouraged them to support the initiative. Third, the approach of transferring resources to a community-based clinic seemed to improve the quality of care without requiring additional funding apart from the initial investment costs. Finally, our experience shows that incentives of the financing system are important. The hard budget constraints for inpatient care combined with activity-based funding for outpatient and day care, coupled with fee-for-service-based remuneration for treating specialists created incentives that promoted the establishment of the clinics and the expansion of activity.
In 2019, the government adopted the Plan of Improving Access to Mental Health Care 2019-2020. 10 The plan suggests the creation of seven new community-based mental health clinics across the country, modelled after the clinics in Riga. The two existing clinics will provide in-service education for staff of the new clinics, and the Latvian version of the quality questionnaire will be used in other mental health institutions. To strengthen the community outreach in Riga, plans exist to enable nurses to do home visits and family therapies. ■    Leçons tirées L'intégration administrative et financière des nouvelles cliniques communautaires au sein des structures hospitalières existantes est une approche efficace. Le transfert des ressources vers les cliniques semble avoir amélioré la qualité des soins prodigués sans nécessiter de fonds supplémentaires, à l'exception de l'investissement initial. Enfin, impliquer les membres du personnel dans la phase de planification a permis de limiter la résistance au projet.
Tradicionalmente, la atención mental se ha centrado en la atención a los pacientes hospitalizados. Cambios importantes En la actualidad, las clínicas prestan la mayor parte de los servicios a los pacientes ambulatorios y el número de pacientes hospitalizados tratados en el hospital disminuyó de 5696 pacientes en 2004 a 4957 en 2018. Los pacientes son tratados en un ambiente más accesible y centrado en el paciente. Lecciones aprendidas La integración administrativa y financiera de las clínicas nuevas en la comunidad dentro de las estructuras que ya existen en el hospital es un enfoque exitoso. La transferencia de recursos a las clínicas parece haber mejorado la calidad de la atención sin requerir el financiamiento adicional aparte de los costos de inversión inicial. La participación de los miembros del personal durante la fase de planificación redujo la complejidad del proyecto.