The Individualized Service Plan (PSI), beyond prison

When a person with serious mental health problems , addictions or in a situation of vulnerability, such as those who require complex care or people with intellectual disabilities, leaves a prison, they must face highly complex situations in relation to key aspects of their social and work integration: family and social relationships, adherence to psychopharmacological treatment that they may need, training or work needs or the stigma and self-stigma that people with mental health problems experience.

In this process, a key tool in Catalonia is the Individualized Services Plan (PSI) , a consolidated strategic instrument of the Department of Health of Catalonia (PDSMiA) as a proposal for an autonomous organizational method and an active transversal process of care based on the community model of Case Management (CM) for people with Mental Health and Addiction problems (Suárez, MA 2004).

The PSI adapts health and social services to the specific needs and capacities of each person, cared for as close as possible to their natural environment or community, and with the aim of consolidating comprehensive care continuity and establishing the same person as a full citizen in their own process of self-determination and recovery (Anthony, WA. 1993, Pilgrim, D. 2008).

This is a healthcare model that was activated in 2017, thanks to the agreement between the Department of Justice and the Department of Health together with the outpatient care services and the reorganization of psychiatric hospitalization units in prisons, with the aim of guaranteeing continuity of care by accompanying people in the penitentiary environment with a high risk of social exclusion as a factor that contributes to the incidence and persistence of mental health problems. From that moment on, the PSI model was deployed throughout the Catalan territory: inclusion of the adolescent and young population with psychotic disorder (first episodes) and dual pathology. An achievement that was preceded by different pilot tests, the first carried out almost a decade earlier, in 1995, at the Sant Joan de Déu Health Park and Sant Pere Claver Foundation for people with serious mental disorders and functional difficulties (Balsera, J. 2002).

A successful healthcare model

The PSI's activity has achieved positive results in general and specific terms in relation to the emotional well-being of the person being cared for and, therefore, to a better quality of life in the community. Some of the research highlights in terms of results are:

• Reduction in hospital stays by 55%, some studies indicate up to 70% (Álvarez, MJ 2020), and in emergency room visits in number and stays (Caño, I. 2015-20). In the year following the program's release, reduction in hospital stays of 31-50% (Álvarez, MJ 2020, Anglès, J. 2018).
• Reduction in the dose of antipsychotics and benzodiazepines (Álvarez, MJ 2019), therefore resulting in economic savings (Álvarez, MJ 2020).
• It favors voluntary hospitalizations.
• It promotes the involvement and connection to the care of the person being cared for (Dieterich, M. 2017). Linkage with the Mental Health Center (80% upon discharge from the PSI).
• Positive effect on the emotional well-being of the person cared for and quality of life in the community (Guillaumet, A. 2022).
• Functional improvement (autonomy) at a clinical and psychosocial level (Anglès, J. 2018).
• Improves the use of community resources.
• Improves coverage of people's needs (English, J. 2018).
• Social support and satisfaction of the person and family.
• Reduction of disability associated with mental disorder.

In moments of existential uncertainty for the community, social and healthcare model due to the COVID-19 pandemic, the PSI has continued to carry out its care activity by visiting people at home. A continuity of care that has helped people with serious mental health disorders in Catalonia not to show a deterioration in their functional or mental health as a result of the pandemic, while other groups in the general population have suffered this impact (Canes, N., Herráez, EM 2020-21).

What support is provided by a PSI?

The PSI assigns to the person being treated a professional providing individualized and local care (in person, by telephone and telematics), called a Case Manager (GC) or Manager (Liria, AF 1990). This is a professional who is a reference for the person and their care network with mobility and assertiveness, intervening in person and in situ in a holistic and transversal manner. This figure is present in the different areas of the person's life: home, community, prison, short- and long-term hospital, family, society, work, housing, training and leisure. It works with specific populations, in situations of vulnerability and severity, such as people who require complex care, people with intellectual disabilities or young people with substance addictions.

The PSI professional team are "street, backpack, phone and laptop", well organized with social, communication and coordination skills, weaving support networks and breaking with the fragmentation of service attention.

Proactive professionals and defenders of human rights (CRPD Convention 2006) and the fight against self-stigma and social stigma suffered by people with mental health problems.

We can summarize the meaning of PSI in a decalogue of the principles that define us:

1. Vulnerability and complexity with risk of social exclusion, as a prioritization criterion.
2. Person- and family-centered care. Promoting personal growth: capacities, competencies and valuing subjective experiences; and self-recognition to achieve the empowerment necessary to make decisions (self-responsibility and self-determination).
3. Defense of rights: dignity and respect for the person's values ​​and preferences.
4. Know the relationship of the person being cared for with the community and natural environment to intervene as soon as a difficulty arises.
5. Recovery: working on hope, social inclusion, supportive relationships, and the person's resilience.
6. Establish an intense therapeutic bond with the person being cared for.
7. Make use of technology as a tool for professional empowerment and for the person being cared for.
8. Accessibility to a flexible and intensive schedule, recommending low attention ratios (1 Case Manager for 15 people treated) and stays in the PSI of between 12 and 36 months (Arca, JM 2020-22).
9. The role of the Case Manager: assertive, reflective-therapeutic, humanist and service manager, referent for the person and the healthcare network (Arca, JM 2020-22).
10. Interdisciplinary and networked work to provide a comprehensive response with healthcare teams and services, local, first-person and family associations.

Recovery, social integration and support upon leaving the prison

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The functions of the PSI are diverse and are included in the services provided by the service portfolio:

• They assess the inclusion of the person to be served according to the criteria established by the PSI program (Reference Case Manager).
• They assign a responsible professional, Case Manager or Individual Project Coordinator (CPI). This professional is the interlocutor and spokesperson for the person being treated between the hospital and community care devices (healthcare and non-healthcare) that intervene throughout the care process.
• Flexibility is provided in the intensity and type of intervention according to the needs of each person being treated.
• Proactive work is carried out to link and make accessible the person receiving care and their family to the PSI and other services involved in care, encouraging the active participation of the person receiving care.
• Data collection and needs assessment are carried out: assessment and diagnosis of the person's care needs, with their participation, that of their immediate environment and that of the agents involved in the care process. It is recommended to reinforce the inclusion and discharge criteria in the PSI that all assessment tools used be reviewed and updated periodically; annually and throughout the beginning of the care process until discharge.
• Preparation of the Action Plan: Preparation, execution and continuous evaluation of the Shared Individualized Therapeutic Plan (PTIC) in a consensual manner with the person, the family and the agents who intervene in the care process, favoring the person's empowerment and protection of rights (for example: implementation of Advance Decision Plans (PDA)).
• Transversal and personalized monitoring with high accessibility and flexibility according to the needs and capabilities of the person being cared for and their families, with interventions of an assertive community nature, acting in the place where the need for action arises and promoting the person's self-management.
• Networking with continuous coordination, formal and informal, at the request of any of the parties, with all the resources that participate in the care process.
• Ensure continuity of care upon discharge from home hospitalization, if necessary.
• Advice and support for families and the community in relation to the prevention and management of mental disorders (Agreed Crisis Plan - PCA) and the promotion of mental health (Empowerment and health education) and defense of the rights of the person being treated (fight against social stigma and self-stigma).
• Home and community visits . Provide support in home care to ensure linkage to the rest of the mental health and addictions network. Central axis where the person will develop; housing, work, family, significant others, personal care, social space and leisure.
• Support and use of technologies for better care: telecare, virtual interconsultation, automated alerts (prevention work and identification of fragile people and people in situations of vulnerability through an automated alert system: people in situations of relapse in emergencies, frequent hospitalizations or abandonment of outpatient follow-up; networking; access to the Computerized Clinical History (SAP) and Shared (HC3) and ICS – ECAP viewer and promotion of La Meva Salut (CatSalut platform).
• Program closure and disassociation process , work on discharge criteria with the review of the objectives achieved with the person, family and the teams and services involved.

Despite being a successful healthcare model in Catalonia, the prison PSI faces numerous challenges :

• Maintain spaces for coordination, intervention, co-creation, training, research, specifically between the professionals and services of the different PSI in Catalonia (Arca, JM 2020) and the prison services in a consensual and continuous manner.
• Coordination with social services or other resources (housing, education, employment, etc.)
• Psychosocial recovery for full integration into the community.
• Early detection of mental health problems and addictions at the individual level in primary care, specialized primary care or community care.
• Continuity of care in transitions between devices, units and levels of care.
• Participation in the conversion of medium and long-stay mental health units, completely avoiding admission and keeping the person in the community.
• Increase the use of Advance Decision Plans (PDAs) (Ramos, J. 2020, FSMC 2018). It should be noted that the study Analysis of the knowledge and attitudes in front of the anticipated intentions of health professionals for the improvement of health care and reduction of inequalities in the matter of rights is being carried out (Ramos, S., Andrés, H.), at the Sant Joan de Déu Health Park.
• Complementarity of PSI with Peer to Peer (peer support), people with their own experience in mental health (users of mental health services) (Eiroa-Orosa, F. 2019, Bardají-Mauri, Á. 2017).