Open Hospitalization and its Implementation in Mental Patients

The basic method of treating psychiatric patients before the 1950s, was institutionalization. However, the inability of reintegrating patients into society caused suspension of the operation of mental institutions. Nowadays, provision of care to psychiatric patients is applied through open hospitalization or community mental health nursing allowing patients to change their treatment programs. These services are based on the values of behavioral and social sciences. Our aim was to introduce the definition and meaning of open hospitalization, its goals, methods and services provided to psychiatric patients, as well as highlight its role in re-socialization of patients. After thorough review of the literature from 1996 to 2013, we compared the advantages and disadvantages of the different types of hospitalization in order to come up with the most beneficial one to psychiatric patients. By conducting the above-described search of the literature, we realized the significance of open hospitalization among other types, owing to the more benefits it has to present for the mentally disturbed patients. Although institutionalization of patients is thought to provide more efficient care, open-hospitalization focuses on humanistic methods aiming to treat their mental disorders, find a job or even a house for them and last but not least, reintegrate patients into society.


Introduction
Modern psychiatry has a wide role. Besides the promotion of mental health at an individual level, through not only the elimination of mental illness but also the assurance of the well-being of the patients, psychiatry aims at the promotion of mental health at a social level (reduction of marginalization, reintegration, ensuring equal opportunities) as well as at a community level (social solidarity and support) [1].
Open nursing of mental patients takes place in the community, that's why it is called community mental health [2].
Values, philosophy, knowledge and practices of these services originate from behavioral and social sciences [3], while respect, appreciation and facilitating of the individuals' efforts for their development are the guiding standard [4].
These principles are: A multidisciplinary team consisting of a psychiatrist, a psychologist, a social worker, a nurse and mental health counselors.
• Prevention of mental illness. • Early diagnosis. • A complete and manifold treatment program. • Continuation of the treatment. • Group and family therapy. • Participation, support and control from the community [3].
The main open psychiatric inpatient services include 24hour emergency services, inpatient services, partial hospitalization services, external services, transitional housing services, rehabilitation services, prevention services (which include community education) [2] and consulting services. Other support services include support groups and supportive living and housing [5]. In addition, other programs refer to specific populations, such as services for children, the elderly, alcoholics and drug users [2]. The services offered are widely accessible [3].
The philosophy of community mental health is based on providing the patients with the opportunity to contact treatment services and to move from one service to another without interrupting their treatment. These services are also able to provide care to the patients without separating them from the community [2].

Goals
The main goal of mental health community services is provision of care to patients through innovative therapeutic approaches [3].
The ideology of open treatment of psychiatric patients includes: • Local community participation and concern. • Focus on primary prevention.
• Orientation towards the goals of social treatment.
• Complete continuation of care. • Total participation of the residents in identifying, creating policy, rendering of services and evaluation of programs [3].

Models and Services of Open Hospitalization
Community mental health services are designed according to response models based on community, which cope with the patients' needs [6].
The basic models are: Assertive Community Treatment and Intensive Case Management.

Assertive community treatment
Assertive Community Treatment (ACT) provides community services to psychiatric patients. This model refers to people with serious mental illnesses such as schizophrenia and bipolar disorders [6].
It is considered ideal for patients who get recently discharged from hospital and who do not usually arrange an appointment or are in need for support [6].
The goals of an ACT program are: • Improvement or elimination of the symptoms of mental illness. • Promotion of mental health by the use of various forms of treatment. • Improvement of patients' social health.
• Helping patients handle difficult family situations by enhancing their social skills. • Actualization and implementation of a treatment program that meets the patients' needs. • Promotion of the patients' independence [7].
Programs based on this model use various treatment and rehabilitation methods that include: • Pharmacotherapy. • Behavior-oriented teaching skills. • Interventions in emergency situations. • Support, informing and skills teaching for family members.
Services are offered via a mobile multi-disciplinary team [6]. The group consists of a psychiatrist, a mental health nurse, a vocational rehabilitation specialist and a social worker per 100 patients [7].
The venues, where these programs are applied, mainly consist of the patients' homes, workplace and recreation areas. These services are offered as long as it is necessary [6].
Programs based on the ACT model, which are also less timeconsuming, have been associated with reduced hospitalization, improved socialization and housing stability, fewer days without housing and reduced symptoms. Additionally, these services are less expensive than other community mental health services [6].

Intensive case management
The model of Intensive Case Management (ICM) was developed according to the needs of patients for high quality services, which could not be filled by traditional case management models [8].
The model ICM operates in accordance with a low proportion of patients and staff [8], where 7-15 patients correspond to each clinician [9], who provides services to the patient's environment as well as assistance in daily activities [8].
The principles of this model of service are: • Provision of a high level of care, with frequent clinical visits and low workload. • Orientation to the community and flexibility.
• Focus on rehabilitation.
• Continuation of care, for which the clinical team is responsible [9].
Studies have shown that services based on ICM model are associated with reduced psychiatric and non-hospital use, reduction of hospital emergency psychiatric services, as well as low total costs [10].

Psychiatric partial hospitalization programs
Partial hospitalization programs (also known as day treatment programs and day hospitals) are usually located in or near a community mental health center or in a closed care unit [3]. Care is usually provided on weekdays, but some programs provide support by telephone, during the night and the rest of the days [11].
These programs are usually used for diagnosis and treatment of serious mental illnesses, provided that there are chances of improvement of the patients' health or that preservation of their functionality is essential. They are usually offered to patients who have recently been discharged from hospital or to prevent their institutionalization [12].
The goals set by this open nursing service are: • Stabilization of symptoms.
• Monitoring the effectiveness of medication.
• Stabilization of the patient's environment.
• Improvement of daily and social activities.
• Acquiring a job or volunteering.
• Monitoring in case of imminent health issues [7].
Each program can be directed to patients with a specific or a wide variety of mental illnesses. However, patients are usually given access to all services of the program, including a daily group and individual therapy. (12) Patients usually follow this program from 4 to 6 months [11].

Community mental health centers
Community mental health centers are the cornerstone of service and care to psychiatric patients. (13) Since 1963, the community centers' primary intention is to prevent patients from getting mentally disturbed and to provide care to psychiatric patients locally [12].
However, apart from prevention, these centers emphasize on the following: • Early diagnosis, treatment and reintegration into society. • Establishment of community centers near the community. • Provision of inpatient and outpatient care, partial hospitalization, emergency care and an update on the patient's mental condition [13].
The provided services include hospital and inpatient care, drug and alcohol rehabilitation programs, job capability evaluation, occupational therapy, family and group therapy, transportation, counseling, interventions in critical situations and education in the community [13].

Residential treatment programs
The residential treatment is an important aspect of community care of psychiatric patients. In many communities, these programs are provided by community mental health centers [3].
Each program can render a wide range of services, which usually incorporate the provision of shelter, food, housekeeping services, personal care and supervision, individual and group counseling, vocational education or training and socialization opportunities. It is also possible to provide family support services, such as parental education and parental support group [3].
Staff can provide support and monitor patients continuously, but can only intervene in emergency situations [3]. The houses, where treatment is provided, may be associated with day-nursing programs or specialized training programs [3].
Success of these programs depends on the offered therapeutic activities and support services to both patients and their families [12].

Homecare psychiatric care programs
Home psychiatric care programs include providing psychiatric, physical and social health services at the patient's home, as long as family members do not have the proper training to render such services themselves [14]. These services are provided to patients who are secluded in their house [15] and who usually suffer from complex diseases, with psychiatric and physical issues [12].
The purpose of this program is continuation of psychiatric care, which aims at improving the patient's functionality [15]. Research has shown that it is an efficient type of open hospitalization [12] and appears to reduce the need for longterm inpatient treatment [14]. Usually these services are of short duration, while patients are able to make use of this service whenever they need it [12].

Emergency psychiatric care
Emergency psychiatric care services are developed to provide immediate evaluation and treatment to patients in emergency situations. For psychiatric patients, mental health changes can lead to uncontrolled incidents (such as suicide attempt), which are considered as "emergency situations" [16].
The goals of emergency psychiatric care are: • Timely provision of emergency psychiatric care.
• Stabilization and assessment of the patient's condition.
• Patient's access to local and community care.
Emergency care is provided by emergency clinics in mental health centers or general hospitals 24 hours a day [3].

Psychiatric rehabilitation programs
Psychiatric or psychosocial rehabilitation services aim at the recovery of psychiatric patients, which includes control of symptoms, management of medication, social reintegration, transformation of patients into independent human beings and improvement of living standards [7].
To achieve the main objectives of psychosocial rehabilitation, programs should target at successful: • Physical health improvement. • Sociability and occupational skills improvement.
• Continuation of treatment. • Reduction in readmissions of patients in psychiatric clinics.

ARCHIVES OF MEDICINE
ISSN 1989-5216 Vol.8 No.4:4 • Involvement of the patient in the decision-making about his treatment. • Recovery of self-esteem and self-awareness [7].
However, the various psychiatric rehabilitation programs offer different services, usually based on the available sources and financing. For example, some programs mainly aim at treating patients, while others include social and recreational services [7].
Example of a psychiatric rehabilitation services model is the "club" which aims to offer psychiatric patients the opportunity to develop their skills and set realistic goals. Services based on this model, help patients find a job and housing, while it continues to offer up-to-date information [12].

Supported employment
Work is an important aspect of psychiatric patients' rehabilitation-process, as it has been associated with treatment of the symptoms, increased functionality, less financial problems, increased self-esteem and sense of recovery. The significance of work for mental health has led to the development of programs that help patients finding a job [17].
The model of Supported Employment aims to help psychiatric patients in their professional career, while providing ongoing training and support [6]. This model is proved to be more effective than conventional vocational rehabilitation methods [17].
Participants work as usual, with no distinction between them and the rest of the employees, who do not suffer from mental illness [6].
The Individual Placement and Support (IPS) is the most studied approach, targeting to employment. This program is responsible for finding a job under working conditions that patients can cope with.
Aims of this program are: • Integration of clinical and professional services. • Implementation of a minimum preliminary assessment. • Conducting search for a job based on the patients' condition and abilities. • Support related to the job, such as transportation or replacement if the patient fails to appear owing to recurrence of symptoms [6].

Supportive housing
Supportive Housing is offered to psychiatric patients at risk of losing their house or to those already homeless. This model combines housing and access to services, such as case management services, treatment for substance abuse, support in finding a job and in everyday life [6].
This program can have either transient or permanent function. Transitional housing is typically provided in groups of patients, with a predefined duration of stay for each person and rendering of services. Permanent supportive housing includes housing in single hotel rooms and apartments, is not limited in time and services are provided in the community [6].

Discussion
Mental diseases cause significant difficulties and limitations, both physical and social, not only for patients themselves, but also for their families and the society [18]. Screening of these patients with false and unfounded standards by community and media has contributed to their social marginalization [19].
The incidents of social stigmatization include not offering assistance to patients, general avoidance of them, imposing compulsory treatment and their institutionalization. Avoidance is considered to be the most extreme form of social stigmatization, as community tries to eliminate any form of interaction with the mentally ill, leaving them abandoned [19]. In addition to their already mentally disturbed and vulnerable bio-psycho-social health, this continuously aggravated situation is one of the major obstacles that effective treatment and care has to face, not to mention the fact that open treatment programs are based on the integration of the patient into the society [20]. Furthermore, stigma corroborates the discriminatory behavior towards patients, particularly when it comes to the access of health services, in violation of the Code of Medical Ethics [21].
Although open mental hospital programs have contributed to improve the functioning and mental health of the patients, the negative effects of their implementation should be taken into account [22].
The main problem is that the open nursing programs are not able to offer protection to patients from stigmatization or even violation incidents coming from the society. Still, there is limited control of treatment and symptoms of the patient, as opposed to closed hospitalization [23]. Some patients are dissatisfied with the care provided, and it is said that it mainly aims to control their situation and not to solve their vital problems and needs. Additionally, these programs may not always be available to patients [22].

Conclusions
Community-based open psychiatric care services have experienced remarkable growth and have undergone significant progress with undoubted results, although hospitalization of psychiatric patients still remains necessary to provide comprehensive care [20].
Patients who undergo community psychiatric care programs show improvement in functionality and limited reoccurrence of psychiatric symptoms in contrast to institutionalized patients, not to mention that they are usually pleased with these services [20].
However, success of these programs is based on the attitude of the community towards patients, which can sometimes be a difficult obstacle to overcome in order to provide them the appropriate care. The dismissive perspective of local community impedes the healing process and negatively affects the quality of therapy provided by supportive housing, while patients experience feelings of loneliness, as well as a need for understanding and social integration [20].
It is commonly approved that hospital-based treatment programs for chronic psychotic patients suffer from "deficiencies" and "inadequacies", whereas humanistic programs (such as open hospitalization) focus on "interpersonal" aspects and "re-socialization" and may be much more therapeutic.