Recovery, Psychiatric Rehabilitation and
Community Integration:
The role of the Rehabilitation Case
Manager’s Service
Max Lachman, PhD. & David Roe, PhD.
The Laszlo Tauber Family Foundation
Mental Health Community Dep’t , Haifa
University
Israel
Outline of presentation
 Recovery, Psychiatric Rehabilitation and Community
Integration – a theoretical framework
 Psychiatric Rehabilitation in Israel
 The Rehabilitation Case Manager’s new service
 Research
 What can we learn from the Israeli experience into the
International Psychiatric Rehabilitation Movement
From Recovery to Community
Integration
Recovery
Vision
Rights and
Legislation
Psychiatric
Rehabilitation
Community
Integration
3
The role of Self Determination
Psychiatric
Rehabilitation
Self
Determination
Recovery Vision
4
Person –
Centered
Planning
Self
Determination
Choices
Self Directed
Care
Values of Psychiatric
Rehabilitation
 Self-determination
 Dignity and worth of the individual
 Optimism or hopefulness for progress of
improvement
 Belief in the capacity of individuals to improve self,
learn, and grow
 Sensitivity/understanding to the culture of others
Core Values of PSR
 Normalized Roles &
Relationships
 Potential for Growth
 Pragmatism
 Learn by Doing
 Egalitarian Relationships
 Holistic Approach
 Blurred Professional Roles
Guiding Principles
 Individualize services
 Maximize client preference and choice
 Ensure normalized, community basis
 Focus on strengths
 Use situational assessments
 Integrate efforts with treatment holistically
 Coordinate services, make them accessible
Emerging Principles
 Multicultural Sensitivity
 Outcomes Focus
 Consumer Empowerment
 Collaboration
 Family Role
 “Recovery”
 Hope
 Prevention of Hospitalization
 Respect & Dignity
 Goal achievement
 Eclectic Approach
 Strengths
PSR Program Elements
 Prevention - Case Management
 Vocational
 Social
 Education
 Residential
 Activities of Daily Living
 Health & Well Being
Community Integration Definition
The opportunity to live in the community and
be valued for abilities and unique qualities
like everyone else
 Housing
 Employment
 Citizenship and civic
engagement
 Education
 Valued Social Roles (e.g.,
marriage, parenting)
 Health Status
 PEER SUPPORT
 Leisure/Recreation
 Self-Determination
 Spirituality
Some data’s…

In Israel 7.500.000 citizens.

We evaluate 10 % of the population as having
Disabilities.

70.000 – 120.000 Persons have Psychiatric
Disabilities.

This is the bigger group from all the Disabilities
groups.

People with Psychiatric Disabilities are
underprivileged and suffer from discrimination.
Barriers to Recovery and PR
implementation in Israel
 Stigma
 Hegemony of the medical model
 Citizenship, war and recovery
 No enough basic training in Mental Health policy
and practice inside the Universities
 Political base practice
Developments of the Israel System of
Care
 Reforms and deinstitutionalization process
 Shift in societal attitudes towards persons with
disabilities
 Consumers movement (Family members &
“Coppers”)
 New legislation and government appointed
committees reports
New Legislations
Treatment of Mental Health Patient Act
1991
National Health Insurance Act
1995
Patient’s Rights Act
1996
Equal Opportunity for Disabled Persons Act 1998
Rehabilitation of Mentally Handicapped Persons in the
Community Act
2000
Basket Rehabilitation
Services
 Admission Criteria
 Types of services (“The Basket itself”)
 Individual Choice and Partnership
The Role of the
District Rehabilitation Coordinator
1. Responsible for all rehabilitation actives in
their district.
2. Coordinates the committees for “basket of
Services”.
3. Responsible for follow up on every client
Plan in rehabilitation services in district.
4. Ongoing assessment of the need for new
services in district.
Basket Rehabilitation
Services
 Admission Criteria
 Types of services (“The Basket itself”)
 Individual Choice and Partnership
Number of Persons using
Psychiatric Rehabilitation Services
16000
14000
12000
10000
8000
6000
4000
2000
0
1999
2000
2001
2002
2003
2010
Challenges
 No data management at all levels (referrals are very
poor in quality and quantity, no data monitoring, no
connection between the clinical and the rehabilitation
data)
 Many clients are referred to rehabilitation without
readiness to change
 Many clients use services without connections to their
personal goals (self determination, abilities
development, motivation)
 The community service system (Health, Mental Health,
Welfare and Psychiatric Rehabilitation) is not
coordinated and organized
20
(Marianne Farkas, 2006)
Recovery means regaining a
meaningful life within a given
cultural context and according to
the person’s personal goals
The right according to the
law
The psychiatric rehabilitation law states that any
adult with at least 40% Medical Psychiatric
Disability of has the right to apply to a Regional
Rehabilitation Basket Committee and present “an
individual rehabilitation plan”. In a meeting with
the committee, the person will be eligible to
receive formal resources (services and
rehabilitation interventions) so he/she can reach
his personals goals and implement their
individual plan.
Obstacles to the implementation of
the law
 Lack of motivation and involvement of the consumer during the
plan creation. (domination of paternalistic attitude and forced
elements during the process)
 A lack of preparation and guidance in implementing the plan
after the committee decisions.
 "The client’s choice” throughout all the stages of the
implementation of the plan is still limited.
 Conflict of interests between the consumer ’ will and ability and
the economics interests of services providers.
 A lack of use of “Individual Rehabilitation Plan” as practice in
the services. No systematic evaluation of micro-outcomes.
 The policy and the practice in Psychiatric Rehabilitation is not
based enough on evidences of the efficacy of the services to
enhance personal goals of the clients. (E.B.P.)
The Service Definition
The “Individual Rehabilitation Plan – Case
management Service” is a new Rehabilitation
Service to support persons with Psychiatric
Disabilities. (who applied and receive approbation
to their personal programs from the Regional
Psychiatric Basket of Services Committee –
Psychiatric Rehabilitation in the Community Law2000).
Research
Ministry of Health
Baskets Committees
Regional Coordinator
Family
New Service
Case Managers
Treatment
Community
Services
Welfare, Heath
Rights
Consumers
Access to
Services
Evaluation and
Relationship
Psychiatric
Rehab.
Services
Rehabilitation
Readiness
Individual
Planning
Recommendations
For ending
the process
Follow
25 up
25
o Strengths Model -Rapp C.
o Rehabilitation Readiness, Boston University ,Farkas M. et
al.
o Definition of
Setting an Overall Rehabilitation Goal (SORG)
o Collaborative Goal Technology (CGT) -Oades L. G. et al.
 Prochaska and DiClemente’s Stages of Change Model
o Recovery Interview – Lachman M.
26
26
Values and Attitudes
The case managers will work in respect to the “client’s choice”.
The relationship between the client and the case manager will be base on
the principle of self-determination and full partnership.
The main activities and tasks are:
1. Help the person access psychiatric rehabilitation services (defined by
the regional committee) and follow the progress in achieving the
different goals by the services. (Micro -Outcomes)
2. Assist the client redefine and initiate new plans and change to achieve
more community integration and quality of life.
This support will be based on the client’s will, strengths, and capacities
in cooperation and support from the family and others professionals
involved.
Ministry of Health, Procedure No 88.001
Service components – Tasks and
Expectations
 Mediation and brokerage between the client, the desire to
build and advance an individual rehabilitation plan and the
formal and informal resources.
 Establish a systematic way of monitoring the Rehabilitation
service of care.
 Support and advocate the client voice in the decision
process.
 Identify and recruit community resources to strengthening
the individual rehabilitation plan .
 Make more resources available in the system by helping
client use fit services, redefine needs and want and not be
stock.
Case manager Activities and tasks
 Individual support, given attention to the client preferences and
will, follow-up and helping the process of change in a way the
process of change can continue.
 Tailoring the individual rehabilitation plans by listening and
knowing the particular expectations and needs of the client.
 Create coordination and division of tasks between all the partners
(family, services, professionals and significant others).
 Assist in the demands of the Law for individual follow-up.
 Evaluation of outcomes (efficiency and efficacy of the services)
 Give interventions to client for enhancing readiness to change
and be able define personal goals.
Direct Professional activities
 Getting to know the clients and create a trust relationship.
 Evaluate the client’ desire of change.
 Define the the individual plan in the most operative level
(objectives, tasks, scheduling, …)
 Recruiting internal and external resources for the plan
realization.
 Knowing and being in contacts with the partners involved in
the realization of the plan .
 Reporting and document the activities to the service and the
“Rehabilitation Basket Committee”
The Pilot deployment

The service will be available in two “rehabilitation areas:

An office will be established in each area, as a centre for
operating the service.

Each service will included: a professional area
coordinator, 15 “rehabilitation case-managers”, and
administrative staff.

Most of the interventions will be provided close to the
rehabilitation activity (mobility)
Main role of the rehabilitation case
managers
 Accompanying and serve a caseload of 30-42 clients
 Routine individual meetings with each clients for implementing and follow-up
progress in their individual rehabilitation plan (at least twice a month)
Routine sessions with the rehab service providers' staff for consolidating the
plan and gaining detailed information on the advancement towards achieving
personal goals that were specifically defined in the plan.
Meetings with the program partners according to the need.
Recruiting essential resources for enhancing the chances of a successful plan.
Ongoing report on the daily activity and implementation of the program
Initiating changes in the plan with the approval of the rehab basket team in the
Ministry of health.
Participating in staff meetings, individual counseling and various training
programs
Basic data on the service
33
 Numbers of referrals to the service by the Rehabilitation Committees
 June 2009-
Referrals 569 (63%)
Referrals 862 (95%)
Referrals 963 (107%)

Dec 2009Feb 2010-

*service data-Feb 2010.doc

Gender
 males 613 (62%)
 females 363 (38%)
34
Active 526 (92%)
Active 777 (90%)
Active 843 (87%)
Individual Rehabilitation
coordinated Plan (IRP)
 Focused on client’s wants and needs
 Integrative rehabilitation plan for each client- plan
per service vs. plan per person
 Review of the plan every 3 months
 The plan is computerized
 IRP Template *Format for Individual Rehabilitation
Plan-Feb 2010.doc
35
Impact of Service on
Rehabilitation System in Israel
 Enhance Recovery values into the way services are
giving to consumers.
 Enhancing clients’ rights to choose services and
plans.
 More Focus on the Person instead of Service
36
Study Goals
Primary:
 To assess the effectiveness of the RPCS intervention for
individuals suffering from severe mental illness
compared to individuals receiving regular rehabilitation
services (the control group) and compared to baseline.
Secondary:
 To assess different subgroups relative to the efficiency of
the service (age, gender, services used etc..).
37
Methodology
 Stratification and randomization: based upon a service-
use and age stratification procedure.
 Wave 1 within the first 2 weeks or 4 meetings of service
inception. Wave 2 after 20 month.
 Assessment based upon 3 sources:
 Structured face to face interviews
 Clinician ratings
 Ministry of Health database
 Two regions studied (Center North/South).
 Two control groups (Within & outside [Haifa]-of RPCS
region)
38
Number of Interviews
1200
1000
800
600
Total
83%
86%
400
200
0
Ever In Service
Currently In Service
Interviewed
Data collection so far- Wave 1
Experimental & Control Group
Center
Total
(regions with service)
Haifa
(control region)
Groups
South
North
805
420
385
713
202
110
401
Control
1518
622
495
401
Total
Study
40
Stratification Results for ‘Veteran’
Users: expected vs. final sample*
Service
Weight
Up to 30 years
31-55 years
55 years >
Expected final Expected final Expected
%
%
%
%
%
final
%
Heavy
16
13
21
21
8
10
medium
12
11
17
21
6
6
Light
8
5
8
10
4
3
*User status was primarily based upon the use of housing services (from
intensive to slight use). If no housing facility was used, user status was based
upon the use of vocational services (from intensive to slight use). Information
for this classification was provided by the Ministry of Health. Results based
upon experimental and control ‘Veteran’ sample. ‘New’ users didn’t use any
services and were thus not part of the stratification procedure.
Interviews done since study inception:
Overall Monthly
198
200
180
160
138
140
131
119
120
101
100
100
98
96
total participant
85
79
80
97
80
60
42
40
34
26
20
3
0
26
18
17
20
Primary findings:
Characteristics of 925
participants
37%
63%*
18%
‫חיפה‬
Haifa
‫צפון‬
‫מרכז‬
North
South
‫דרום‬
‫מרכז‬
43%
39%
‫חדש‬
New
‫ותיק‬
Veterans
Status
Region
59% are study participants and 41% control group
*Within the ‘New’ category there are between 15-25% veteran ‘Revolving
43 door’
service receivers
Characterization of study
and control groups
Control Group
Study Group
60.0%
61.4%
40.0%
38.6%
42 years (12.6)
37 years (12.3)
Men Gender
Women
Mean Age (Sd)
*p<.001
 Most participants are single and with only basic or lower
education
44
SCALE DOMAINS
•Goals
Number & Kinds
Achievement
Barriers & Support
•Quality of Life (subjective and objective functioning)
Physical Health
Leisure
Community Integration
Residence
Interpersonal/Social
Employment
Financial
Education
•Satisfaction
•Optimism
•Psychiatric Symptoms
45