High and Intensive Care (HIC) in psychiatry: development, implementation & effects

SUMMARY The central aim of this thesis is to investigate the development, implementation, and effects of the High and Intensive Care (HIC) model on the quality of care and the use of coercive measures in acute mental healthcare in the Netherlands. The HIC model aims to create a national approach for high quality inpatient care. Central to the HIC model is to work proactively to reduce the use of coercive measures, to foster contact between professionals, patient and family, and to improve cooperation between outpatient care and the clinic. The HIC model was developed after several projects to reduce seclusion started in the period 2006 -2012 ended with insufficient results. At the time, institutions differed greatly in their use of coercive measures and choice of best practices and evidence based practices. A new national standard in which principles from the recovery approach and care ethical values were taken into account was needed to strive for good quality care and to further reduce coercion. In 2012, consensus was sought by experts of various disciplines and backgrounds in combining evidence -and experience based practices and insights from the former nationwide program to develop the comprehensive High and Intensive Care (HIC) model. In 2013, a book describing the full HIC model was presented, including a model fidelity scale; the HIC monitor. This thesis seeks to evaluate the HIC model. The main research question of the thesis is: “What is the relevance of HIC for mental healthcare, and in particular for the quality of care and the reduction of coercion?” The thesis contains three parts: development, implementation, and effects. The first part (development) examines the question how the HIC model was developed and what the most important elements of the HIC model are. Moreover, the question how to measure compliance to the HIC model is addressed. The second part (implementation) focusses on the question to what degree the HIC model is implemented by mental healthcare institutions throughout the Netherlands. Also, the facilitators and barriers in the implementation process are investigated. In the final part (effects), the question what the effects of implementation of the HIC model are on the quality of care and on the use of coercive measures is studied. The thesis ends with a general discussion, in which the research questions are answered and a reflection on the findings is given from an care ethical perspective. In conclusion, the HIC model has brought about major changes in the organization of Dutch mental healthcare. HIC is in line with the needs in psychiatric practice, especially the need to reduce coercion. The close cooperation with stakeholders in practice has resulted in an innovative, comprehensive and feasible approach. Five care ethical values (attentiveness, responsibility, competence, responsiveness, and solidarity) can be recognized in the core elements of the HIC model, and also in the different steps that were taken to develop, implement and study the HIC model, care ethical values can be recognized. Fostering the quality of mental healthcare requires not just the implementation of new ways of working, but also the improvement of practice from an ethical perspective. The integration of strategies makes the HIC model highly relevant for good quality care in acute psychiatry, and for the reduction of coercion.