High and Intensive Care in Psychiatry: A New Model for Acute Inpatient Care

In 2011, a literature study about methods and interventions aimed at the reduction of coercion was performed, resulting in a narrative synthesis. In addition, interviews and focus groups to discuss initiatives, successes, and bottlenecks were conducted in 26 mental health care hospitals in the Netherlands (8). The literature study and the qualitative data from the interviews and focus groups resulted in a proposal for a new approach to inpatient care: the HIC model. The model contains a structured set of requirements for the organization of inpatient care, including team structure, team process, treatment (interventions), organization of care, monitoring, professionalization, facilities, and (evaluation of) coercive measures. In three 2-day expert meetings with participants from 15 mental health care institutions in the Netherlands, the proposal was discussed, and the model was refined. Four psychiatrists, four nurses, two patients, two representatives of family organizations, two psychologists, two managers, and four researchers were present. The participating groups contributed on the basis of their experience and expertise. Patients mentioned the importance of recovery-oriented care and the involvement of peer workers. Family representatives emphasized cooperation with relatives and the possibility to stay overnight (rooming in). Nurses indicated that development of knowledge and skills is required to provide good care to patients in complex situations. Psychiatrists stressed the need for clear admission criteria and for giving attention to various treatment options (including medication) in the model. In several meetings, the model was presented to professionals and to patients and their families in all mental health care institutions in the Netherlands to elicit feedback and create support in the field. A writing team, working closely together over 3 months, described the model in a handbook. A model fidelity scale describing specific elements of the model was developed, which enables measurement of the level of implementation. This scale has been validated (9).

The main goal of the HIC approach is to provide optimal treatment and safety while restoring and maintaining contact between staff, patients, and relatives and promoting crisis prevention. Its aim is to provide safe, protective, and respectful care. Core characteristics of the HIC model are as follows.

The HIC model entails a new approach to mental health care in the Netherlands. It resembles the PICU model, in that it focuses on early risk assessment, de-escalation, and use of an ICU (extra care area in the PICU model). However, the HIC model is also different. First, admission is seen as a temporary break in outpatient care, and the outpatient care team is directly involved in the care planning meetings. Second, the HIC model also utilizes stepped care within the ward, using the ICU and the HSR only when needed. Third, the HIC model, unlike the PICU model, aims to minimize coercion. Thus, the core characteristics of the HIC model correspond with the three reforms in psychiatry in the Netherlands mentioned above. The HIC model aims to reduce coercion by focusing on contact and cooperation between staff, patients, and family. It is complementary to outpatient care, aiming for continuity between community and inpatient care. It integrates principles of recovery with a medical approach, making recovery a cornerstone of inpatient care.

During the process of developing the HIC model, we learned various lessons. First, support is needed of all stakeholders, especially of core opinion leaders in psychiatry. Second, all participants should be actively involved in the process. By presenting the development of HIC as special, we ensured that participants felt honored to be able to contribute. During the meetings, we continuously focused on learning from and with each other. This approach inspired participants and led to new insights that participants then discussed at their own institutions. Finally, the elements of the model should be concrete. We achieved this aim by developing a model fidelity scale describing key components. This scale provided support in implementing HIC. These lessons can be useful for others who want to develop a similar strategy.

Because the HIC model was the result of a bottom-up process of development that included professionals, user organizations, management, and patient and family representatives, the model is widely accepted and has been implemented in Dutch mental health care. Further research is needed to investigate the process of implementation and the effects on reduction of coercion, quality of care, continuity of care, and recovery.