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Schwarz  et al. BMC Psychiatry (2022) 22:826 https://doi.org/10.1186/s12888-022-04477-y RESEARCH © The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativeco mmons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Open Access Equal access to outreach mental health care? Exploring how the place of residence influences the use of intensive home treatment in a rural catchment area in Germany Julian Schwarz 1,2,3* , Jan Hemmerling 4 , Nadja Kabisch 5 , Laura Galbusera 1 , Martin Heinze 1,2,3 , Sebastian von Peter 1,3 and Jan Wolff 6 Abstract Background: Internationally, intensive psychiatric home treatment has been increasingly implemented as a com- munity-based alternative to inpatient admission. Since 2018, the so-called Inpatient Equivalent Home Treatment (IEHT; German: "Stationsäquivalente Behandlung", short: "StäB") has been introduced as a particularly intensive form of home treatment that provides at least one daily treatment contact in the service users' (SU) home environment. Prior research shows that this can be challenging in rural catchment areas. Our paper investigates to which extent the location of the SU home location within the catchment area as well as the distance between the home and the clinic influence the utilisation of inpatient treatment compared to IEHT. Method: Routine data of one psychiatric hospital in the federal state of Brandenburg in Germany were analysed for the observational period 07/2018-06/2021. Two comparison groups were formed: SU receiving inpatient treatment and SU receiving IEHT. The SU places of residence were respectively anonymised and converted into geo-coordinates. A geographic information system (GIS) was used to visualise the places of residence, and car travel distances as well as travel times to the clinic were determined. Spatial analyses were performed to show the differences between compar- ison groups. In a more in-depth analysis, the proximity of SU residences to each other was examined as an indicator of possible clustering. Results: During the observational period, the location of 687 inpatient and 140 IEHT unique SU were mapped using the GIS. SU receiving treatment resided predominantly within the catchment area, and this proportion was slightly higher for SU receiving IEHT than for those treated in inpatient setting (95.3% vs. 84.7%). In the catchment area, the geographical distribution of SU place of residence was similar in the two groups. There was a general higher service provision in the more densely populated communities close to Berlin. SU with residence in peripheral communities were mainly treated within the inpatient setting. The mean travel times and distances to the place of residence only differed minimally between the two groups of SU ( p > 0.05). The places of residence of SU treated with IEHT were located in greater proximity to each other than those of SU treated in inpatient setting ( p < 0.1). *Correspondence: [email protected] 2 Centre for Health Services Research, Brandenburg Medical School, Rüdersdorf, Germany Full list of author information is available at the end of the article
Page 2 of 10 Schwarz  et al. BMC Psychiatry (2022) 22:826 Conclusion: In especially peripheral parts of the examined catchment area, it may be more difficult to have access to IEHT rather than to inpatient services. The results raise questions regarding health equity and the planning of health care services and have important implications for the further development of intensive home treatment. Telehealth interventions such as blended-care approaches and an increase of flexibility in treatment intensity, e.g. eliminating the daily visit requirement, could ease the implementation of intensive home treatment especially in rural areas. Keywords: Health care access, Health equity, Home-treatment, Crisis resolution teams, Outreach care, Health care planning, Geography, Spatial analysis, Mental health services, Stationsäquivalente Behandlung, StäB Background Equal access to care services is a leading principle of health care systems [ 1 ]. A central goal of these systems is providing medical services according to the needs of the population and as community-based as possible. The access to services is influenced by non-spatial (e.g. eco- nomic, cultural and social) as well as spatial factors, such as the local availability of health care infrastructures and the geographic distance to them. As early as 1866, the epidemiologist and psychiatrist E. Jarvis was able to prove a significant correlation between the rate of admission and the distance of service users' (SU) place of residence to the psychiatric hospital. SU that lived close to the hospital were more likely to be treated as inpatients than those that lived further away [ 2 ]. This so-called "Distance Decay" effect has been dem- onstrated in a variety of studies on psychiatric settings [ 1 , 3 - 8 ]. In 2011, Zulian et al. showed that the citizens of a rural community in the region of Verona (Italy) were less likely to utilise a healthcare facility, the more the (car travel) distance separated their place of residence and the service provision [ 1 ]. Following the assumption that psy- chiatric SU often do not have a car, Stulz et al. were able to prove in a more recent study that the utilisation of out- patient psychiatric services recedes with increasing travel time by public transport [ 3 ]. This difference did not apply to inpatient services though, which were equally accessed by SU regardless of the distance between their home and the hospital [ 3 ]. To date, it has not been investigated to what extent the usage of (intensive) home treatment depends on the place of residence, or whether a greater distance between the place of residence and the hospital constitutes a nega- tive predictor for outreach psychiatric service usage. Since outreach intensive care services are being inter- nationally increasingly implemented as an alternative to inpatient psychiatric care [ 9 - 12 ], this issue is nowadays of great clinical and scientific relevance. In contrast to other settings, acute outreach mental health care ena- bles a stronger integration of treatment into SU everyday life and social network (and vice versa) through mobile, multi-professional teams, and is recommended in sev- eral guidelines with the highest level of evidence [ 13 , 14 ]. Consequently, access to inpatient-treatment-replacing care services should generally be ensured for all SU in the interests of equity of care. In Germany, the possibility for psychiatric hospitals with a catchment area to offer the so-called Inpatient- Equivalent Home Treatment (IEHT; according to §115d social code V) as part of routine health care services exists since 2018-01-01 [ 15 , 16 ]. The legal framework specifies that this intensive form of home treatment must be equivalent to inpatient psychiatric treatment in terms of service content, complexity and flexibility, and that thus a multi-professional team is required to per- form at least one daily visit in the home environment. At the moment, about 50 hospitals within Germany with a mainly urban catchment area provide IEHT, with a ris- ing tendency [ 17 ]. In rural areas the provision of IEHT is made difficult by longer travel distances and lack of personnel [ 18 ]. Especially the legally required daily treat- ment contacts present a challenge in the care of SU that live far away from the hospital. Thus, the goal of this study is to investigate to what extent IEHT, a particular intensive form of home treat- ment, is utilised in a large rural catchment area in com- parison to inpatient treatment, and whether this is influenced by the previously mentioned distance effects. The following research questions are explored: 1. Is intensive home treatment utilised equally across the catchment area studied, or are there differences depending on the place of residence? 2. How do the distances and the car travel time from place of residence to hospital differ between SU treated in the home treatment or inpatient setting? Method Design Analyses of the utilisation and mapping of health care services have been performed for research and planning purposes using geographic information systems (GIS) [ 7 , 19 ]. This study uses the „Google Distance Matrix "inter- face (Google LLC, California, USA) to depict the usage of IEHT and inpatient treatment within one hospital
Page 3 of 10 Schwarz  et al. BMC Psychiatry (2022) 22:826 catchment area and to calculate the car travel times and distances between hospital and the SU home address. Furthermore, spatial analyses have been performed to demonstrate a possible "Distance Decay" effect and clus- tering as an indicator for an irregular distribution of SU treated within the catchment area [ 20 - 22 ]. The differ- ence between both settings has been determined using descriptive statistics. The analysis is based on hospital routine data (according to §21 hospital remuneration law). The ethics committee of the Medical School Han- nover confirmed that our study did not require ethical oversight. Anonymity and confidentiality were ensured in that only anonymous data without personal reference were processed. Setting The study was performed at the Department for Psy- chiatry and Psychotherapy of the Brandenburg Medi- cal University, Immanuel Hospital Rüdersdorf (IHR). Additionally, to the main site in Rüdersdorf, two satellite locations in Strausberg and Fürstenwalde belong to the hospital, and both include a day-care unit and a psychiat- ric outpatient centre. The IHR is responsible for the acute mental health care for the two regions Märkisch-Oder- land (MOL) and Oder-Spree (LOS) that border Berlin to the east. The catchment area of the hospital includes 239.908 inhabitants (recorded 2020-12-30) and a surface of 1.550 km 2 . This area is just about double the size of Berlin. 70% of the inhabitants of the catchment area live in the more densely populated communities close to Ber- lin [ 23 ]. At IHR, IEHT has been offered since May 2018. Dur- ing the observational period (1. July 2018-30. June 2021) the mean caseload of IEHT, i.e. the amount of SU treated simultaneously, was 7.2. Treatment con- tacts were usually performed by two team members working together, driving by car from one SU to the next. Depending on the distribution of SU within the catchment area, one or two different routes, a north- western and a south-eastern one, were travelled every day. The mean length of an exemplary travel route (Fig.  1 ) amounted to roughly 126 km with a travel time of about 2 hours and 45 minutes. In principle, all SU within the entire catchment area can be treated in the IEHT setting as long as the criteria for inpatient hos- pital admission are met, i.e., an acute psychiatric dis- order is present and the treatment goals are likely to be best achieved in the IEHT setting. In addition, the home environment must be suitable for the provision of IEHT. This is not the case, for example, if there is no privacy for a therapeutic one-on-one conversation, or child welfare risks are imminent or already exist. SU Fig. 1 Catchment area of the study hospital ( A ) and its geographical position within the state of Brandenburg ( B ). A: The orange line marks exemplary travel routes of the IEHT team; the orange circle marks the position of the hospital (Rüdersdorf), the satellite units (each including a day-care centre and an outpatient centre) are represented by a square (Strausberg) and a triangle (Fürstenwalde). The numbers 1-17 mark the various communities, cities and administrative offices of the catchment area. The colouring of the regions in different shades of grey corresponds to the respective population density (see figure for legend). B: The catchment area of the study hospital (white) as part of the Brandenburg districts Märkisch-Oderland (MOL) and Oder-Spree (LOS). The other areas marked in red represent the districts of the states of Brandenburg and Berlin
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