Introduction

In 1930, day care centers started in the Union of Soviet Socialist Republics as an alternative to hospitalization. By 1950s, it became popular in the West and was seeing its success by 1970s. Later these centers started becoming unpopular as it was presumed that home care treatment was more appropriate and cost effective.1

The term “day care” is not easily defined and is best clarified by first defining the functions of day care and then relating these to the various structures to provide them: to provide an alternative to inpatient care, shorten its duration and promote recovery, and maintenance in the community. These three functions can be provided by day care programs from three different sources: day hospitals, employment services, and social care facilities.2

In the West by 1930s process of deinstitutionalization began to promote social inclusion of mentally ill patients. To overcome the problems faced, community mental health services were started but soon led to failure due to two reasons, one is that there were set of patients who did not improve and other reason being poor implementation of the services. To overcome these, concept of rehabilitation was developed.3

Most patients admitted in day care center suffer from schizophrenia who do not recover fully due to nagging negative symptoms and cognitive deficits which linger and persist making the patients unfit and unacceptable for the employment. But regular employment can help in recovery. In this way day care centers would help in recovery of patients and hence the need for these kind of centers. In India day care centers are in infancy stage and to a larger extent are inadequately used.4 There is no data available from psychiatry day care center run as public–private partnership (PPP) project in a tertiary care general hospital psychiatry unit (GHPU). This model is first of its kind in India. Here, we narrate experiences gained in the last 2 years.

Aims/Objectives

To narrate the challenges and opportunities in a psychiatry day care center in PPP model.

Methodology

It is a cross-sectional study.

Description of day care center: Day care center was started as PPP model called Manasadhara model in the state of Karnataka, first of its kind in India. A memorandum of understanding (MoU) was signed between the college and the government in April 2017, as per the regulations laid by the government. The day care center is located in the premises of the hospital and is managed by the department of psychiatry.

Results

Discussion

The state government came out with ambitious plan to have residential day care centers which later were changed to nonresidential day care centers to be housed in district hospital premises. Budgetary allocations with how and on whom it is to be spent and the necessary list of resource persons and the areas in which the patients should be trained and for what period were specified. Our center started as PPP project, since for various reasons it did not materialize in the district hospital. Suitable place in our hospital premises which is very user- and patient-friendly but at the same time provided suitable privacy was identified and procured. As it is said easier than done, when the day care center started functioning we had a poor response. Our team conducted initial awareness program in and around the city covering up to 200 km. We advertised through banners and distributing pamphlets. We also informed all the psychiatrists practicing in and around the city. Social organizations like Rotary clubs and some NGOs were also informed. Efforts were made to inform all the patients and their relatives who visited department of psychiatry for treatment. All medical officers, health workers, Anganwadi workers, etc., with the help of DHO/additional district mental health officers were approached, sensitized, and requested to refer suitable persons in their areas. Indian Medical Association branches in and around the district were informed. Medical practitioners, opinion makers, and social workers were approached.

In a study done in India by Agarwal et al showed 71% of patients who were admitted in day care center had a diagnosis of schizophrenia as compared with our study which accounted for 88%, this shows that majority of patients who get admitted suffered from chronic illness like schizophrenia. However, only 06.06% admitted were diagnosed to have mood disorders in contrast to 16% in the Agarwal et al study. This difference could be because patients with mood disorders either relapsed which may be the reason for discontinuation in the day care center, or another reason could be they remain asymptomatic and get discharged faster. Comparing time spent in illness, both the studies showed that most of the patients were in same age group, that is, between 6 and 10 years, indicating that duration of illness was at least 5 years before they were enrolled in the day care center. Note that 51.52% of our study patients' age of onset of illness was between 21 and 30 years.

In our study, 62% completed 3 months as compared with only 50% in the Agarwal et al study. This difference could be because most patients found day care center useful. Our study showed less number of patients (38%) got employed after discharge as compared with 49% in the Agarwal et al study. This could be because patients were unfit for employment or had symptom relapse or employers refused to give any employment at various places. Sixty-two percent of our patients had financial difficulties which was one of the major reasons for discontinuation

Sixty-two percent of patients after discharge had employment difficulties, most did not find a job. This tells us that patients with psychiatric illness are either refused employment or are considered that they are less efficient than others. It could also be possible that these patients could be staying at home and helping family members in household activities, as this is a common attitude of families toward psychiatric illness patients.

Forty-two percent of our patients had poor family support in the form that, there was no single person to look after on a regular basis. Hence, patients were not brought to day care center on a regular basis. Invariably, these patients did not do well. Some patients experienced negative expressed emotions.

The two most common problems which were faced by patients/families were: most of them complained that their expenses increased in taking care of patients and also in spending extra money in transportation. Here, we suggest that government can provide free bus passes for the patients and concession to one caregiver in public transport so that their financial burden could be reduced. Also, most families expect/request for a residential place. Many NGOs/private institutions may be wary of this model for logistic, safety, and medico-legal problems.

Second common problem was rehabilitating these patients, more than 50% were not rehabilitated. The reasons could be ours is a day care center run in a GHPU where the college does not have any links to small-scale industries where patients can be employed. These kind of attachments are present in central institutes like National Institute of Mental Health and Neuro-Sciences where most patients get rehabilitated. Second, the place where the day care center is situated in a district place there might not be enough employment opportunities. Our district does not have a large number of industries. The skills in which a patient is to be trained needs to be decided by the patient profile, the socioeconomic status, and geographical characters of the place where the center is situated. Agriculture, horticulture, and dairy are the main occupation where most of our patients could be rehabilitated or trained and retrained. But the place, space, and location area available need to be appropriate and sufficient. So we feel that in a general hospital unit setting it is difficult to rehabilitate all patients. To generate employment our center has employed two patients in our own hospital. By doing so, we have spread awareness and reduced stigma. Recreational aspects, cognitive remediation, physical fitness, and training in soft skills like basic computer learning are possible in day care centers like ours.

From the management point of view the following hurdles were faced. Since it is mandate that occupational therapist (OT) be present at day care center, it is difficult to get an OT at district places. Second, since it is a MoU between government and private college, the funding comes from the government. It is observed in the past 2 years that the funding has always been irregular and most of the employees feel that it is inadequate. We suggest that a separate fund allocation for running a day care center be made at the government level which will allow for smoother functioning and encourage better functioning of the center. Also, we have learnt that the need of clinical psychologist at the day care center is minimal. Instead, the salary paid to the clinical psychologist can be diverted to manage other affairs at the day care center.

Conclusions

• Of the 33 patients who joined the day care program, 62% could continue regularly.

• Nearly 38% could take up jobs.

• Social and occupational behaviors improved.

• Note that 36% discontinued due to various reasons.

• Running a day care center in PPP model that too in a GHPU set up is not easy.

• Skills in which patients need to be trained should be decided based on patients' profile, socioeconomic status, and cultural basis of the place where the day care center is located.

• Common problems faced were poor placements, transportation, financial difficulties. and poor funding.