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Table 1 The final Collaborative Community Based Care (CCBC) model

From: The development of a lay health worker delivered collaborative community based intervention for people with schizophrenia in India

Intervention component Specific actions When delivered
Engagement and collaborative treatment planning ■ Building a trusting professional relationship with the individual and the key caregivers based on genuineness, respect and empathy
■ Engaging the caregiver in the intervention by encouraging their participation and providing support
■ Exploring and recording of needs and priorities of individuals and their caregivers through a structured needs assessment
■ Detailing and responding to social difficulties faced by the caregivers
■ Developing a treatment plan in collaboration with individuals, caregivers and treating psychiatrists
Specific focus in the intensive engagement phase, with the needs assessment repeated at the end of every 3 months
Medical reviews ■ Providing pharmacological treatment
■ Providing information on medications and stressing need for adherence
■ Referring acute episodes or relapses to inpatient care
Specific focus in the intensive engagement phase, and continued throughout 12 months
Adherence management ■ Understanding adherence related beliefs and stressing the need for adherence
■ Providing information about medications (benefits and side effects)
■ Maximising family support in monitoring
■ Making treatments accessible for non-adherent people by accompanying them on clinical visits or bringing home regular supplies of medications
■ Implementing adherence strategies such as use of incentives, aids (e.g. reminders, pill boxes) or changing doses/medicines
■ Side-effect management
Specific focus in the intensive engagement phase, and continued throughout 12 months
Psycho-education (for stigma actions please see below) ■ Providing information about schizophrenia, (medications, dealing with difficult symptoms, relapse prevention) for both people with schizophrenia and their caregivers Specific focus in the intensive engagement phase, and continued throughout 12 months
Health promotion ■ Providing information and advice on healthy diets
■ Encouraging healthier lifestyle (e.g. physical exercise, stopping smoking)
■ Referring people with physical health problems to physicians
■ Helping reducing stress and anger by recognising triggers and teaching coping strategies (e.g. relaxation exercises, peaceful imagery)
Specific focus in the stabilisation phase, and continued as necessary
Rehabilitation ■ Improving self-care
■ Improving functioning in Activities of Daily Living (ADL)
■ Enhancing coping with distressing symptoms by using positive coping strategies (e.g. recreation, keeping busy)
■ Encouraging work at home or elsewhere by teaching prevocational (e.g. organisational ability) and vocational skills (e.g. computer skills)
■ Improving social interactions through social skills training
■ Encouraging attendance to community activities and resuming roles in society
Specific focus in the stabilisation phase, and continued as necessary
Referral to community agencies ■ Providing information on government schemes for disability benefits
■ Enlisting support of the local government and employers for providing employment opportunities
■ Improving access to employment opportunities through referrals to vocational and rehabilitation centres
Specific focus in the intensive engagement (while responding to social difficulties) and stabilisation phases, and continued as necessary
Self-help initiatives (meetings of affected persons/caregivers) ■ Sharing of common experiences
■ Exchanging of useful information, e.g. positive coping strategies
■ Emphasising emotional support
■ Facilitating forming of social relationships
Specific focus in the stabilisation phase, and continued as necessary
Strategies to deal with stigma and discrimination ■ Providing accurate information about the illness to dispel myths
■ Emphasising concepts of 'it's nobody's fault' or 'illness like any other'
■ Emphasising the possibility of positive outcomes
■ Addressing low self-esteem by identifying strengths and building them
■ Exploring likely outcomes of illness disclosure along with potential advantages and disadvantages of disclosing
■ Discussing ways of responding to and coping with discrimination from others
Specific focus in the maintenance phase
Supervision and quality assurance ■ For individual cases, onsite supervision by the mental health team coordinator; quarterly reviews by the whole team; and fortnightly reviews with psychiatrists.
■ For overall quality assurance and support to CLHWs, monthly meetings with the whole team
Initiated in the intensive engagement phase and continued till termination
Termination and transfer of care ■ Reviewing clinical state and treatment progress
■ Introducing strategies for long term maintenance of overall health and emotional wellbeing and for preventing relapses
■ Emphasising links with community agencies and follow up of activities to minimise experiences of stigma and discrimination
■ Formal transfer of care back to treating psychiatrists
At the end of 12 months