Sociotherapy
Sociotherapy (in the sense of the German Social Security Code ) describes the outpatient care of patients with strongly pronounced mental illnesses , but for whom it can generally be assumed that outpatient therapy would be promising. It is intended to enable patients to perceive the therapy options independently and on their own responsibility, for example by motivating them to do so and promoting understanding of their necessity. This should avoid hospital treatment.
Sociotherapy is also used synonymously with social therapy .
Legal regulations in Germany
In Germany, sociotherapy is a defined outpatient care service for patients with severe mental disorders that is intended to enable them to take advantage of other medical treatments. Sociotherapy in this context includes training and motivational methods as well as coordination measures and is provided by contractually approved persons. In order for the statutory health insurance to assume the costs of this service, which the insured person is obliged to pay in accordance with Section 37 a (3) SGB V , a specialist doctor or psychotherapeutic prescription and approval from the responsible health insurance company are required. The additional payment amounts to 10% of the daily costs, however at least 5 euros, at most 10 euros.
Sociotherapy was introduced as Section 37a SGB V with the law to reform statutory health insurance from 2000 (GKV-Gesundheitsreform 2000). As an outpatient service for seriously mentally ill people, it should avoid unnecessary hospital stays and costs of inpatient stays. Depending on the clinical picture, these people are often not able to make use of the services they are entitled to independently. This can lead to recurring inpatient stays (so-called " revolving door effect ").
In accordance with Section 37a (2) of the Social Code Book V , the Federal Joint Committee determines the details of the requirements, type and scope of care, in particular clinical pictures, goals, content, scope, duration and frequency of sociotherapy, conditions under which doctors and Psychotherapists are entitled to prescribe sociotherapy, requirements for the patient's ability to treat as well as the content and scope of the collaboration between the prescribing doctor / psychotherapist and the service provider. The currently applicable sociotherapy guideline of January 22, 2015 ( BAnz AT 04/14/2015 B5 ) came into force on April 15, 2015 and replaced the previously applicable sociotherapy guideline of August 23, 2001.
Sociotherapy can be prescribed on the basis of an individual medical necessity, which consists of the diagnosis , severity and duration of the illness, as well as the ability disorders typical of the disease. Prerequisites are a positive prognosis and / or therapeutic ability and the need to avoid, shorten or replace hospital stays if these are not feasible. This service is usually carried out by social workers , social pedagogues or specialist nurses or nurses for psychiatry . The service provider must meet special requirements to sociotherapy acc. To be allowed to carry out § 37a SGB V at the expense of the GKV.
indication
Indications for sociotherapy is the case with any of the following serious mental illness:
- schizophrenia
- Schizotypic disorder
- persistent or induced delusional disorder
- Schizoaffective disorder
- Bipolar disorder
- Affective disorder
- major depressive episodes
- chronic alcohol and / or drug addiction
However, the severity of the disturbances must not fall below a value of 20 and not exceed a value of 50 on the GAF scale . In justified individual cases, patients with diagnoses from the range F00 to F99 that are not mentioned here will also receive a doctor's prescription. Criteria such as co-morbidities, severely restricted abilities in everyday tasks and independent use of medically or medically prescribed measures or severely restricted ability to travel are decisive.
Implementation problems
The legal anchoring of sociotherapy was preceded by a model project "Outpatient rehabilitation of the mentally ill". It was initiated by the Federal Ministry of Health and carried out by the central associations of statutory health insurance companies. The health insurance companies involved were reluctant. The Federal Association of AOK have stated that the health insurance companies should be burdened solely with the financing of sociotherapy. Sociotherapy is the attempt to shift public services at the expense of health insurance companies. In the model project it could be shown that sociotherapy is a practicable and effective instrument for the prevention of recurrences and that the expenditure for sociotherapy is offset by considerable savings in inpatient treatment costs. The implementation guidelines were only available after two years and an excruciatingly long discussion process. It is criticized that the implementation guidelines and the following "Assessment guidelines for outpatient sociotherapy" of the medical service of the health insurance are characterized by keeping the scope of sociotherapy low and excluding benefits that can be allocated to social welfare or other cost carriers.
In large parts of the country, sociotherapy can in principle be prescribed, but actually not used, as the report by the management on behalf of the Sociotherapy Subcommittee of the Federal Joint Committee of January 17, 2008 shows. The causes of the implementation problems in sociotherapy should therefore be evaluated. To this end, seven theses were drawn up and examined:
- The performance of sociotherapy is not known in the area of general practitioner care.
- Sociotherapeutic service providers are not available in sufficient quantities.
- The indications of the guideline do not cover all seriously mentally ill within the meaning of the law.
- Sociotherapeutic prescribers are not available in sufficient quantities.
- Instead of sociotherapy, other services are provided / prescribed.
- The MDK does not base its decisions on the guidelines.
- Sociotherapy does not improve the care of the severely mentally ill.
The investigation by the G-BA yielded the following results and recommendations for action:
1. Lack of awareness of the service
63% of general practitioners were unfamiliar with sociotherapy. The primary care level should therefore be informed about the sociotherapy guidelines by the National Association of Statutory Health Insurance Physicians (KBV) and its subdivisions. For this purpose, the health insurance companies should provide lists of approved service providers in order to make the sociotherapeutic contacts known to the general practitioners. The KBV voted to also inform the specialists with the field designation psychiatry or neurology.
2. Missing service providers
The findings indicated that there was a lack of service providers. For some federal states, not a single service provider could be identified as a contact. Maybe u. a. associated regional supply differences.
| state | number |
|---|---|
| Baden-Württemberg | 78 |
| Bavaria | 76 |
| Berlin | 11 |
| Brandenburg | 0 |
| Bremen | 4th |
| Hamburg | 1 |
| Hesse | 6th |
| Mecklenburg-Western Pomerania | 1 |
| Lower Saxony | 13 |
| North Rhine-Westphalia | 23 |
| Rhineland-Palatinate | 77 |
| Saarland | 0 |
| Saxony | 9 |
| Saxony-Anhalt | 23 |
| Schleswig-Holstein | 13 |
| Thuringia | 3 |
A mechanism for creating regional transparency about the need for sociotherapeutic service providers was recommended: Doctors should register a need for missing service providers. The central associations of the health insurers should also internally pass on information about differences in the individual federal states. The patient representatives discussed that questions of structural quality (qualification requirements of the health insurance companies) and questions of remuneration also had to be taken into account.
3. The indications of the guideline do not cover all seriously mentally ill within the meaning of the law
The neurologists questioned indicated that patients with personality disorders, e.g. B. Borderline personality disorders and patients with major depression could benefit from sociotherapy. The service providers also pointed out personality disorders as well as patients with severe depression who could benefit from sociotherapy.
The Sociotherapy Subcommittee wanted to examine the results in detail and discuss whether the sociotherapy guidelines should be changed. The patient representatives pointed out that advice on the catalog of indications should be given in the overall context, particularly in connection with home psychiatric nursing.
4. The number of socio-therapeutic prescribers (specialists) is not needs-based
The results of the investigation also showed very different supply situations here. In some territorial states, only a few specialists are authorized to prescribe sociotherapy if necessary.
| state | number |
|---|---|
| Baden-Württemberg | 101 |
| Bavaria | 188 |
| Berlin | 101 |
| Brandenburg | 10 |
| Bremen | 36 |
| Hamburg | 3 |
| Hesse | 41 |
| Mecklenburg-Western Pomerania | 27 |
| Lower Saxony | 64 |
| North Rhine-Westphalia | 151 |
| Rhineland-Palatinate | 30th |
| Saarland | 30th |
| Saxony | 20th |
| Saxony-Anhalt | 40 |
| Schleswig-Holstein | 60 |
| Thuringia | 14th |
The subcommittee of the G-BA assumed that the recommendations for action made to general practitioners and specialists (information about sociotherapy) would also have a positive effect on this problem. General practitioners should be provided with a list of the prescribing specialists in psychiatry and neurology.
5. Instead of sociotherapy, other services are provided / prescribed
Specialists authorized to prescribe were asked whether their patients who had been prescribed sociotherapy regularly use other services as part of their mental illness. Similarly, service providers were also surveyed.
The answers vary. However, the question asked of specialists and service providers differed from the initial question. The problem was whether other services were prescribed instead of sociotherapy. It thus implicitly aimed at whether sociotherapy might be compensated by other services. The actual question was only aimed at whether other services were prescribed in addition to sociotherapy, which is why it cannot result in a solution to the specific problem. Recommendations for action were not given here.
6. The MDK does not base its decisions on the guidelines
No recommendation for action was made here either. This was justified by the fact that the question - whether the MDK bases its decisions on the guidelines or not - had not been asked at all. It can be concluded that the MDK is based on the guidelines, since the main reasons for not advocating sociotherapy are reasons that relate directly to the sociotherapy guidelines.
7. Sociotherapy does not improve the care of the severely mentally ill
87% of the specialists questioned answered yes to the question of whether the possibility of prescribing sociotherapy improves the care of their patients. The hypothesis could therefore not be upheld.
The National Association of Statutory Health Insurance Physicians determined in 2009 that the statutory health insurance had spent around 3.4 million euros on sociotherapy in 2008. This corresponds to a share of 0.002% of total SHI expenditure. Although the expenditures have increased steadily, it remains to be stated that sociotherapy has so far only been inadequately implemented.
In 2010 the 83rd Conference of Health Ministers of the federal states dealt with the implementation problems of sociotherapy.
In 2010, a federal-state working group on the availability of sociotherapy found that, based on 100,000 inhabitants, the number of licensed sociotherapists between the federal states varies by a factor of 40 (from 0.05–2.0). Actually approved sociotherapy cases vary between 0.5 and 30 cases per 100,000 inhabitants, with more than 10 cases per 100,000 being achieved in only 3 federal states.
The reasons given for the low degree of implementation of sociotherapy were:
- The main problem is the performance remuneration, which varies between € 24 and € 42 depending on the federal state and is not in proportion to the required qualifications of the service provider (social pedagogue, social worker or specialist nurse for psychiatry with 3 years of professional experience in a specialist clinic).
- The number of doctors who prescribe sociotherapy is low, because the service is too little known (connection with the offer of service providers) and the procedure for ordering is cumbersome, time-consuming and poorly remunerated.
With regard to the overriding problem of inadequate remuneration, the federal states had no room for maneuver, as the price of the service had to be set in a contract. The contracts are to be negotiated between health insurers and service providers. The assessment of the appropriateness of the remuneration is not the responsibility of the federal states. The Federal Joint Committee could also determine the requirements, type and scope of care, but not the service providers. It was discussed that countries should exert greater influence on the health insurance associations in order to promote the implementation of the service. There was also the consideration of asking the Federal Ministry of Health to ask the Federal Joint Committee to expand the range of services offered by sociotherapy, e.g. B. to severe addiction disorders as well as severe personality and anxiety disorders.
On July 1, 2010, the Conference of Health Ministers decided unanimously to optimize implementation in the federal states:
“The ministers and senators for health of the federal states ask the umbrella association for health insurance companies to sound out all possible ways in which the provision of sociotherapeutic services according to Section 37a SGB V can be improved and expanded across the board. Embedded in the respective psychiatric care system, particular attention should be paid to checking the access authorization for the provision of services and accelerating the approval process. "
The expansion of the diagnostic spectrum was not pursued further during the bombardment. The health insurances or their umbrella association, which had already been opposed to the benefits before the introduction of sociotherapy, were asked with the decision to “sound out” ways in which the care can be expanded. It is not known whether, to what extent and, if so, with what interest possibilities for improving care have actually been explored.
In the psychiatric professional world, the status of sociotherapy is assessed inconsistently. Sometimes it is viewed as "failed". To this day, sociotherapy is not prescribed and used across the board. In addition to the implementation problems named by the G-BA, the lengthy approval process of the health insurance companies for the approval of service providers and the cooperation with the medical service with regard to the content of sociotherapy, which can be classified as being in need of improvement, are aggravating. In addition, the inadequate remuneration for neurologists and sociotherapists could be improved. The importance of sociotherapy as a measure to overcome the interfaces between different care and financing areas is not yet sufficiently recognized and implemented. But even if sociotherapy is currently like a patchwork quilt in the care landscape, it will steadily expand and be woven into innovative patterns. Proven models are available and promising new approaches are on the way. Sociotherapy has by no means failed, but will continue to establish and prove itself as an instrument for tailor-made and efficient treatment and aftercare.
Sociotherapy for addictions
In the field of addiction therapy or the treatment of the dependency syndrome one speaks of social therapy or sociotherapy, for which there are training courses recognized by the sponsors and for which differentiated models exist, such as the integrative sociotherapy founded by Hilarion Petzold in 1972, which also provides psychosocial assistance in other fields is used by people from disadvantaged backgrounds or in gerontotherapy .
Literature (chronological)
- Markus Jüster: Integrative Sociotherapy . In: J. Sieper, I. Orth, W. Schuch (ed.): New ways of integrative therapy. Clinical Science, Human Therapy, Cultural Work - Polyloge. Edition Sirius, Aisthesis Verlag, Bielefeld 2007, pp. 491-528.
- Wulf Rössler, Heiner Melchinger, Sibylle Schreckling: The outpatient sociotherapy according to § 37a SGB V has failed . In: Psychiatric Practice . tape 39 , no. 03 . Thieme, April 1, 2012, ISSN 0303-4259 , p. 106-108 , doi : 10.1055 / s-0032-1304856 ( thieme-connect.com [accessed April 4, 2018]).
- Federal Chamber of Psychotherapists (Ed.): Praxis-Info Soziotherapie . Berlin November 1, 2017 ( bptk.de [PDF]).
Web links
- Sociotherapy Directive / ST-RL of the Federal Joint Committee of January 22, 2015 ( BAnz AT April 14 , 2015 B5 )
- Collection of guidelines for sociotherapy of the AOK
- Overview of the basics of sociotherapy
- Professional association of sociotherapists
Individual evidence
- ↑ Andreas Knoll: Social work in psychiatry: From care to social therapy , Springer-Verlag 2013; Excerpt .
- ↑ According to Rolf Schwendter, the terms social therapy , sociotherapy and social therapy offer a variety of terms that are not based on any objective contradictions; Schwendter: Introduction to Social Therapy , Tübingen 2000, p. 7.
- ↑ Own contribution, last updated on July 8, 2012 . National Association of Statutory Health Insurance Funds. Archived from the original on September 8, 2012. Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. Retrieved July 8, 2012.
- ↑ Draft of a law to reform the statutory health insurance from 2000 (GKV-Gesundheitsreform 2000) from June 23, 1999 (PDF; 1.1 MB) German Bundestag. Retrieved July 8, 2012.
- ↑ Sociotherapy guidelines of August 23, 2001 . Federal Joint Committee. Retrieved July 8, 2012.
- ↑ Sociotherapy guidelines of August 23, 2001 (PDF) ( page no longer available , search in web archives ) Info: The link was automatically marked as defective. Please check the link according to the instructions and then remove this notice.
- ↑ This extension can be found in the new sociotherapy guideline of January 22, 2015
- ↑ Melchinger, Heiner: Outpatient sociotherapy, evaluation and analytical evaluation of the model project “Outpatient rehabilitation of the mentally ill” of the central associations of the statutory health insurance companies. Series of publications by the Federal Ministry of Health; Vol. 115, 1999.
- ↑ The outpatient sociotherapy according to Section 37a SGB V has failed. (PDF; 70 kB) Rössler / Melchinger in Rössler, Wulf; Melchinger, Heiner; Schreckling, Sibylle in Psychiatrische Praxis 2012; 39 (03) pp. 106-108. Archived from the original on December 3, 2013. Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. Retrieved July 8, 2012.
- ↑ [ http://www.g-ba.de/downloads/17-98-2516/2008-01-17-Evaluationsbericht-Soziotherapie_korr.pdf Causes for the implementation problems in sociotherapy - evaluation report of January 17, 2008] (PDF ; 6.1 MB) Federal Joint Committee. Retrieved July 8, 2012.
- ↑ State Association of Sociotherapy Saxony-Anhalt
- ↑ Development of expenditure on sociotherapy, last change from November 9, 2009 . National Association of Statutory Health Insurance Physicians. Archived from the original on April 21, 2013. Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. Retrieved July 8, 2012.
- ^ Resolution of the 83rd Conference of Health Ministers of the Länder on July 1, 2010 . Conference of Health Ministers of the Länder. Retrieved July 8, 2012.
- ↑ The future of outpatient sociotherapy for the mentally ill. Options for action by the federal states. Presentation for the lecture on the “Future of Outpatient Sociotherapy for Mentally Ill People” conference on February 24, 2010 in Kassel (PDF; 121 kB) Köpke, Michael. Retrieved July 8, 2012.
- ^ Resolution of the 83rd Conference of Health Ministers of the Länder on July 1, 2010 . Conference of Health Ministers of the Länder. Retrieved July 8, 2012.
- ↑ Social Psychiatry - Where To? (PDF; 145 kB) Hans Joachim Salize in Psychiatric Practice 2012; 39 (05) pp. 199-201. Archived from the original on December 3, 2013. Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. Retrieved July 8, 2012.
- ↑ The outpatient sociotherapy according to Section 37a SGB V has failed. (PDF; 70 kB) Rössler, Wulf; Melchinger, Heiner; Schreckling, Sibylle in Psychiatrische Praxis 2012; 39 (03) pp. 106-108. Archived from the original on December 3, 2013. Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. Retrieved July 8, 2012.
- ↑ Godel-Ehrhardt, Petra: The wedge in the revolving door. Psychosocial Review 2005; 3/18
- ↑ The outpatient sociotherapy according to Section 37a SGB V has failed. (PDF; 70 kB) Rössler, Wulf; Melchinger, Heiner; Schreckling, Sibylle in Psychiatrische Praxis 2012; 39 (03) pp. 106-108. Archived from the original on December 3, 2013. Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. Retrieved July 8, 2012.
- ^ Hilarion G. Petzold, Peter Schay, Wolfgang Ebert: Integrative addiction therapy: theory, methods, practice, research. Publishing house for social sciences, Wiesbaden.
