Introduction
During the 1970s and 1980s, global movements toward deinstitutionalization emerged, leading to varied care models 1,2. While some countries still prioritize hospital-based services 2-4, especially in developing regions, Western nations 5 have shifted towards community-based care and recovery-oriented practices. This transition has empowered individuals with long-term mental health disorders to live independently or in supported accommodations like residential facilities (RFs) 5-7. RFs focus on rehabilitating individuals with severe mental disorders (SMD) by teaching or reteaching the skills necessary for independent community living 8-10.
In Italy, approximately 28,000 people reside in RFs, incurring significant costs to the Department of Mental Health (DMH) and taxpayers, constituting about 3.6% of all DMH patients. Italy’s density of RFs per capita, at 0.7 per 10,000 inhabitants 11, surpasses that of other high-income European countries. RFs in Italy play a crucial role in the mental health system for patients with SMD. Patients are integrated through the “progressive care pathway” or “continuum across facilities”, involving a gradual transition from RFs providing intensive support to those offering minimal support, eventually leading to private accommodations.
Italian RFs are categorized into three types based on the level of therapeutic-rehabilitative intervention and the intensity of care provided: RF1, RF2, and RF3. RF1 refers to intensive therapeutic-rehabilitative treatments with a maximum length of stay of 18 months, extendable for another 6 months. RF2 refers to extensive therapeutic-rehabilitative treatments with a maximum lenght of stay of 36 months, extendable for another 12 months. RF3 refers to socio-rehabilitative interventions with three subtypes of assistance intensity: 1. health staff during specified hours (no more than 6 hours) or as needed (at least on weekdays), 2. daily presence of health staff during the 12 daylight hours (at least on weekdays), 3. 24-hour daily presence of health staff 12-14. Ministerial guidelines 13 require RFs to meet specific standards and adopt approaches oriented towards personal recovery and empowerment. This entails promoting the quality of life and addressing the needs of individuals with SMD through collaborative socio-therapeutic-rehabilitative pathways between service users and professionals 8,15,16.
One challenge in the Italian residential system is monitoring residents’ pathway within RFs responding to Ministry of Health and regional accreditation requirements. To address this, two steps are typically taken: assessing residents’ functioning/functional autonomy 17 and correlating their level of functioning/functional autonomy with measurable and realistic goals scheduled in individualized therapeutic projects.
Evaluating the ‘functional autonomy’ of patients with mental disorders in residential settings
International literature has identified various tools for assessing the functioning of patients with mental disorders 18. Globally, there are 60 instruments that study the “functional or performance ability” of patients with mental disorders and can be used in residential settings. These tools vary in terms of age specificity, diagnosis, type of care, and investigated theme. The themes investigated may specifically or nonspecifically relate to daily activities, productive activities, relationships, recreational activities, aggressive behavior, symptoms, self-esteem, and empowerment. These tools primarily investigate functioning and/or disability, while functional autonomy is assessed only in certain categories of patients (such as the elderly with cognitive disorders). Evaluation can be conducted by professionals, while in other cases, it can be done by the users themselves. Out of these instruments, 15 are also available in the Italian language. However, internationally, there are no tools usable in the daily clinical practice by both professionals of all disciplines and patients residing in RFs that assesses the functional autonomy specifically in these settings.
Monitoring of the pathway of rehabilitation: development and psychometric properties
In 2014, mental health professionals from RFs of the Interdepartmental Mental Health Department of Verona (formerly AULSS 20) collaborated to develop the initial draft of the MPR in response to the identified need for a common assessment tool meeting Ministry of Health and regional accreditation requirements 19,20 and aligning mental health service standards with national and regional guidelines 13. These experts, overseeing rehabilitative approaches in RFs within the former AULSS 20, ensured the MPR’s relevance and practicality.
To facilitate adoption and understanding of the tool, training courses were conducted in 2015 and 2016 as part of improvement projects initiated by the former AULSS 20.
In the following years of experimentation and iterations 21, guided by an active research-participation model, the MPR evolved into its current definitive version 18. The experimentation of the MPR in Verona’s RFs facilitated a bottom-up approach with the refinement of the initial draft based on the experiences and immediate feedback from professionals, enhancing its usability in daily clinical practice.
In 2022, a formal validation study examined the psychometric properties of the MPR 18. The data revealed excellent inter-rater reliability, with all intra-class correlation coefficients exceeding 0.70 22. This indicates high agreement among professionals in assessing residents’ functional autonomy, enhancing the tool’s reproducibility. Concurrent validity was also acceptable, showing moderate to high correlations with the Personal and Social Functioning Scale (FPS) 23 when measuring similar constructs. Professionals reported high satisfaction with the MPR, indicating its ease of collaboration, and completion times below 30 minutes were deemed appropriate.
Monitoring of the pathway of rehabilitation (MPR)
The MPR is used to assess the service users’ functional autonomy in ten basic skills during their stay in the RF. These skills include self-care, care of living space, feeding, orientation/movement, other autonomies (money, cigarettes, free time), relational skills, social-recreational skills, occupational-work skills, physical health management, and mental health management.
Each skill is detailed through four items, and autonomy is evaluated on a Likert scale ranging from 0 (“not autonomous”) to 3 (“autonomous”), or NA (“not applicable” scored as 0).
The total score for each skill is calculated by summing the four items, with scores ranging from 0 to 12. These scores are then depicted in a radar diagram for ease of interpretation. Higher scores indicate greater autonomy. The sum of the total scores across all skill areas determines the service user’s overall functional autonomy stage, categorized as Poor (0-23), Moderate (24-47), Fair (48-71), Good (72-95), or Excellent (96-120).
The MPR is compiled by the RF staff (MPR-S) and users (MPR-U). After the completion of MPR-S and MPR-U, a user-professional meeting is organized to establish a treatment plan with SMART (specific, measurable, achievable, relevant, and time-bound) goals to achieve by the user with detailed interventions and outcomes’ evaluations 24.
An additional component of the MPR is the Activity and Intervention Log Form, documenting monthly and daily residential interventions. This module includes 59 interventions/activities required by Ministry of Health and regional RF accreditation and a diary to collect further important data.
In the appendixes, MPR-S, MPR-U, and intervention/activity log and operational instructions for using the tool and its attachments, are provided.
For a practical illustration of the MPR in clinical settings, refer to Martinelli et al. 2023 21.
Acknowledgements
We thank all the professionals from the residential facilities of the former ULSS20 for their suggestions, guidance, and invaluable contribution to improving the MPR and its experimentation. In particular, we thank Professor Mirella Ruggeri who, from 2015 to 2018, as Director of the Interdepartmental Department of Mental Health, encouraged the implementation of the tool and its dissemination in residential facilities and supported its validation. Finally, we thank for their fundamental collaboration in the validation work Dr. Chiara Bonetto, Dr. Doriana Cristofalo, Dr. Camilla D’Astore, and Dr. Elena Procura.
Conflict of interest statement
The authors declare no onflicts of interest.
Funding
This work was supported by the Italian Ministry of Health (Ricerca Corrente).
Authors’ contributions
TP and EDC developed the idea for this assessement tool. TP, AM and EDC revised MPR drafts. AM wrote the first draft of this manuscript. TP and EDC authors reviewed and revised the manuscript and agreed the final version.
Ethical consideration
Ethics approval and consent to participate were not deemed necessary for this study, as it primarily involved the description of an assessment tool, which did not involve direct participation of human subjects.
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