An intervention program for highly complex cases

The members of the two GUIA Teams meet to coordinate and assess new cases. To carry out the interventions, the GUIA Team members divide into two groups to attend to between 20 and 30 cases of people residing in the towns of the metropolitan area south of Barcelona, as well as the towns of the Vallès Oriental region.

The cases that come to this unit are people with severe mental illness, who have a long history of using mental health services and who, in some way, have exhausted the available resources. In this unit, creativity and the ability to adapt solutions for these individuals are the main strengths: thinking outside the box to adapt existing resources to different realities.

Since these are extremely complex cases, it is sometimes necessary to discuss the possibilities of care in interdepartmental working committees, which meet regularly, and which involve different departments of the Generalitat of Catalonia: Health, Labor, social services and families, Education and Justice.

The goal is to provide intensive care to these individuals, optimizing existing resources and reconnecting them to the monitoring teams in their territory and community.

As part of the follow-up with those receiving services, video calls are sometimes made to assess their situation. In these calls, the person receiving services can explain how they are feeling, if they are experiencing difficulties, and the team can determine through the interview if there is anything that requires an in-person visit or intervention.

The family's role in recovery is key, which is why we work very closely with the family unit, establishing a close and trusting relationship so that the family can share concerns and doubts and help in the stabilization and recovery process of the young person receiving care. The shared goal is for the person receiving care to be as functional as possible and able to develop a life plan. In this regard, we strive to offer guidance, health education, and emotional support during this difficult process.

The team, however, adapts its intervention to each family's situation, which can vary greatly and be more or less collaborative. Working within the family and social environment of the person receiving care provides invaluable information, enabling the team to better guide its intervention in the short and medium term.

We visited the Sant Joan de Déu Residence, where one of the young people receiving care from this unit lives. These visits, which also include leisurely walks around the grounds, create a relaxed and trusting environment where we can build or strengthen the bonds between the residents and the team.