Open-door flexible hospital care

1. Introduction

Version followed: the practice of the Klinik für Psychiatrie, Psychotherapie und Psychosomatik, Kliniken Landkreis Heidenheim gGmbH (Baden-Württemberg, Germany), as its then chief physician Martin Zinkler described it in written statements to the German Bundestag and the German Ethics Council (2017), in his 2016 paper on Heidenheim (Laws 5(1):15) and in a WHO QualityRights webinar (reported 2024), plus the clinic's own publications (2023, 2025). The concept papers by Zinkler and von Peter (2019; 2021) and a 2018 overview of the § 64b model projects (Kliemt et al.) are cited for context and marked where they are proposals rather than descriptions of Heidenheim. WHO listed the clinic as a good-practice example in Hospital-based mental health services: promoting person-centred and rights-based approaches (2021); nothing below is taken from the WHO text, and the § 64b evaluation (EVA64) reports for Heidenheim are not drawn on [uncertain]. [source: Zinkler 2017 Bundestag; Zinkler 2017 Ethikrat; Zinkler 2016; Fidelis 2024; KLH 2023 flyer; KLH 2025 press release] Home-treatment team make-up and visit frequency, night-time arrangements and police handling are not published and stay marked [uncertain].

What it is. This is a service model, not a psychotherapy. It is a general-hospital psychiatric department that has the legal duty to care for its whole district (Landkreis Heidenheim, about 130,000 people), including people detained under court orders and under state mental health law. Its main features are [source: Zinkler 2017 Ethikrat; Fidelis 2024; KLH 2023; KLH 2025]:

No locked ward. All wards are open during the day, roughly 08:00 to 20:00, including for detained patients [source: Zinkler 2017 Ethikrat]. The department has worked with open doors since it opened in 1995, and voluntary and detained patients are treated on the same open wards [source: Zinkler 2016].
All staff are trained in de-escalation. The department has no seclusion rooms. It belongs to a voluntary network of hospitals that aims to reduce coercion [source: Zinkler 2016].
About 1,250–1,300 admissions a year [source: Zinkler 2016].
Since 2011, no coercive antipsychotic treatment. Before 2011 there were 2–5 coercive medications a year, up to 0.4% of inpatients [source: Zinkler 2016]. In more than 7,000 admissions there was one court-approved coercive treatment, for a life-threatening thyroid condition, not for the psychiatric illness.
Restraint (Fixierung) is kept to an immediate danger that cannot be averted any other way, mostly danger to other people.
Inpatient care, day hospital and home treatment are offered flexibly, without waiting, under a population-based regional budget (§ 64b SGB V model project, January 2017, agreed with all statutory and private insurers).
Medication is offered, not required, and kept to a minimum.

There is no single founder or treatment manual. The model is linked to Zinkler, who was chief physician for most of the 2010s and early 2020s; José-Marie Koussemou was chief physician by mid-2023 [source: KLH 2023] and still led the clinic in 2025. The clinic opened 30 years before 2025, and an earlier chief physician was Wolfram Voigtländer. [source: KLH 2025] Zinkler (2016) dates the open-door approach to the department's opening in 1995, so open doors are older than the no-coercive-medication policy (2011) and the regional budget (2017). [source: Zinkler 2016] [uncertain: exact dates of Zinkler's tenure are not published]

Core idea of change. Zinkler gives the therapeutic relationship built on trust top priority. In his account, giving up coercion makes the clinic more credible, so people come earlier and voluntarily, and the revolving door slows. Flexible settings let people keep their everyday lives during treatment. A budget that does not pay per bed-day removes the incentive to keep beds full. Zinkler (2016) reports that antipsychotic use in the department fell by more than 40% between 2009 and 2014, and puts this down to a change in therapeutic culture, not to a specific technique. Giving up coercive medication did not lead to more restraint, closed wards, more antipsychotic use or more aggression [source: Zinkler 2016; Psychiatr Prax 2014 meeting report]. Bed occupancy reportedly fell from about 95% to about 60% after 2017. [source: Zinkler 2017 Ethikrat; Fidelis 2024; Schwarz et al. 2020 for budget-model mechanisms]

The clinic's legal frame is the UN CRPD, especially General Comment No. 1 on Article 12 (equal recognition before the law, and support rather than substitution in decision-making). [source: Zinkler 2017 Bundestag]

2. Framework

The sources describe no formal phases, session counts or manualised stages. What follows is a care pathway I built from the described elements. The sequence and the transition criteria are [synthesis]. The individual elements are sourced.

Stage	Goals	Format / setting	Moving on when…
A. First contact / crisis	Agree on a setting without delay. Avoid involuntary admission where possible.	Choice of open ward, day hospital or home treatment, offered at once [source: Fidelis 2024]. If someone is detained, help them appeal. A court hearing is due within about 3 days [source: Fidelis 2024].	Person and team agree on a setting. Any detention order has been heard. [synthesis]
B. Acute care	Safety through relationship, not barriers. Negotiate treatment.	Open ward 08:00–20:00. Intensive 1:1 support for people at acute risk, from any ward professional [source: Zinkler 2017 Ethikrat; Fidelis 2024]. Meetings in an open-dialogue style [source: Fidelis 2024]. Medication offered, not required.	The person no longer needs continuous 1:1 support. A treatment agreement or plan has been negotiated. [synthesis]
C. Step-down / flexible continuation	Keep everyday life going. Keep care continuous.	Move between ward, day hospital and home treatment as needs change [source: Schwarz et al. 2020 on global-budget models; Fidelis 2024]. Home treatment in the person's home [source: KLH 2023].	Crisis resolved. The person chooses outpatient follow-up (PIA). [synthesis]
D. Aftercare and crisis prevention	Prevent future coercion. Make re-access easy.	Outpatient clinic (PIA). Joint crisis plan or advance directive. Treatment agreement (Behandlungsvereinbarung) [source: Zinkler 2017 Ethikrat; Fidelis 2024; KLH 2025].	Ongoing. The person knows how to come back voluntarily. [synthesis]

Structure [source: KLH 2025; KLH 2023]:

Three inpatient wards, a psychiatric day hospital (Tagesklinik), the hospital outpatient clinic (Psychiatrische Institutsambulanz, PIA) and home treatment.
Home treatment started in January 2017 and had treated 525 people by the end of Q1 2023.
The § 64b agreement runs for seven years and can be extended.
What the § 64b model projects have in common: one shared budget replaces the separate budgets for inpatient and day-hospital care and for the PIA. The model contracts allow home treatment. Patients do not have to enrol: everyone insured with a participating insurer is treated under the model. Heidenheim is the first of 21 model clinics in the national evaluation (EVA64) [source: Kliemt et al. 2018].
Home treatment has run since January 2017 for acutely ill people who can be treated in their home surroundings, under a § 64b SGB V model-project contract concluded in 2016 with all statutory and private health insurers, for seven years with an option to extend [source: KLH 2023]. Heidenheim's detailed home-treatment eligibility rules, visit frequency, team make-up and out-of-hours cover are not published [uncertain].

Resources. Zinkler stated in 2017 that the clinic had no special staffing or structural resources beyond those of comparable clinics. He attributed differences between clinics to staff attitudes and to how the law is read. [source: Zinkler 2017 Bundestag]

3. Guiding principles

Relationship first. A trusting therapeutic relationship has top priority. → In practice, protect the alliance before any procedure, including when the person refuses treatment. [source: Zinkler 2017 Ethikrat]
Non-coercion as the default. No coercive psychiatric medication. → Treat refusal as the start of a negotiation, not a reason to go to court. [source: Zinkler 2017 Bundestag; Ethikrat]
One narrow threshold for restraint. Only for an immediate, serious danger that cannot be averted any other way, usually to third parties. The same threshold applies to everyone. → Restraint "for the person's own good" is not used. [source: Zinkler 2017 Ethikrat]
Open doors include detained patients. → Safety comes from people (1:1 presence), not from locks. [source: Zinkler 2017 Ethikrat; Fidelis 2024]
Legal capacity and supported decision-making (CRPD Art. 12, General Comment 1). → Help the person exercise their rights: appeal detention, write advance directives or crisis plans. Do not decide for them. [source: Zinkler 2017 Bundestag; Fidelis 2024]
The person sets the agenda. In meetings the person decides what is discussed. Times and places are agreed jointly. → Start each meeting by asking what they want to talk about. [source: Fidelis 2024]
Choice of setting without delay. → Offer ward, day hospital and home treatment as real alternatives at first contact. [source: Fidelis 2024]
Medication is optional, even in acute psychosis, and kept to a minimum. → Present medication as one offer among several. Respect a refusal. [source: Fidelis 2024; KLH 2025]
Time and patience. Agreement sometimes took weeks or months. → Plan for longer negotiation instead of escalating. [source: Zinkler 2017 Ethikrat]
Involve relatives and the clinical ethics committee in hard cases. [source: Zinkler 2017 Ethikrat]
A "maternalistic" rather than "paternalistic" stance. Zinkler cites Dörner for this. → Care and stay present without taking over. [source: Zinkler 2017 Ethikrat] [uncertain: this is Zinkler's general framing, not a written clinic policy]
Credibility breaks the revolving door. If people trust that they will not be coerced, they come back voluntarily and earlier. [source: Zinkler 2017 Ethikrat]
Remove financial incentives to fill beds (regional budget). → Choose the setting by need, not by how it is paid. [source: Fidelis 2024; Schwarz et al. 2020]
Attitude matters more than extra resources. [source: Zinkler 2017 Bundestag]

Principles added in the October 2026 verification pass:

De-escalation skills for everyone, no seclusion rooms. All staff are trained in de-escalation, and the department has no seclusion rooms. → Every professional on the ward, not only a specialist team, is expected to calm a conflict. [source: Zinkler 2016]
Measure coercion openly. Heidenheim publishes yearly restraint rates and violent-incident counts, and belongs to a voluntary hospital network that aims to reduce coercion. → Keep your own figures and discuss them with the team. [source: Zinkler 2016]
Will and preferences, not best interests (concept paper, not a written Heidenheim policy). Zinkler and von Peter separate a person's longer-standing preferences from their will in the moment, and ask professionals to help the person reconcile the two. Only when neither can be found out do staff act on the best interpretation of them, together with relatives, the ethics committee or the court, never on staff's view of the person's best interests alone. → When will and preferences clash, help the person weigh them; do not decide for them. [source: Zinkler & von Peter 2019, section 3.2]

4. Intervention inventory

These are service-level and clinical procedures, not psychotherapy techniques. The sources name what is done. They rarely give step-by-step detail. Where the steps are mine, they are marked [synthesis]. All example wording is illustrative and mine; none of it is Zinkler's or the clinic's. [source for section: Zinkler 2017 Bundestag; Zinkler 2017 Ethikrat; Fidelis 2024; KLH 2023; KLH 2025]

4.1 Running an open ward during the day, including for detained patients

Purpose / when: Always. All wards are open about 08:00–20:00, and there is no closed ward [source: Zinkler 2017 Ethikrat]. Detained patients are not released, but they are cared for on the open ward [source: Fidelis 2024].
Steps [synthesis unless tagged]:
1. At admission, tell every patient that the door is open by day. Then work out together what the team does if they want to leave, or leave without saying.
2. If a patient is detained, explain plainly what the court order means, that the ward is still open, and what will happen if they leave (for example, the team will try to contact them and the order remains in force).
3. Agree a simple check-in rhythm: when they go out and come back, and who they tell.
4. Watch for people at acute risk and move them to intensive 1:1 support (4.2) rather than locking the door [source: Zinkler 2017 Ethikrat].
5. Doors close at night (about 20:00–08:00) [source: Zinkler 2017 Ethikrat]. How night-time is handled is not described. [uncertain]
Example language (illustrative): "This door stays open during the day, for you too. We'd rather keep you safe by being with you than by locking you in. If you feel you have to leave, will you tell one of us first, so we can talk about it?"
Watch for / working: absconding, missed returns, and staff wanting to lock up after an incident. It is working if detained patients stay on the ward or come back, and conflicts at the door are rare. In a Berlin acute ward, opening the doors about 90% of the day went with less aggression and less coercive medication, and absconding did not rise significantly [source: Cibis et al. 2017; retrospective, not Heidenheim].

4.2 Intensive one-to-one support in acute crisis

Purpose / when: For people at acute risk of harming themselves, or in severe crisis. This replaces locking the door or restraining [source: Zinkler 2017 Ethikrat]. In acute crises any ward professional provides individual support, not only nurses [source: Fidelis 2024].
Steps [synthesis]:
1. Name one person to stay with the patient. Swap in a colleague at agreed times so the person is never left alone.
2. Stay physically close but not crowding. Lower stimulation (a quieter room, fewer people).
3. Listen and validate. Do not argue about beliefs. Offer practical comfort: drink, food, somewhere to walk.
4. Re-check suicide risk regularly, using current standard practice: thoughts, intent, plans, protective factors. Record it.
5. Do lethal-means counselling with the person and relatives: agree to remove or securely store dangerous items at home before leave or discharge. Do not discuss method details.
6. Step down to normal observation when the person and team agree the acute danger has passed.
Example language (illustrative): "I'm going to stay with you for now. You don't have to talk, but I'm here if you want to. What would help in the next hour?"
Watch for / working: staff fatigue, and 1:1 that turns into guarding. It is working if the person calms, starts talking, and can plan the next hours.

4.3 Negotiating consensual treatment instead of coercive medication

Purpose / when: When someone refuses treatment, including people in acute psychosis or who are detained. The clinic has used no coercive antipsychotic treatment since 2011 [source: Zinkler 2017 Bundestag; Ethikrat]. Heidenheim did not bring coercive antipsychotic medication back when the 2013 federal law allowed it again. That law permits coercive treatment only if the person lacks capacity, serious attempts to reach consent have failed, the treatment averts serious harm, nothing less restrictive will do, and the benefit clearly outweighs the harm. It also requires a second opinion and a route of appeal [source: Zinkler 2016]. Agreement sometimes took weeks or months, through conversations, explanation, talks with relatives and the clinical ethics committee [source: Zinkler 2017 Ethikrat]. Zinkler notes one limit: detention itself was not abolished, so detained patients may still feel they must accept medical advice in order to be discharged [source: Zinkler 2016].
Steps [synthesis built on the sourced elements]:
1. Accept the refusal for now. Say clearly that no one will be medicated by force.
2. Find out why they refuse: past side effects, past coercion, beliefs about the illness, fears.
3. Offer alternatives and smaller steps: a lower dose, a different drug, medication only at night or as needed, no medication but a structured day, sleep help, or psychotherapy contacts.
4. Involve relatives if the patient agrees (4.13).
5. Come back to the topic regularly without pressure. Write down what was offered and what was agreed.
6. If the situation is stuck and there is a real risk to health, ask the clinical ethics committee (4.14).
Example language (illustrative): "You've told us you don't want this medication, and nobody will force you. Can you tell me what happened with it before? Maybe we can find something that fits you better, or something to try instead."
Watch for / working: physical deterioration (food, fluids, sleep, untreated physical illness). The only court-approved coercive treatment since 2011 was for a life-threatening physical condition, not the psychiatric illness [source: Zinkler 2017 Bundestag]. It is working if the person accepts some offers, trust grows, and they come back voluntarily.

4.4 Offering medication as an option, at minimum dose

Purpose / when: Always. Medication is optional, not mandatory, even in acute psychosis [source: Fidelis 2024]. The clinic aims to keep psychotropic use to a minimum [source: KLH 2025].
Steps [synthesis]:
1. Explain the expected benefits, side effects and alternatives in plain language.
2. Ask what the person wants and what they have experienced before.
3. Agree a trial with a clear review date and agreed stopping criteria.
4. Review regularly, and taper when it is no longer needed. No dosing guidance is given here.
Example language (illustrative): "Medication is one option among several. Let's look at what it could do for you, what the downsides are, and what else we can try."
Watch for: side effects, and pressure from staff or relatives that undermines real choice.

4.5 Restraint only as a last resort, under one narrow threshold

Purpose / when: Only for an immediate, serious danger that cannot be averted any other way, usually to third parties. The same threshold applies to all patients. Restraint for the person's own welfare is described as practically no longer needed. 3–5% of patients were restrained or secluded [source: Zinkler 2017 Ethikrat; 2017 data]. Mechanical restraint is the measure for which yearly figures exist: 3.2% of inpatients in 2009, 3.1% (2010), 4.5% (2011), 5.2% (2012), 5.4% (2013), 4.8% (2014) and 2.9% (2015). There are no seclusion rooms [source: Zinkler 2016]. The rise in 2011–2013 is not discussed in the paper.
Steps [synthesis following general German practice and good-practice standards, not a Heidenheim protocol]:
1. De-escalate first: talk, give space, reduce the audience, offer choices.
2. If the threshold is met, use the least restrictive measure for the shortest possible time, with continuous 1:1 presence.
3. Follow German legal requirements: the Federal Constitutional Court ruled on 24 July 2018 (2 BvR 309/15, 2 BvR 502/16) that a 5-point or 7-point restraint lasting more than a short period (about 30 minutes) is a separate deprivation of liberty that needs its own judicial approval [source: LTO 2019]. Document everything. Check the current federal and state (PsychKHG) provisions that implement the ruling [uncertain: their current wording is not cited here].
4. End it as soon as the danger has passed.
5. Debrief with the patient and with staff afterwards. Add what was learned to the crisis plan (4.7).
Example language (illustrative): "We're stopping this now. As soon as it's safe, it ends, and someone is with you the whole time. Afterwards I want to hear how this was for you."
Watch for: creeping use "for the person's own good", and restraint on the open ward becoming routine. It is working if restraint is rare, short, and always debriefed. Heidenheim tracks the yearly share of inpatients restrained and the number of violent incidents (4.16) [source: Zinkler 2016].

4.6 Supporting detained patients to exercise their rights

Purpose / when: For anyone held under a court or state mental-health-law order. Staff do not release them, but help them appeal. A court hearing is due within about three days [source: Fidelis 2024]. This puts the CRPD principle of legal capacity into practice [source: Zinkler 2017 Bundestag].
Steps [synthesis]:
1. Explain the order, the right to appeal, and the deadlines.
2. Help contact a lawyer or procedural guardian (Verfahrenspfleger), the court, and trusted people.
3. Help write the appeal, or arrange help to write it.
4. Prepare the person for the hearing. Keep the treatment relationship separate from the dispute about the detention.
Example language (illustrative): "You disagree with this order, and you have the right to challenge it. I'll help you do that. Whatever the court decides, we keep working together."
Watch for: staff seeing an appeal as a personal attack. It is working if the person feels taken seriously and the relationship survives the hearing.

4.7 Joint crisis plans and advance directives

Purpose / when: During and after a stay, to guide future crises and prevent coercion. Staff help draft advance directives, or preferably joint crisis plans [source: Fidelis 2024].
Steps [synthesis]:
1. Once the person is stable, offer time to work on a plan with a trusted person present if they wish.
2. Record together: early warning signs, what helps, what harms, preferred setting (ward, day hospital or home treatment), medication preferences and refusals, people to contact, practical matters (children, pets, work).
3. Sign and date it. With consent, give copies to the PIA, the ward, and trusted people.
4. Review it after every crisis.
Example language (illustrative): "Let's write down what you want us to do if things get difficult again, so we follow your wishes even when it's hard for you to tell us."
Watch for: plans written by staff "for" the person. It is working if the plan is actually used in the next crisis and the person recognises it as theirs.

4.8 Treatment agreements (Behandlungsvereinbarung)

Purpose / when: For people with repeated admissions. Zinkler reports that treatment agreements helped break the revolving door: some patients now come in voluntarily when things get hard, expecting to be treated without coercion [source: Zinkler 2017 Ethikrat].
Steps [synthesis]:
1. Negotiate a written agreement between the person and the clinic: how admission works, which setting, what the clinic will and will not do (for example, no coercive medication), and what the person agrees to (for example, early contact).
2. Make the agreement easy to find in the hospital record.
3. Honour it at the next contact. Review it afterwards.
Example language (illustrative): "If you notice the signs coming back, call us early. We've written down that you can come in and that we'll stick to what we agreed here."
Watch for / working: It is working if the next contact is earlier, voluntary, and follows the agreement.

4.9 Dialogue meetings in which the person sets the agenda

Purpose / when: Throughout care. In Zinkler's description (reported as "open dialogue"), the person decides what is discussed, and the times and places of future meetings are agreed together [source: Fidelis 2024]. [uncertain: how fully Heidenheim follows the Finnish Open Dialogue model, for example network meetings and two therapists in each meeting, is not published]. In their concept paper (not a description of Heidenheim), Zinkler and von Peter recommend opening with an open question about what the person needs, instead of with treatment demands, and giving explanation, extra time and communication aids [source: Zinkler & von Peter 2019, section 3.2].
Steps [synthesis]:
1. Open the meeting by asking what the person wants to talk about.
2. Invite the people they want present.
3. Reflect and summarise without imposing an agenda. Treatment decisions are discussed openly in front of the person.
4. End by agreeing together when and where (ward, day hospital, home) to meet next.
Example language (illustrative): "What would you like us to talk about today? … When and where would suit you for our next meeting?"
Watch for / working: staff steering back to their own agenda. It is working if the person brings their own topics and turns up to the agreed meetings.

4.10 Offering a choice of setting without delay

Purpose / when: At first contact in an acute crisis. Day hospital and home treatment are offered without waiting, so the person can choose among three settings. This can avoid an involuntary admission [source: Fidelis 2024].
Steps [synthesis]:
1. Assess urgency, risk, home situation and supports.
2. Describe the three options concretely: open ward, day hospital (daytime programme, nights at home) and home treatment (the team visits).
3. Ask which the person prefers. Discuss safety needs openly.
4. Agree the setting and a review point.
Example language (illustrative): "You could stay with us on the ward, come to the day clinic and sleep at home, or we can come to you. Which would help you most right now?"
Watch for: defaulting to the ward out of staff habit. It is working if the setting matches the person's wishes and coercion is not needed.

4.11 Home treatment

Purpose / when: Acute treatment in the person's own home, since January 2017, under the § 64b model project [source: KLH 2023]. 525 people were treated by Q1 2023 [source: KLH 2023]. The § 64b contracts allow home treatment within the shared budget, without enrolment [source: Kliemt et al. 2018]. In their concept paper Zinkler and von Peter argue that support should be available wherever the person wants it (home, crisis centre, a friend's home), including 24-hour help at home, and that money now spent on coercive inpatient care should move to outreach [source: Zinkler & von Peter 2019, section 4]. This is a proposal, not a description of Heidenheim's service.
Steps [synthesis; Heidenheim's eligibility criteria, visit frequency and team make-up are not published] [uncertain]:
1. Check the home is safe and the person consents. Ask about the people they live with.
2. Agree visit times and a contact route for crises.
3. Make multiprofessional visits: assessment, conversations, medication offers, practical support.
4. Move to the day hospital or ward if needs rise, and back again when possible (4.12).
Example language (illustrative): "We'll visit you at home. Let's agree when suits you and how you can reach us in between."
Watch for: burden on relatives (an earlier evaluation of German § 64b models found relatives more ambivalent than patients, and nursing staff reporting more strain [source: Kliemt et al. 2018, on EvaMod64b]), safety in the home, and loneliness between visits. It is working if the person keeps their everyday life going and the crisis eases.

4.12 Moving between settings within one treatment episode

Purpose / when: As needs change during treatment. Global or regional budget models let services combine inpatient, day-hospital and outpatient units. Flexibility, continuity of care and keeping everyday life going were found to be core mechanisms of change in such models [source: Schwarz et al. 2020, process evaluation of German global-budget models; Heidenheim is not named there]. Heidenheim's regional budget runs from 2017 [source: Fidelis 2024; KLH 2023].
Steps [synthesis]:
1. Review the setting at every key meeting.
2. Step down (ward → day hospital → home treatment → outpatient clinic) or step up without new referral hurdles.
3. Keep the same key staff, where possible, across settings.
Example language (illustrative): "You're sleeping better now. Would you like to try coming in just for the day, or should we visit you at home instead?"
Watch for: breaks in continuity at handovers. It is working if moves happen smoothly and the person keeps the same contacts.

4.13 Involving relatives

Purpose / when: In negotiations about treatment, and in crises, with the person's consent [source: Zinkler 2017 Ethikrat].
Steps [synthesis]:
1. Ask the person whom they want involved.
2. Hold joint conversations. Explain the clinic's no-coercion approach, which may surprise relatives who expect it.
3. Hear the relatives' worries and burden. Include them in crisis plans.
Example language (illustrative): "We don't treat people against their will here. We'd like to work out with both of you what will help."
Watch for: relatives pushing for coercion. It is working if they become allies in the plan.

4.14 Clinical ethics committee consultation

Purpose / when: For stuck cases where refusal may endanger health [source: Zinkler 2017 Ethikrat].
Steps [synthesis]:
1. Present the case with the patient's views fully represented.
2. Look at all non-coercive options.
3. Document the advice. Keep coercion strictly for life-threatening situations that meet the legal requirements (compare the single thyroid case) [source: Zinkler 2017 Bundestag].
Watch for: the committee being used to justify coercion rather than to find alternatives.

4.15 Adapting open doors in another service

This is for clinicians who want to bring the model elsewhere. [synthesis]

Context: Heidenheim and Herne are named as prominent open-door models [source: Schreiber et al. 2024]. In that study, two other German acute wards (Friedrichshafen, Tübingen) kept their doors open for up to 80% of opening hours [source: Schreiber et al. 2024].
Steps [synthesis]:
1. Secure leadership commitment and agree in writing on the narrow restraint threshold (4.5).
2. Build staff capacity for 1:1 crisis support and de-escalation.
3. Start with daytime opening. Keep a log of door status, absconding, aggression and coercion.
4. Introduce crisis plans and treatment agreements.
5. Develop day-hospital and home-treatment alternatives, and, where possible, a budget model that does not pay per bed-day.
6. Review the data monthly with the team.
Watch for: relapse into locking after one serious incident. Respond with a case review, not a policy reversal.

4.16 De-escalation training and coercion monitoring

Purpose / when: Always, as the staff-level basis of the open-door, low-coercion model. All Heidenheim staff are trained in de-escalation, there are no seclusion rooms, and the department records each year the share of inpatients put in mechanical restraint and the number of violent incidents. It belongs to a voluntary hospital network that aims to reduce coercion [source: Zinkler 2016]. The content of the training is not described. [uncertain]
Steps [synthesis unless tagged]:
1. Train every professional group in de-escalation, including doctors, psychologists and therapists, not only nurses.
2. Use one clear definition of a violent incident. Heidenheim counts disruptive behaviour that leads to painful or harmful physical contact (for example kicking, hitting, hair-pulling), not threats alone [source: Zinkler 2016].
3. Record every restraint, coercive medication and violent incident. Work out yearly rates as a share of inpatients [source: Zinkler 2016 for the measures].
4. Review the figures with the team. Look into any rise; Zinkler's own figures show a temporary rise in restraint in 2011–2013 [source: Zinkler 2016].
5. Join or set up a network with other hospitals to compare figures and share approaches [source: Zinkler 2016 for the network].
Example language (illustrative): "Last year we restrained fewer people than the year before. Let's look at the three incidents we had and ask what might have prevented each one."
Watch for / working: figures used to blame individual staff, and under-reporting. It is working if coercion stays low or falls while violent incidents do not rise, as Zinkler reports for Heidenheim after coercive medication ended [source: Zinkler 2016; Psychiatr Prax 2014 meeting report].

5. Handling problems

The sources give only a little problem-handling guidance: give it time, involve relatives, consult the ethics committee, provide 1:1 support, and restrain only above the narrow threshold [source: Zinkler 2017 Ethikrat]. Everything else here is [synthesis].

Persistent refusal of all treatment ("stuck"). Sourced: keep negotiating, sometimes for weeks or months, with relatives and the ethics committee [source: Zinkler 2017 Ethikrat]. [synthesis] Lower the bar: offer sleep, food, a quiet room, practical help, or simply time with staff. Agree to meet again rather than to accept treatment. Check physical health regularly. If a life-threatening physical condition arises, follow legal procedure, as in the one thyroid case [source: Zinkler 2017 Bundestag].
A detained patient leaves the open ward. [synthesis] Have a plan agreed in advance (4.1): phone the person and their contacts, and invite them back without blame. Follow local legal duties to inform the court or authorities. Afterwards, review what made them leave and add it to the crisis plan. Do not respond by locking the ward.
Acute suicide risk on an open ward. Sourced: intensive 1:1 support [source: Zinkler 2017 Ethikrat]. [synthesis] Use structured, current risk assessment. In their concept paper Zinkler and von Peter discuss a person who says, for the first time, that they want to end their life: a short court-ordered stay of a few hours, while the person's will and preferences are clarified with family or friends, and information about community options including 24-hour help at home [source: Zinkler & von Peter 2019, section 3.2; a proposal, not Heidenheim practice]. Do safety planning and lethal-means counselling with relatives (removing or securely storing means at home; no method detail). Reassess often. Write any need for a temporarily higher level of support into the crisis plan.
Aggression toward others. Sourced: restraint only for an immediate, serious danger that cannot be averted otherwise [source: Zinkler 2017 Ethikrat]. [synthesis] De-escalate first, protect other patients, debrief afterwards. Sourced context: all Heidenheim staff are trained in de-escalation, there are no seclusion rooms, and recorded violent incidents (painful or harmful physical contact, not threats) were 14–49 a year in 2009–2015, with no rise after coercive medication ended [source: Zinkler 2016]. Heidenheim's own police and criminal-law handling is not published, and the clinic does no forensic psychiatry [source: Zinkler 2017 Ethikrat]. [uncertain] In their concept paper (a proposal, not Heidenheim practice) Zinkler and von Peter argue that police should detain someone only on the general criteria that apply to everyone, should ask whether the person wants a psychiatric consultation, and that services should be reachable around the clock to counsel people in custody [source: Zinkler & von Peter 2019, sections 3.1 and 3.3]. The same authors later wrote that they had themselves used coercion when they could find no other solution to a conflict [source: von Peter & Zinkler 2021, section 4].
Staff fear and pressure to close the doors. [synthesis] Hold team debriefs after incidents. Train staff in de-escalation and 1:1 presence. Share outcome data (in Heidenheim, 3–5% restraint and one court-approved coercive medication since 2011 [source: Zinkler 2017 Ethikrat]). Make leadership commitment visible. An earlier evaluation of German § 64b models found that nursing staff reported more strain under the new model [source: Kliemt et al. 2018, on EvaMod64b], so plan staff support from the start. Zinkler stresses that attitude matters more than extra resources [source: Zinkler 2017 Bundestag].
Relatives, guardians, courts or referrers expect coercion. [synthesis] Explain the approach and its legal basis (CRPD Art. 12 [source: Zinkler 2017 Bundestag]). Offer joint meetings. Write down which alternatives were offered.
Rupture after restraint or a detention order. [synthesis] Repair openly: acknowledge what happened, ask the person how it was for them, apologise for distress where right, help with the appeal (4.6), and update the crisis plan.
Non-attendance in home treatment or day hospital. [synthesis] Phone and visit, and agree new times and places together (4.9). Change the setting if the current one does not fit.
Overwhelm (too many people, too much talking). [synthesis] Reduce the number of people in meetings. Let the person set the topics and the length. Use a quieter setting or treatment at home.
Burden on relatives in home treatment. [synthesis] Check carer strain at every visit. Offer to move to the day hospital or ward, and give the family their own crisis contact.
Revolving-door patterns. Sourced: treatment agreements [source: Zinkler 2017 Ethikrat]. [synthesis] Review each readmission against the agreement and crisis plan, and adjust them.
Night-time (doors closed about 20:00–08:00). How Heidenheim handles nights is not published (Zinkler 2016 says only that there are no locked wards). [uncertain] [synthesis] Explain at admission what happens at night and how someone can leave at night if they are not detained.
Peer support. Zinkler calls peer workers a promising approach in general. Published sources do not show that they are an established role at Heidenheim [source: Zinkler 2017 Bundestag] [uncertain]. In their concept paper Zinkler and von Peter propose staff with lived experience as crisis workers and advocates [source: Zinkler & von Peter 2019]. They also cite a user-led review of every seclusion incident in Canberra, after which seclusion fell sharply [source: von Peter & Zinkler 2021, section 3.2]. [synthesis] Consider adding peer workers, and peer review of coercive incidents, when adapting the model.

Sources

Sources used:

Cited by title only [uncertain]:

Zinkler M (2021). Modellvorhaben nach § 64b SGB V in der Corona-Pandemie. Recht & Psychiatrie 2/2021 (publisher listing).
EVA64 interim report (2022) and final report (2023) for the Heidenheim model project, Universitätsklinikum Dresden; content not used here.

← Previous · V-170Basal Exposure Therapy Next · V-172 →CAPS psychosocial care centres (Brazil)