Utilization of psychiatric inpatient care. A study of changes related to the introduction of a sectorized care organization

Utilization of inpatient care in a catchment area was studied by means of a 4-year comparison before and after a sectorization of the care organization. There was almost no reduction in the number of patients hospitalized, but the number of admissions was reduced by 20% and the total number of days in hospital by 40%. An initial rise in the hospitalization of nonpsychotic patients was found in the new organization, probably because of the increased accessibility and availability of psychiatric care in the catchment area. The rate of hospitalization decreased for schizophrenic patients and remained unchanged for other psychotic patients. There was a significant reduction in rates of readmission, and mean length of stay in hospital was reduced for all groups of patients except patients with a diagnosis of neurosis or personality disorder. A reduction in rates of compulsory care, primarily for patients with alcohol diagnosis, was found. The sectorized care organization has fulfilled the objective of reducing inpatient care. However, great attention must be paid to evaluating new patient categories reached by the development of outpatient facilities, especially in areas where accessibility to and availability of the care organization were formerly low.     

The phenomenology of psychiatric hospitalization: the patient's experience and expectations

Patients admitted to a psychiatric hospital are confronted by complex and, at times, conflicting models and theories about the cause and treatment of their illness. The patient's understanding and experience of this process are analyzed in this phenomenological study. The need for patients' increased understanding of the purpose and functions of hospitalization is underlined as well as the possible discrepancy between the patients' and the hospital's perspectives on treatment objectives.     

The prevalence of people with intellectual disability admitted to general hospital psychiatric units: level of handicap, psychiatric diagnoses and care utilization

Previous studies have stated that people with intellectual disability (ID) are more often afflicted by psychiatric disorders than the general population. In spite of the high prevalence of psychiatric disorders among people with ID, it is not known how many actually receive psychiatric in-patient care and treatment by the mental health services. In the present study, the number of people with mild and severe ID admitted to in-patient psychiatric care were compared with corresponding figures in the general population in Sweden. The results show a low frequency of psychiatric care utilization among people with ID and coexisting psychiatric disorders in comparison to the proportion of psychiatric care utilization among people with psychiatric disorders in the general population. The results are discussed in terms of how the level of ID might influence referral or diagnoses, the length of admissions, and the support provided within the special services to people with ID and psychiatric disorders.     

Transparent criteria for specialist level adolescent psychiatric care

Background Rising health care costs and long waiting lists pose a challenge to public specialist level health services. In Finland, the Ministry of Social Affairs and Health required all medical specialities to create a priority-rating tool for elective patients, preferably giving a numerical rating ranging 0–100, with 50 as an entry threshold. Objective To create and test the psychometric properties of a point-count measure for prioritising entry to public specialist level adolescent psychiatric services. Method Around 710 referred adolescents were given ratings on 17 items focusing on symptom severity, problem behaviours, functioning, progress of adolescent development and prognosis. The structured ratings were compared to an overall assessment of need for treatment on a VAS scale. In order to ensure that the tool was not inappropriately sensitive to confounding by non-disturbance related factors, the associations between the structured priority rating and sex, age, referring agent, study site and diagnosis were analysed. Results Of the 17 items, 15 were included in the final priority-rating tool. The requirement than threshold score for entry to services being set at 50 points necessitated scoring factors rather than individual items. Four blocks of items were formed: symptoms and risks; impaired functioning; other relevant issues, and prognosis without specialist level treatment. Most of the referred adolescents scored over the threshold of 50. When diagnosis was controlled for, scoring over 50 was largely independent of age, sex, referring agent or study site. Conclusion The structured priority ratings corresponded well with clinical global rating of need for care. The tool was not inappropriately sensitive to age, sex, referring agent or study site. In the future, follow-up studies will be needed to evaluate the predictive value of priority ratings.     

Ward atmosphere in acute psychiatric in-patient care: patients' perceptions, ideals and satisfaction

OBJECTIVE: To investigate the relationship between patients' perception of the real and ideal ward atmosphere and their satisfaction. METHOD: Patients filled in the Ward Atmosphere Scale (WAS, Real and Ideal Form) and a satisfaction questionnaire. Patient characteristics were derived from clinical assessments. RESULTS: WAS ratings were almost independent of patient characteristics. Patients in locked wards perceived more anger and aggression and patients subjected to coercive measures perceived less autonomy and practical orientation. Patient satisfaction was predicted by higher scores on the WAS Relationship- and System Maintenance dimensions, explaining 41% of the variance. In particular support, order and organization predicted satisfaction. Except from the areas of anger/aggression and staff control, patients gave the 'ideal' ward higher ratings on all subscales. The perceived gap between the 'ideal' and 'real' ward explained 45% of variance in satisfaction. CONCLUSION: Patients' perception of ward atmosphere is a clinically meaningful measure appearing to be a strong predictor of satisfaction.     

Inpatient care and its outcome in a specialist psychiatric unit for people with intellectual disability: a prospective study

The outcome of treatment in care units has been thought to reflect the effectiveness of treatment. There have been only a few studies describing inpatient care and its outcome in patients with intellectual disability and psychiatric symptoms. The present study describes the psychiatric inpatient treatment in the specialist psychiatric unit of the Special Welfare District of South-west Finland and the need for aftercare among people with intellectual disability and psychiatric disorders (n = 40). As an outcome measure of care, the level of psychiatric symptoms was evaluated either with the Brief Psychiatric Rating Scale (BPRS) or with the Diagnostic Assessment for the Severely Handicapped (DASH) scale; self-reports (visual analogue scale) were also used. Patients’ psychotic symptoms were reduced significantly on the BPRS during inpatient care and aftercare, but non-psychotic symptoms were reduced significantly only during aftercare. For one patient, the psychiatric symptoms were reduced significantly during inpatient care on the DASH scale, while the psychiatric symptoms remained the same for three patients. Patients and their primary carers considered the patient’s psychiatric condition to have improved significantly during inpatient care, but not during aftercare. The specialist unit filled the gap in the care of people with intellectual disability and psychiatric problems in Southwest Finland. It is concluded that psychotic patients particularly benefit from the inpatient care in the specialist psychiatric unit. The care in the unit should include support for primary carers. All patients’ outpatient treatment should also be re-evaluated. The present study poses two important questions. Firstly, could these treatment outcomes have been achieved with other interventions? Secondly, what are the necessary services for people with intellectual disability?     

Clinical outcomes of a specialised inpatient unit for adults with mild to severe intellectual disability and mental illness

Background   Limitations of general psychiatric services have led to the development of specialised psychiatric programmes for patients with intellectual disability (ID) and mental health needs. Few studies have examined treatment outcomes of specialised inpatient units, and no studies have explored how the effects of intervention may differ for individuals at varying levels of cognitive ability. The present study examined clinical outcomes of inpatients with mild ID in contrast to inpatients with moderate to severe ID within the same service.
Method   Thirty-three patients (17 with mild ID and 16 with moderate to severe ID) discharged between 2006 and 2008 from a specialised inpatient unit in Canada for adults with ID and mental illness were studied. In addition to examining change in scores on clinical measures, outcomes with regard to length of stay, diagnostic change, residential change and re-admission to hospital were explored.
Results   Both groups demonstrated clinical improvement from admission to discharge. However, only patients with mild ID demonstrated improvements on the Global Assessment of Functioning.
Conclusions   This study is one of the first to consider outcomes of higher and lower functioning individuals with ID on a specialised inpatient unit. Results suggest that outcomes may be different for these groups, and some clinical measures may be more sensitive to changes in patients with more severe disabilities.     

Cost variation in child and adolescent psychiatric inpatient treatment

Publicly available costs data for child and adolescent psychiatric inpatient services do not allow links to be made with patients’ needs and outcomes. Without this information commissioners may reduce the role of inpatient services on the basis of budgetary impacts alone. This study estimates the support costs before, during and after an inpatient admission and explores the associations between costs, needs and outcomes. A detailed prospective cohort study of eight child and adolescent units was undertaken in which participants were assessed at referral, admission, decision to discharge and 1 year later. Mean admission costs were ￡24,120, although the range was wide. Associations were found between costs and patients’ global impairment, age and exclusion status. Support costs after admission were similar to pre-admission costs, but there was some evidence to suggest that services were better targeted. Moves in England to develop national tariffs for inpatient psychiatric episodes should be based on the likely cost of the episode of treatment rather than costs per day, and good commissioning requires more information on the predictors of such costs.     

Cause-specific mortality after discharge from inpatient psychiatric care in Taiwan: A national matched cohort study

Aims

We aimed to investigate the trajectories of absolute and relative risks of cause-specific mortality among patients discharged from inpatient psychiatric services.

Methods

We conducted a national matched cohort study (2002–2013) using data from the Taiwan National Health Insurance database linked to national cause-of-death data files. Patients discharged from inpatient psychiatric care without prior psychiatric hospitalizations were individually matched to 20 comparison individuals based on sex and age. The rates, rate differences, and relative risks (hazard ratios, HRs) of cause-specific mortality were calculated at six follow-up periods post-discharge. Cumulative mortality incidence was assessed at 5 years of follow-up.

Results

The mortality risks of all causes were increased among patients (n = 158 065) relative to comparison individuals (n = 3 161 300). Mortality rate differences were greater for natural causes, while relative risks (HRs) were higher for unnatural causes. Suicide was the leading cause of death within the first year of discharge, while circulatory and respiratory diseases were the leading causes of death from the second year. The mortality rates and HRs for all causes of death (except homicide) were highest during the first 3 months. The elevated risk of unnatural-cause mortality declined rapidly after discharge but remained high in the long term; in contrast, risk elevation for natural-cause mortality was more stable over time. Approximately one-eighth of patients (12.9%, 95% confidence interval 12.7–13.7%) died within 5 years of follow-up.

Conclusions

Integrated physical and mental health care is needed to reduce excess mortality, particularly during the first 3 months post-discharge, among psychiatric patients.     

Persons with intellectual disability receiving psychiatric treatment

Determinants of (1) referral to psychiatric services and (2) the amount of mental health care consumed were analysed in a population of individuals with intellectual disability, using data from a cumulative mental health case register in a defined geographical area. Associations between level of disability, gender, age and social environment on the one hand, and psychiatric referral and service consumption on the other were expressed as odds ratios (ORs). Being older (OR = 1.9; 95% Cl = 1.5–2.5), having milder intellectual disability (OR= 1.4; 95% Cl = 0.9–2.3) and living alone (OR = 5.8; 95% Cl = 2.8–1 1.9) predicted a higher probability of receiving psychiatric treatment. Living alone (OR = 15.3; 95% Cl = 1.7–136.1) was also associated with higher level of mental health service consumption.     

Attitudes of health care professionals towards care of the elderly

The effect of a short psychogeriatrics training course for primary health care physicians, nurses and social workers on their attitudes towards care of the elderly was explored using the Snape Attitude Scale before and after the training. Participants' attitudes were not altered significantly. The most positive attitudes were found in a reference group formed by nurses specializing in psychiatry. The groups regarded physicians as having the least interest in geriatric care while social workers were felt to have the greatest willingness to care for the elderly.     

Development and application of a brief multi-faceted tool for evaluating inpatient psychiatric care

Increasingly, hospitals are expected to monitor and document service delivery variables, such as treatment outcome and patient satisfaction with care, which are thought to be associated with the quality of care received by patients. Documenting the patient's collaboration in the treatment-planning process also has become more important. However, for many clinically oriented units, translating these expectations into a useable instrument and an efficient measurement procedure is a complex and difficult task. This paper outlines the development of a brief multi-faceted program evaluation instrument and assessment process for completing these tasks. The authors describe the rationale behind their approach to these measurement issues, and they introduce an instrument capable of effectively measuring both outcome and satisfaction. They also provide an overview of how they apply the instrument in their inpatient psychiatry service. The strengths and weakness of this assessment strategy are reviewed.     

Relations between patients in psychiatric and psychotherapeutic inpatient care: A literature review and conclusions for clinical practice and research

Objective. In psychiatric inpatient units patients live closely together, which facilitates mutual interactions. Patient relations are part of the therapeutic milieu, which is an important factor in helping patients to recover. Types of patient relations are nonbinding superficial encounters, working alliances, personal relations like close partner relationships, or sexual contacts. Intimate relations between patients are scientifically and in clinical practice, a rather, neglected topic. Methods. A data search was conducted using the PubMed/MEDLINE databases with the key terms “patient relations” or “intimate relations between patients”. Results. Depending on the type of relation and inpatient unit, prevalence rates of 1.5–30% for intimate relations between patients in psychiatric hospitals are reported. Such relations can have beneficial effects, like the feelings of bonding or being liked, but also negative consequences, like burdening, worsening of the illness, treatment complications, or direct harm to the patient. Conclusion. Only a few units have development guidelines. It is the responsibility of the therapeutic staff and the hospital management to support a helpful therapeutic milieu, including positive patient interactions, and to protect as far as it is possible patients from negative encounters.     

Mental health care in Germany

Germany turned towards community-based mental health care in the mid seventies, during a general climate of social and political reform. The continuing deinstitutionalisation process and the implementation of community mental health services was considerably affected by the reunification of East and West Germany in 1990, which required dramatic changes in the structure and quality of the mental health care system of the former German Democratic Republic (GDR). Overall, German mental health care is organised as a subsidiary system, where planning and regulating mental health care is the responsibility of the 16 federal states. So German mental health care provision is spread among many sectors and characterised by considerable regional differences. A key characteristic is the particularly wide gap between inpatient and outpatient services, which are funded separately and staffed by different teams. In 2003 the total number of psychiatric beds was a mere two thirds of the overall bed capacity in 1991, the first year as a re-unified Germany, when psychiatric beds in East and West Germany totalled 80,275. From 1970 onwards the number of psychiatric beds was cut by roughly half. So the momentum of the reform has been strong enough to assimilate the completely different mental health care system of the former German Democratic Republic and, in the course of a decade, to re-structure mental health services for an additional 17–18 million new inhabitants. In an ongoing struggle to adapt to changing administrative set-ups, legal frameworks, and financial constraints, psychiatry in Germany in currently facing specific problems and is seriously challenged to defend to considerable achievements of the past. A major obstacle to achieving this aim lies in the fragmented system of mental health care provision and mental health care funding.     

Psychological consultation in older adult inpatient settings: A qualitative investigation of the impact on staff's daily practice and the mechanisms of change

Objectives: Psychological consultation is becoming increasingly common within older adult mental health and dementia services. However, there is very little research that examines the impact or effectiveness of this method of working. This study explored how psychological consultation impacted on the daily practice of staff working on mental health and dementia inpatient units. It also examined the mechanisms that enabled this process.

Method: Given the lack of current literature in this area, an exploratory qualitative design was employed. Ten staff who had received psychological consultation were individually interviewed. Staff comprised qualified and unqualified staff from a range of professions, and worked on older adult mental health or dementia units. Interviews were subject to thematic analysis.

Results: Five themes were identified from the analysis: (1) ‘It makes you understand the reasons why people are like they are’; (2) ‘It depends on the patient or service user’; (3) the importance of visibility and accessibility; (4) impact of psychology consultation on the effectiveness of the team; and (5) impact of psychology consultation on feelings invoked in the workplace.

Conclusions: The findings suggest that psychological consultation impacted on staffs’ daily practice in a variety of ways. Psychological consultation also appeared to increase team efficiency. Less positive findings were identified within the dementia setting. Specific recommendations are drawn from the conclusions to further guide clinical psychologists working within teams. Direction for future research in the area of psychological consultation is also suggested.     

Health care utilization in children and adolescents with psychiatric disorders

Objective

Mental illness is increasing among young people and likewise the request for health care services. At the same time, somatic comorbidity is common in children and adolescents with psychiatric disorders. There is a lack of studies on health care use in children and adolescents, and the hypothesis was that children and adolescents with psychiatric disorders use more primary-, and specialized somatic health care compared to children without psychiatric disorders.

Methods

In this retrospective population-based register study, all individuals aged 3–17 years living in Västra Götaland region in Sweden in 2017 were included (n = 298,877). Linear and Poisson regression were used to compare health care use during 2016–2018 between children with and without psychiatric diagnoses, controlling for age and gender. The results were reported as unstandardised beta coefficient (ß) and adjusted prevalence ratio (aPR) respectively.

Results

Having a psychiatric diagnosis was associated with more primary care visits (ß 2.35, 95% CI 2.30–2.40). This applied to most diagnoses investigated. Girls had more primary care visits than boys. Likewise, individuals with psychiatric diagnoses had more specialized somatic outpatient care (ß 1.70, 95% CI 1.67–1.73), both planned and unplanned (ß 1.23, 95% CI 1.21–1.25; ß 0.18, 95% CI 0.17–0.19). Somatic inpatient care was more common in those having a psychiatric diagnosis (aPR 1.65, 95% CI 1.58–1.72), with the diagnoses of psychosis and substance use exerting the greatest risk.

Conclusions

Psychiatric diagnoses were associated with increased primary-, somatic outpatient- as well as somatic inpatient care. Increased awareness of comorbidity and easy access to relevant health care could be beneficial for patients and caregivers. The results call for a review of current health care systems with distinct division between medical disciplines and levels of health care.     

Organization of services and pattern of psychiatric care in Nicaragua: result of a survey in 1986

Organization of services and patterns of psychiatric care were studied in Nicaragua in 1986, 7 years after the substantial changes in health policy launched after the revolution. The overall re-organization of the system is indicated by the progressive abandoning of the mental hospital as the center of psychiatric care and the creation of 15 community-based mental health centers now functioning throughout the country. Quality of care judged through analysis of a consecutive sample of 342 patients seen by services over a month confirmed the positive orientation of the system which seemed able to deliver good care following the new perspective of "de-institutionalization". Some problems emerged to a large extent common to psychiatric care in industrialized countries looking at psychotropic drug use and at the relationship between primary health care and the psychiatric system especially when care delivered in urban and rural areas was compared.     

Longitudinal analysis of inpatient care utilization among people with intellectual disabilities: 1999–2002

Background There has been no longitudinal study in Taiwan to identify the nature and the scale of medical care utilization of people with intellectual disabilities (IDs) up to the present. The aim of this study is to describe inpatient utilization among people under ID care in institutions in order to identify the pattern of medical care needs and the factors affecting utilization in Taiwan. Method The subject cohort was 168 individuals with ID who were cared for by a large public disability institution from 1999 to 2002 in Taipei, Taiwan. Results On the examination of the inpatient care that these persons underwent, it was found that these individuals had a heightened need (inpatient rate: 10.1–14.9%) for inpatient care compared with the general population with disabilities (9.37%) in Taiwan. The main reasons for hospitalization were pneumonia, gastrointestinal disorders, cellulites, orthopaedic problems, epilepsy and bronchitis. Using the full model of Generalized Estimating Equations for inpatient care utilization, the factors including low income family, living in an institution, being a subject with cerebral palsy and being a high outpatient user all influenced the use of inpatient care. Conclusions This study highlights that health authorities need to promote health planning more in order to ensure an excellent quality of health monitoring and health promotion among people with ID cared for by institutions.