Accreditation, certification, and the quality of care in state hospitals

Data on 216 state psychiatric hospitals were analyzed to determine whether accreditation by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) or certification by the Health Care Financing Administration (HCFA) were related to seven hospital characteristics generally accepted as reflecting quality of care. The characteristics were average cost per patient, per diem bed cost, total staff hours per patient, clinical staff hours per patient, percent of staff hours provided by medical staff, bed turnover, and percent of beds occupied. While a majority of the hospitals had either JCAHO accreditation, HCFA certification, or both, analysis revealed a weak relationship between accreditation or certification status and the indicators of quality of care. Accredited or certified hospitals were, however, more likely to have higher values on specific indicators than hospitals without accreditation.     

Hospitalization for psychiatric illness under Medicare, 1985

National and state-level data on Medicare-covered hospital discharges after treatment for psychiatric illness in 1985 were analyzed to determine the distribution of cases among various types of psychiatric and general hospitals. In most states, 80 to 90 percent of Medicare patients with psychiatric conditions received care in a setting that provided specialized treatment for psychiatric illness. However, the distribution of discharges among public and private psychiatric hospitals and general hospitals with psychiatric units varied substantially among states. Between 1984, the first year of Medicare's prospective payment system, and 1985, the number of discharges decreased overall, and a shift toward treatment in specialized psychiatric facilities and toward settings exempt from the prospective payment system was apparent.     

Differences in resource use and cost among facilities treating alcohol, drug abuse, and mental disorders: implications for design of a prospective payment system

Specialized psychiatric facilities, including qualified distinct-part units in general hospitals, are exempt from Medicare's diagnosis-related group prospective payment system (PPS). One major reason for continuing the exemption is the redistribution of revenue that would probably occur if a single national price were established for care at the diverse facilities that treat patients with psychiatric and substance abuse disorders. This study investigated the extent of such potential redistribution in a private health insurance data base and found that a PPS would systematically underpay specialized facilities and systematically overpay general hospitals without specialized units. Alternatives for addressing this problem are discussed.     

Changes in psychiatric inpatient treatment of children and youth in general hospitals: 1980-1985

Changes in the prevalence of inpatient psychiatric treatment of children and youth in short-term general hospitals between 1980 and 1985 were investigated. During that period, the locus of treatment of mental illness among children and youth shifted dramatically away from specialized facilities to general hospitals without psychiatric units. Among general hospitals without psychiatric units, the number of inpatient psychiatric episodes treated increased dramatically, patients' average length of stay almost doubled, and the total days of care provided more than tripled. The increased care was paid for primarily by Medicaid and commercial insurance. Total days of care for drug and alcohol problems among children and youth in general hospitals decreased substantially. The results suggest that general hospitals may be relying on psychiatric treatment to supplement revenues that were limited by Medicare's prospective payment system, which became effective during the period under study.     

Simulating policy options for psychiatric care in general hospitals under Medicare's PPS

Psychiatric hospitals and certain distinct part psychiatric units of general hospitals are currently exempt from diagnosis related group (DRG)-based payment under Medicare's prospective payment system (PPS), in large part due to concern about the degree to which such payment would match historical costs for these facilities. This communication simulates DRG-based payments for psychiatric admissions to general hospitals under the PPS and also under a modified version of the PPS. Two major types of modifications are made: (1) an increase in the role of outlier payments and (2) a restructuring of the DRG classification to allow for a difference in the basic payment rate, depending on whether or not care is provided in a facility that is currently exempt. When compared with cost data from just before the start of the PPS, the simulation results show the degree to which these hypothetical modifications will decrease the systematic risk of general hospitals with exempt units from receiving payments that fall short of costs.     

The psychiatric health facility: an alternative for acute inpatient treatment in a nonhospital setting

The psychiatric health facility (PHF) is a new kind of California health facility licensed for psychiatric inpatient treatment. PHFs provide acute short-term treatment in nonhospital settings that have more flexible facility and staffing requirements than do hospitals. The enabling legislation states that the average per diem cost should be approximately 60 percent of the cost of similar services provided in a general hospital. In late 1985 one private and 16 public PHFs were operating in California. The number of applicants wishing to open private-sector PHFs continue to increase, partly due to recently mandated insurance coverage for the facilities. Data on existing PHFs show that the characteristics of patients in PHFs and general hospitals are similar, and that state hospital utilization for counties using PHFs is lower than for non-PHF counties.     

An analysis of DRG-based reimbursement for psychiatric admissions to general hospitals

The authors analyzed the potential financial impact of paying general hospitals on the basis of diagnosis-related groups (DRGs) for Medicare alcohol-drug abuse and psychiatric admissions. Average costs per admission were substantially higher for general hospitals with special psychiatric units that are currently exempt from the prospective payment system (PPS) than for hospitals without exempt units. Simulations of DRG-related payments indicated that these payments would be greater for admissions to hospitals with exempt psychiatric units than for admissions to hospitals without exempt units. However, the differences in costs between these two types of facilities were greater than the differences in payments that would occur under a PPS.     

Nonhospital alternatives for acute psychiatric care in California

In California multiple social forces and financial constraints are leading to the rapid development of local alternatives not only to state hospitals but to general hospital psychiatric units as well. Two dissimilar patterns of acute-care services are emerging: the use of skilled nursing facilities with additional staff to provide mental health services and the development of a wide range of primarily nonmedical facilities under the licensing category of "residential care facility." The author summarizes characteristics of both kinds of programs and describes how they draw on all available sources of revenue before using state and county mental health funds. He also describes Santa Clara County's plan for local acute-care services in which a 54-bed residential building and a 15-bed psychiatric unit in a county hospital will replace two county-hospital psychiatric wards.     

Treatment, care, and rehabilitation of the chronic mentally ill in Sweden

For the last 20 years in Sweden, there has been a trend to integrate psychiatry with general medical services. However, mental hospitals remain the dominant resource for psychiatric care, with psychiatric units in general hospitals providing less than 20 percent of psychiatric hospital beds. The imbalance between the high number of inpatient facilities and the low rate of outpatient visits is beginning to be corrected by the newly introduced sector system, which allocates mental health care resources among geographic zones. The sector system has been criticized, however, because some believe it is fostering disintegration of existing resources and loss of research opportunities. A general spirit of improvement exists, but at the same time the public budget is being squeezed.     

Treatment of acute schizophrenia in open general medical wards in Jamaica

OBJECTIVE: The study assessed the efficacy of treating acute psychotic illness in open medical wards of general hospitals. METHODS: The sample consisted of 120 patients with schizophrenia whose first contact with a psychiatric service in Jamaica was in 1992 and who were treated as inpatients during the acute phase of their illness. Based on the geographic catchment area where they lived, patients were admitted to open medical wards in general hospitals, to psychiatric units in general hospitals, or to acute care wards in a custodial mental hospital. At first contact, patients' severity of illness was assessed, and sociodemographic variables, pathways to care, and legal status were determined. At discharge and for the subsequent 12 months, patients' outcomes were assessed by blinded observers using variables that included relapse, length of stay, employment status after discharge, and clinical status. RESULTS: More than half (53 percent) of the patients were admitted to the mental hospital, 28 percent to general hospital medical wards, and 19 percent to psychiatric units in general hospitals. The three groups did not differ significantly in geographic incidence rates, patterns of symptoms, and severity of psychosis. The mean length of stay was 90.9 days for patients in the mental hospital, 27.9 days in the general hospital psychiatric units, and 17.3 days in the general hospital medical wards. Clinical outcome variables were significantly better for patients treated in the general hospital medical wards than for those treated in the mental hospital, as were outpatient compliance and gainful employment. CONCLUSIONS: While allowing for possible differences in the three patient groups and the clinical settings, it appears that treatment in general hospital medical wards results in outcome that is at least equivalent to, and for some patients superior to, the outcome of treatment in conventional psychiatric facilities.     

A method for comparing two systems of acute 24-hour psychiatric care

A quasi-experimental method was developed to evaluate the cost-effectiveness of a public system of 24-hour acute psychiatric care in Santa Clara County, California, before and after a new treatment setting was introduced. The original system relied on a 54-bed psychiatric unit in a county general hospital; the new system consisted of a 20-bed unit in the general hospital plus a 45-bed nonhospital psychiatric health facility. The study demonstrated that the per diem cost of the psychiatric health facility was approximately 60 percent that of the original general hospital unit, but the average difference in cost per episode between the two systems was only about +25, primarily due to longer lengths of stay in the new system. In addition, patients treated in the new, combined system appeared sicker at discharge than those treated in the old system. The findings suggest the importance of simultaneously evaluating both cost and treatment effectiveness to make sure that one element does not dominate program direction at the expense of the other.     

DRGs: an overview of the issues

The prospective payment system based on diagnostic related groups adopted by Medicare in 1983 has many deficiencies with respect to psychiatric care. Due to the efforts of the American Psychiatric Association, psychiatric units in general hospitals have been temporarily exempted from this system of per-care payment. A number of problematic issues need to be addressed in the design of any modified or alternative system of financing psychiatric care. These issues include the problems of premature discharge, code manipulation, cost-shifting, and equitable patient access to psychiatric services. The potential effects of a DRG system of payment on clinical practice are reviewed. The reasons for the shortcomings of the DRG system in predicting utilization of services are discussed, and areas for future research are suggested.     

Repeated assaults by patients in VA hospital and clinic settings

OBJECTIVE: The study aim was to determine the prevalence of repeated assaults on staff and other patients and characteristics of patients who commit repeated assaults in the Veterans Health Administration of the Department of Veterans Affairs. METHODS: Patients in VA medical centers and freestanding outpatient clinics who committed two or more assaults in fiscal years 1995 and 1996 were identified through a survey of facility quality or risk managers. For each repeatedly assaultive patient, structured information, including incident reports, was obtained for all assault occasions. RESULTS: A total of 153 VA facilities responded, for a response rate of 99 percent. The survey identified 8,968 incidents of repeated assault by 2,233 patients, for a mean of 4.02 assaults per patient in the two-year study period. In 92 percent of the incidents, the assaultive patient had a primary or secondary psychiatric diagnosis. The mean age of the repeat assaulters was 62 years. Ninety-eight percent of the repeat assaulters were male, and 76.6 percent were Caucasian. At least 16 percent of the assaulters, 22 percent of the patients assaulted, and 20 percent of the staff assaulted required medical attention for injuries, which, along with the number of lost work days, indicates that repeated assaults are costly. CONCLUSIONS: Repeatedly assaultive patients represent major challenges to their own safety as well as to that of other patients and staff. Identifying patients at risk for repeated assaults and developing intervention strategies is critically important for ensuring the provision of health care to the vulnerable population of assaultive patients.     

Organisation des soins en psychiatrie au Gabon durant l’épidémie du COVID-19

Gabonese psychiatry is facing a crisis, which results in a decrease in material and human resources. Hospital beds are closed and consultations are mainly on an out-patient basis. This article shows how health care workers are coping with this pandemic, and the challenges of maintaining the therapeutic alliance. It presents a synthesis of works on confinement, COVID-19 and mental disorders. Clinical observations reveal that the COVID-19 epidemic has strengthened the dysfunctions observed in care. In rural areas, there is a suppression of follow-up at home. In general, this health crisis had an impact on the purchasing power of patients. What caused a difficulty of payment of the psychiatric consultations in liberal, a difficulty of access to the expensive psychotropic drugs, thus favouring a non-observance of the care, and a decompensation of the psychiatric picture. In urban areas, there is a considerable decrease in out-patient consultations. There is still concern about the inter- and post COVID-19 psychiatric care. This pandemic calls on leaders leading to a reorganisation of the psychiatric care system (decentralisation of establishments throughout the country, training of qualified nursing staff, fall in the prices of expensive psychotropic drugs). The establishment of helplines in psychiatric facilities, the opening of hospital beds, COVID-19 devices in public and private facilities for patients with mental disorders are essential.     

The religious component of acute hospital treatment

A clinically trained chaplain working part time in an acute psychiatric day hospital unit affords patients an opportunity to explore the religious dimension of their lives and educates staff about how to address patients' religious beliefs and incorporate them into treatment and discharge planning. The chaplain meets individually with patients at their request, is coleader with a mental health professional of a patients' group that discusses way of enriching one's life, and participates in clinical team meetings. During the first 12 months of the program, a pastoral consultation was requested by 59 percent of patients who were offered one at admission. About another 10 percent sought consultation later or attended the patient group. By incorporating a religious component in acute treatment programs, mental health care facilities can serve the broader purpose of increasing collaboration with religious and other groups in the community and expand the resources available to the patient at discharge.     

Psychiatric services: a survey of nursing homes and homes for the aged in Ontario.

A survey was conducted to determine perceptions and attitudes of psychiatric services available to nursing homes and homes for the aged across Ontario. A questionnaire was sent by mail to medical and nursing directors separately. Thirty-six point eight percent of responders reported that the nursing home residents never receive psychiatric care, and 88.2% of responders estimated the total psychiatric care received by all of their residents per month was five hours or less. Almost three-quarters of the responders stated that they require more psychiatric services. Significantly more nursing directors than medical directors wanted more psychiatric services. Southwestern Ontario, followed by Northern Ontario, had the least perceived availability of a visiting psychiatrist. Perceived availability was greatest in larger urban areas and least in rural areas. The mean percentage of residents perceived to have psychiatric or behavioural problems was 30.5%, while the mean percentage perceived to require psychotropic medication was 37.4%. Physical aggression, wandering and agitation were identified as the behavioural problems of greatest concern to staff. When a visiting psychiatrist is not available, residents sometimes have to travel long distances for psychiatric evaluation. Planning is required to facilitate and encourage the development of efficient and effective psychiatric services for long term care facilities for the elderly.     

The reform of psychiatric care in Poland--2001

Both positive and negative effects of the reform of the health care financing system are noted. Low prices offered by Sickness Funds for particular services (a bed-day, a visit) should be regarded as a negative effect of the reform. Particularly insufficient were the prices of services in some specialised psychiatric wards and in outpatient clinics. Prices in many community-based psychiatric facilities were also considerably underestimated. Undoubtedly, the reform has led to positive changes in the organization of inpatient care. These changes include: further reduction of beds in large hospitals organisational structure as well as a marked increase in the number of psychiatric wards at general hospitals, which should be the key units of psychiatric inpatient care. Increase in the number of day hospitals is another positive effect of the reform. The programme of psychiatric care transformation is presented mostly in the Mental Health Programme. The main goal of this programme is to ensure appropriate care for the mentally disordered people, namely comprehensive and accessible health care as well as other forms of help and and support necessary for living in family and in society. This goal will be accomplished by health care and other forms of help mentioned in the Mental Health Act and in the Social Help Act. Community-based model of psychiatric care is the key element of this system. Also, the Programme states desired accessibility rates for staff, number of beds and number of particular forms of psychiatric and alcohol treatment care. Separate rates for adult and children/youth population have been elaborated.     

A program to reduce use of physical restraint in psychiatric inpatient facilities

The authors describe a program to reduce the use of physical restraint on three psychiatric units of a university hospital. One component of the program involved interviewing patients to determine their stress triggers and personal crisis management strategies. The second consisted of training staff members in crisis de-escalation and nonviolent intervention. During the first two quarters after implementation of the program, physical restraint rates declined significantly and remained low on all three units for the remainder of the year after implementation. Hospitals should consider instituting comprehensive staff training that encourages adaptive patient behaviors and nonviolent staff intervention to reduce the physical and mechanical restraint of children and adults in inpatient facilities.     

A survey of hospital practices related to pelvic and rectal examinations of psychiatric inpatients.

Fifty-three inpatient units in Texas and Massachusetts--15 free-standing psychiatric hospitals and 38 units of general hospitals--responded to a survey to determine current practice in conducting pelvic and rectal examinations of psychiatric patients. Pelvic examinations were never done at 15 of the facilities (28 percent), and rectal examinations were never done at 12 (23 percent). The other facilities did these examinations selectively based on patients' clinical history. Because selective use of these examinations is consistent with recommendations of the American Psychiatric Association and because hospitals that conduct examination selectively have received approval by the Joint Commission on Accreditation of Healthcare Organizations, it appears that selective rather than routine pelvic and rectal examinations are now considered reasonable practice.