Community care for long-stay psychiatric patients: need- or policy-driven?

This paper describes an economic analysis undertaken as part of an evaluation of mental health services in Clwyd. This project was conducted in response to the decision to close the North Wales Hospital, Denbigh; a long-stay psychiatric hospital. Cost data were collected in both the hospital setting and subsequent community care settings. These data are compared with effectiveness data developed in other parts of the overall project in order to place the discussion in a cost effectiveness framework. Little significant difference in care effectiveness between hospital and community settings is identified, although minor improvements in some aspects for some patients are noted. However, there are considerable changes in the care costs. The cost estimates show that old long-stay patients cost more to care for in the community than the new long-stay patients, whilst in hospital they had cost less. In addition, the results highlight the significant influence of pay scales and capital funding on cost of care. The paper concludes that the cost of care is substantially affected by non-needs-driven policy decisions as well as by direct patient needs.     

Alzheimer's disease: the burden of the illness in England

This paper reports the findings of a study that estimated the socioeconomic costs, both direct and indirect, of Alzheimer's Disease in England by using a 'burden of illness' framework. The burden of illness was calculated for all main areas of provision: hospital and residential care, general practice, day care, home care and informal care, including the calculations of costs by age-group and by service provider. The results show that the cost of this care amounted to around 1,039m pounds in 1990/91, establishing that spending associated with Alzheimer's Disease is a major area of care expenditure. Such burden of illness data should help those involved with health care decision-making, planning and priority setting, especially for health districts and social services establishing base plans for care in the community.     

Moving home: costs associated with different models of accommodation for adults with learning disabilities

This paper reports on variation in the cost and social outcomes of provision for clients with learning disabilities, resettled across different models of community accommodation; identifying personal and service-related characteristics influential on such variation. The study was conducted to inform the community reprovisioning strategy associated with the phased closure of the Gogarburn and Tornaveen learning disability hospitals in the Lothian region, Scotland. Total mean service costs, quality of life and community integration outcome data were collected and compared. Total mean service costs ranged between pound16 438 and pound74 097 per year (mean pound42 023; SD = pound16 712). Cost estimates varied by age and dependency group, with costs for elderly clients comparatively low. Overall, there was an inverse relationship between total mean costs and size of accommodation. There was no evidence of a direct relationship between costs and changes in social outcomes. Services with the lowest mean costs were, however, associated with the smallest increases in social outcomes. The most expensive services did not realise proportionally greater gains in social outcomes. The paper concludes that clients generally benefited from the transition from hospital to community accommodation. However, some experienced better outcomes than others. In the absence of a clear link between levels and type of resource use and social outcomes, it is difficult to identify which service features are more or less efficacious in achieving positive outcomes. Broader evaluation perspectives, embracing a fuller range of costs and benefits, will be required to unpack exactly what it is about different models of community care provision that leads to positive outcomes, or otherwise, for learning disability clients. A more sound evidence base is required before effective strategies can be designed to ensure that key policy outcomes are realised and social integration truly achieved.     

The burden of fall-related injury among older persons in New South Wales

Objective: To develop a comprehensive estimate of the burden of fall‐related injury among older people in New South Wales. Methods: Fall injuries in 2006/07 were estimated using information from several datasets and the literature. Healthcare costs were calculated using Australia‐Refined – Diagnostic‐Related Group costs for hospital episodes of care and average costs for Emergency Department presentations, ambulance transport and residential aged care (RAC). Ratios of the cost of inpatient care relative to other health services, derived from the literature, were used to estimate the costs associated with these services. Results: In 2006/07, in NSW, there were almost 143,000 falls, among older people, resulting in injuries requiring medical treatment. The total cost of healthcare associated with these falls was estimated at $558.5 million. Although accounting for only 6% of the NSW population aged 65 years and older, persons in RAC accounted for 15% of the total cost of falls injury and 21% of hospital inpatient costs. Conclusion and implications: This study demonstrates the extremely high economic cost of falls in older persons and highlights the disproportionate impact of falls in RAC. The study underscores the urgent need for significant investment in fall‐injury prevention efforts in both the community and RAC settings.     

The implementation cost of a safety‐net hospital program addressing social needs in Atlanta

ObjectiveTo describe the cost of integrating social needs activities into a health care program that works toward health equity by addressing socioeconomic barriers.Data Sources/Study SettingCosts for a heart failure health care program based in a safety‐net hospital were reported by program staff for the program year May 2018–April 2019. Additional data sources included hospital records, invoices, and staff survey.Study DesignWe conducted a retrospective, cross‐sectional, case study of a program that includes health education, outpatient care, financial counseling and free medication; transportation and home services for those most in need; and connections to other social services. Program costs were summarized overall and for mutually exclusive categories: health care program (fixed and variable) and social needs activities.Data CollectionProgram cost data were collected using a activity‐based, micro‐costing approach. In addition, we conducted a survey that was completed by key staff to understand time allocation.Principal FindingsProgram costs were approximately $1.33 million, and the annual per patient cost was $1455. Thirty percent of the program costs was for social needs activities: 18% for 30‐day supply of medications and addressing socioeconomic barriers to medication adherence, 18% for mobile health services (outpatient home visits), 53% for navigating services through a financial counselor and community health worker, and 12% for transportation to visits and addressing transportation barriers. Most of the program costs were for personnel: 92% of the health care program fixed, 95% of the health care program variable, and 78% of social needs activities.DiscussionHistorically, social and health care services are funded by different systems and have not been integrated. We estimate the cost of implementing social needs activities into a health care program. This work can inform implementation for hospitals attempting to address social determinants of health and social needs in their patient population.     

Youths living away from families in the US mental health system

This study examines the clinical characteristics of youths who lived away from families at the time of admission to specialty mental health services, and investigates the association between type of nonfamily living situation and admission to residential versus outpatient programs. Of 3995 youths sampled from 1598 mental health programs in the United States, 14% lived away from their own families, either in foster care, group care settings, or correctional settings, or were emancipated. As a group, youths living away from families were more seriously emotionally disturbed and more likely to receive treatment in residential care programs. Youths who lived in foster care were more likely to be admitted to outpatient programs, while youths who lived in group care settings or correctional settings were more likely to be admitted to residential care programs, controlling on demographic and clinical characteristics. Targeting resources to enhance the availability and therapeutic capacity of foster care may facilitate community living, and decrease time spent in institutional settings.     

Community care for the elderly: Costs and dependency

The aim of the paper is to examine the costs of care of elderly persons who live in their own homes as compared to those in residential homes. This is seen as a necessary first step in any planning process. From a survey of elderly persons in Britain, the levels of domiciliary services provided to those in their own homes was ascertained, and unit costs of each service was applied. Costs were based on the economic concept of social opportunity costs, so that all costs were included, and not just those accruing to the local authority. Recognising the fact that the costs of care in the community were likely to vary with the level of health of the elderly person, an attempt was made to categorise elderly persons into various levels of dependency. Secondly, regression techniques were used to ascertain whether the level of dependency did significantly affect the costs of care. It was found that variations in the average costs of care were significantly explained by both physical and mental characteristics of the elderly person. In addition, sex was important, as well as the elderly person's area of residence. This has important implications by itself for planning care services. It was also found that very few persons who were sampled in the community had a total cost of care greater than the average cost found in residential homes.     

<Emphasis Type="Bold">Community Health Workers Bring Cost Savings to Patient-Centered Medical Home</Emphasis>s

The Patient-Centered Medical Home (PCMH) model demonstrated that processes of care can be improved while unnecessary care, such as preventable emergency department utilization, can be reduced through better care coordination. A complementary model, the Integrated Primary Care and Community Support (I-PaCS) model, which integrates community health workers (CHWs) into primary care settings, functions beyond improved coordination of primary medical care to include management of the social determinants of health. However, the PCMH model puts downward pressure on the panel sizes of primary care providers, increasing the average fixed costs of care at the practice level. While the I-PaCS model layers an additional cost of the CHWs into the primary care cost structure, that additional costs is relatively small. The purpose of this study is to simulate the effects of the PCMH and I-PaCS models over a 3-year period to account for program initiation to maturity. The costs and cost offsets of the model were estimated at the clinic practice level. The studies which find the largest cost savings are for high-risk, paneled patients and therefore do not represent the effects of the PCMH model on moderate-utilizing patients or practice-level effects. We modeled a 12.6% decrease in the inpatient hospital, outpatient hospital and emergency department costs of high and moderate risk patients. The PCMH is expected to realize a 1.7% annual savings by year three while the I-PaCS program is expected to a 7.1% savings in the third year. The two models are complementary, the I-PaCS program enhancing the cost reduction capability of the PCMH.     

The costs and service implications of substituting intermediate care for acute hospital care.

Intermediate care is part of a package of initiatives introduced by the UK Government mainly to relieve pressure on acute hospital beds and reduce delayed discharge (bed blocking). Intermediate care involves caring for patients in a range of settings, such as in the home or community or in nursing and residential homes. This paper considers the scope of intermediate care and its role in relation to acute hospital services. In particular, it develops a framework that can be used to inform decisions about the most cost-effective care pathways for given clinical situations, and also for wider planning purposes. It does this by providing a model for evaluating the costs of intermediate care services provided by different agencies and techniques for calibrating the model locally. It finds that consistent application of the techniques over a period of time, coupled with sound planning and accounting, should result in savings to the health economy.     

Demograghic and socio-economic determinants of community and hospital services costs for people with HIV/AIDS in London.

We examined the influence of demographic, social and economic background of people with HIV/AIDS in London on total community and hospital services costs. This was a retrospective study of community and hospital service use, needs and costs based on structured questionnaires administered by trained interviewers and costing information obtained from the service purchasers and providers, based on two Genito-urinary Medicine clinics in London: the Jefferiss Wing at St. Mary's Hospital and Patric Clements at the Central Middlesex Hospital, London, England. The subjects were 225 HIV infected patients (105 asymptomatic, 59 symptomatic non-AIDS and 61 AIDS). We found that over and above well established determinants of health care costs for HIV infected people such as disease stage and transmission category, social and economic factors such as employment and support of a living-in partner significantly reduced community services costs. Private health insurance had a similar effect, though only a small proportion of HIV people had such cover. The cost of community services for HIV infected non-European Union nationals, mainly of African origin, was one quarter that for the European Union nationals. Community services costs were highest for heterosexually infected women and lowest for heterosexually infected men after adjusting for other factors. Hospital services costs were significantly higher for HIV infected people lacking educational qualifications and employment. We conclude that access to community care for HIV infected non-EU nationals appears to be very poor as the cost of their community services was one quarter that for the EU nationals after adjusting for the effects of transmission category, disease stage, living with a partner, employment and having a private health insurance. Additional incentives for informal care for HIV infected people could be a cost-effective way to improve their community health service provisions.     

Buying time II: an economic evaluation of a joint NHS/Social Services residential rehabilitation unit for older people on discharge from hospital

The study's aim was to investigate the cost-effectiveness of an NHS/Social Services short-term residential rehabilitation unit (a form of intermediate care) for older people on discharge from community hospital compared with 'usual' community services. An economic evaluation was conducted alongside a prospective controlled trial, which explored the effectiveness of a rehabilitation unit in a practice setting. The aim of the unit was to help individuals regain independence. A matched control group went home from hospital with the health/social care services they would ordinarily receive. The research was conducted in two matched geographical areas in Devon: one with a rehabilitation unit, one without. Participants were recruited from January 1999 to October 2000 in 10 community hospitals and their eligibility determined using the unit's strict inclusion/exclusion criteria, including 55 years or older and likely to benefit from a short-term rehabilitation programme: potential to improve, realistic, achievable goals, motivation to participate. Ninety-four people were recruited to the intervention and 112 to the control group. Details were collated of the NHS and Social Services resources participants used over a 12-month follow-up. The cost of the resource use was compared between those who went to the unit and those who went straight home. Overall, costs were very similar between the two groups. Aggregated mean NHS/Social Services costs for the 12 months of follow-up were pound 8542.28 for the intervention group and pound 8510.68 for the control. However, there was a clear 'seesaw' effect between the NHS and Social Services: the cost of the unit option fell more heavily on Social Services (pound 5011.56, whereas pound 3530.72 to the NHS), the community option more so on the NHS (pound 5146.74, whereas pound 3363.94 to Social Services). This suggests that residential rehabilitation for older people is no more cost-effective over a year after discharge from community hospital than usual community services. The variability in cost burden between the NHS and Social Services has implications for 'who pays' and being sure that agencies share both pain and gain.     

Understanding Occupational Therapy: Nursing and Physician Assistant Students' Knowledge About Occupational Therapy

Until very recently, occupational therapy services have been provided in institutional settings and have followed the medical model. The escalating costs of hospital care have been the primary incentives for moving patients out of acute settings and thus increasing the need for occupational therapy services in the community. Yet, relatively few therapists have moved from the medical model even though the need exists and legislation encourages that service be provided in the least restrictive alternative. Further, occupational therapists have been slow to adopt distinct strategies for planning with patients for their roles and needs after treatment even though the heart of the occupational therapy philosophy centers on adaptation to life roles. This paper explores the current trends away from institution-based health care and towards a continuum of health and social services, and the roles for occupational therapists in community settings. Occupational therapists are urged to act as facilitators in assisting patients to move successfully from active treatment to independence in whatever settings they find themselves.     

Fiscal outcomes of the closing of Central State Hospital: An analysis of the costs to state government

This study reports estimates of the preclosure and postclosure costs of mental health services for patients directly affected by the closing of Central State Hospital. The data come from state budget documents and from the billing records of the community mental health centers serving the discharged clients. On average, it cost Indiana approximately $68,347 (in 1995 dollars) to provide 12 months of state hospital care for this client cohort in fiscal year 1993. In contrast, during the first year following the closure, the average per patient cost to the state was $55,417. When clients were served exclusively in community care settings, the average annual per patient cost was $40,618. The analyses suggest that the closing reduced the costs of caring for this cohort of patients by approximately 18.9%. A significant portion of the cost savings to the state mental health budget was achieved by shifting some of the direct patient care costs to Medicaid/Medicare.The analyses and conclusions reported here are the sole responsibility of the author and do not necessarily reflect the position or opinions of the funding institutions, the individuals named in the acknowledgments section, the agencies that participated in this study, or Indiana University.He is also with the Indiana Consortium for Mental Health Services Research in Bloominton.     

The cost effectiveness of specialised facilities for service users with persistent challenging behaviours

Little systematic research relates specifically to the last people to leave a psychiatric hospital at the end of a closure programme. The long-running evaluation of the reprovision of services from Friern Hospital in North London allowed a special study to be made of such a group (67 people in all), whose range of problem behaviours made placement in community settings most difficult. The patients were relatively young, with a shorter length of stay than the remainder of the former long-stay hospital population. They were assessed three times: before leaving Friern, and one and 5 years after relocation. The social and clinical characteristics of each person were measured, and the full costs of their care calculated. The "difficult-to-place" patients moved to four highly staffed rehabilitation facilities, where the total cost of their care was, on average, 1230 UK pounds per week. There was no overall change in their psychiatric state over the 5 years after they left Friern Hospital although, in the longer-term, they gained skills in several areas of daily functioning. Most importantly, there was a fall of almost 50% in the number of challenging behaviours exhibited by the study group. At the five-year follow-up point, the cost of care had fallen, on average, by 170 UK pounds per week, and 24 people had been able to move to more independent accommodation arrangements. Study participants had gained a new network of community service contacts, and used services provided by a greater variety of agencies. The indicators suggest that high expenditure on alternative care was justified retrospectively by overall long-term outcomes. An important policy lesson from the Friern Hospital reprovision study is that adequate funds should be reserved until the end of the closure programme to allow the investment of resources in provision for patients with the most severe problem behaviours.     

Elderly people with cognitive impairment: costing possible changes in the balance of care

The objective of this paper is to investigate the service needs and support costs of elderly people with cognitive impairment on hospital and community health services, primary health care, social services, and informal carers in England. It examines the resource consequences of major changes in the provision of care, exploring the implications for both cost and effectiveness. The study was designed to provide a secondary analysis of the OPCS disability surveys in order to estimate the balance of care, and current provision of services. It also estimates of costs of present provision and potential policy options. Results show large scale improvements in the provision of care for people living in private households and local authority homes require significant increases in funding, but reductions in the provision of long-stay hospital beds can significantly reduce the cost burden to the public purse. Given the increasing demand pressure on health and social care expenditure, it seems unlikely that large scale improvements in the care supplied to elderly people with cognitive impairment can be achieved without some change in the balance of care. The cost of implementing improvements in care for the 200000 people living in private households and the 45000 people in local authority homes could be offset by reducing the provision of costly long stay hospital provision with alternative institutional care such as NHS nursing homes.     

Consolidation of community hospitals

The largest component of U.S. health care expenditures is the cost of hospital care. Evidence seems to indicate that community hospital costs can be reduced through the consolidation of some, or even all, hospital services. Although no discernible set of relevant minimal costs for the hospital industry has been established as yet, significant economies of scale can be attributed to the consolidation process. In addition to potential economic benefits, medical benefits can also accure to the community as well when inefficient, low-volume services are combined to provide more attractive resources to highly qualified specialists. Many independent community hospitals operate autonomously, often to the detriment of community health needs and economy. Those hospitals that fail to take advantage of the opportunities offered by consolidation may not be keeping faith with the population they claim to serve.     

A cost function analysis of residential services for adults with a learning disability

Successive UK governments have pursued a policy of community care for people with learning disabilities which, in the past ten years, has led to a marked change in the nature of residential provision. Research evidence on the costs and quality of alternative forms of community provision is inconclusive and contradictory. It is therefore timely to consider whether or not community residential facilities have delivered the expected quality of service at appropriate cost. The paper presents the results of a cost function analysis of a random stratified sample of staffed community facilities in England excluding London. Both costs and quality of care were found to vary greatly amongst community residential facilities. The most important factors explaining differences in cost were case-mix factors relating to client age, dependency and length of stay. Facility characteristics such as the type of building, the internal layout and the structural quality were not significant. Quality of service measures such as the extent to which care-regimes were client orientated and made use of local community services were positively and significantly associated with costs. Type of provider had no impact on costs independent of differences in case-mix and quality of care with the exception of the private for profit sector which appeared less expensive than other agencies. The shortcomings of the methods and implications of these findings for policy makers are discussed.     

Costs of health care and social services during the first year after ischemic stroke

OBJECTIVES: Knowledge of resource use and costs can be useful when evaluating existing services or planning new services. This study investigates the use of health care and social services during the first year after a stroke. Total costs are calculated, costs are compared across subgroups of patients, and resource items of major importance for the total costs are identified. METHODS: The study is based on a database comprising data on all stroke patients admitted to a university hospital in Copenhagen, Denmark, over a 1-year period, 1994-95. Patients were followed for 1 year after the stroke, and data on resource use during and after hospitalization were collected prospectively at interviews. This paper focuses on a subset of 385 patients who were admitted because of cerebral infarct or unspecified stroke. RESULTS: The mean cost, based on all patients, of health care and social services during the first year was 142,900 DKK (US $25,500). The hospital care until the first discharge, including acute care and rehabilitation, cost 101,600 Danish krones (DKK) (US $18,100), i.e., 71% of the total cost. Major resource items after discharge were nursing homes, readmissions, outpatient rehabilitation, and home help. The cost during the first year varied with a number of factors, with the most important being survival and degree of disability. Patients who survived the acute phase and who had severe disability (Barthel Activities of Daily Living [ADL] Index: 0-9) 7-10 days after admission had a total cost during the first year that was five times as high as patients with no disability (Barthel ADL Index: 20). CONCLUSION: Costs of health care and social services during the first year after a stroke vary considerably. Disability as measured with the Barthel ADL Index is a stronger predictor of costs than Scandinavian Stroke Scale scores and other clinical and demographic variables.     

Care homes. Home truths

Proposed joint inspectorates of care homes open the way for health input into residential care. An investigation into quality-of-care measures concluded that health professionals should be included in inspectorate teams, particularly in view of the increasing dependency of residents. No association was shown between cost and quality, but higher costs were associated with short-term car provision. When costing residential care, the impact on community and primary healthcare services may need to be taken into account.