Reducing psychiatric hospitalization among mentally ill veterans living in board-and-care homes

OBJECTIVE: The effectiveness of a community-based case management program at the Veterans Affairs West Los Angeles Healthcare Center in reducing hospital readmission of mentally ill veterans living in privately operated board-and-care homes was evaluated. METHODS: A retrospective cohort design was used. The sample consisted of 321 patients identified by hospital records as living in one of 24 board-and-care homes in the Los Angeles area that were approved by the community residential care program. A total of 214 subjects who received monthly home visits from case managers (program group) were compared with 107 subjects who did not receive monthly home visits (comparison group). The median number of psychiatric bed-days used was calculated for the two years before and after follow-up. The number of days from the start of follow-up to the first psychiatric hospitalization was also calculated. RESULTS: Among subjects in the program group, the median number of psychiatric bed-days used decreased significantly, from 59 days to 50 days. No significant change in the median number was observed for comparison subjects. Comparison subjects were rehospitalized 1.7 times more often than program subjects. Overall, program subjects under age 62 (younger subjects) were rehospitalized 2.5 times more often than older subjects. In the program group, those who had received home visits for more than two years were hospitalized three times more often than those who had received visits for less than two years, and younger subjects were rehospitalized 1.8 times more often than older subjects. CONCLUSIONS: The findings suggest that home visits conducted by case managers in a community residential care program helped reduce psychiatric hospitalization among veteran patients living in privately operated board-and-care homes.     

Three years of follow-up monitoring: Perspectives of formerly hospitalized patients and their families

In recent years, the need for evaluation of hospitalized psychiatric patients has become widely recognized. However, evaluation is a broad term encompassing many varied approaches. Erickson⁷ suggests that hospital programs may involve as many as six parties, including the patient, state, local community, family, hospital staff, and therapist. Each party has particular goals and a unique perspective. Thus, evaluation requires a decision as to whose perspective to take.Earlier analyses of human service organizations rarely used patient or family perspectives, tending to perpetuate the notion that the client's perspective is biased.⁹ However, recently, several investigators have attested to the reliability and validity of these viewpoints.^6–8,10,11 After carrying out a number of studies, Ellsworth,⁶ in particular, highlights the value of using feedback from former patients and their families to provide a better understanding of the community experience following hospital discharge.In the present follow-up evaluation, we focused on the perspectives of former inpatients and their nearest relatives with regard to aspects of the patients' general level of functioning and satisfaction with hospital care 6 months post-discharge.     

Consumer education in discharge planning for continuity of care

The need to establish continuity of care for patients in transition from the hospital; to community is essential for adequate community adjustment. The Resource Group model of discharge planning is based upon a consumer education model with emphasizes the responsibility of the individual in discharge planning. In these groups, the partial hospitalization program staff representative and the clinical pharmacist, in conjunction with inpatient clinical social workers, begin discharge planning with inpatients during the early phase of hospitalization. Increased utilization of partial hospitalization services has resulted in greater continuity of care.     

Needs-based planning for persons with schizophrenia residing in board-and-care homes

Data available from a recent planning project provided an opportunity to examine impairment and service needs of individuals with schizophrenia spectrum diagnoses living in a large board-and-care program. When first implemented, this minimum-support custodial program was assumed to be adequate for discharged long-term inpatients with schizophrenia and other chronic mental illnesses. However, the needs assessments indicated considerable heterogeneity in resident level of impairment. When a validated planning template was applied to assign residents to an appropriate level of care, almost one-quarter were assigned to independent living with minimal support, one-third to community living with intensive support, and 40 percent to residential or inpatient treatment. The authors conclude that this program is not able to meet the varying needs of residents. Despite a common diagnosis, many can function in more independent settings, while others need more treatment and rehabilitation than they are currently provided.     

Using volunteer therapists to reduce hospital readmissions.

Two aftercare programs using volunteers as therapists for former inpatients have been effective in reducing hospital readmissions. The volunteer therapists ensure that patients take medications, evaluate them for decompensation, help them find housing and jobs, and give them supportive counseling. In the first program the recidivism rate after one year for 36 chronic schizophrenic women was 11 per cent for the group treated by volunteers and 34 per cent for the control group receiving traditional aftercare. In the second program the recidivism rate after one year for 11 men and women with various types of schizophrenia was 9 per cent for the treatment group and 37 per cent for the control group.     

Controlled trial of dementia training with a peer support group for aged care staff

OBJECTIVE: This study evaluated the impact of an eight-session training program for aged care staff in managing dementia-related challenging behaviours. Participation in the training program with an additional five-session peer support group was compared with both participation in training only and a wait-list control condition. METHODS: Outcomes were evaluated for 90 participating staff members and 113 residents with challenging behaviours from six aged care facilities. Measures of staff attitudes and the behaviours of staff and residents were collected pre- and post-intervention, and at six month follow-up. RESULTS: Staff members in both dementia training groups reported improved attitudes regarding their knowledge and skills in managing residents with challenging behaviours, immediately after the training and six months later. Facility supervisors rated the nursing performance of trained staff more positively, particularly those who participated in a peer support group. The dementia training programs, whether with or without the inclusion of peer support, did not impact on levels of staff burnout or substantially reduce the level of challenging behaviours among aged care residents. CONCLUSIONS: While training programs may impact positively on staff performance, organisational characteristics of aged care facilities, including low levels of management support for staff training initiatives, limit the potential outcomes. Methodological limitations are discussed.     

Incarceration and hospital care

Risk for jail or prison recidivism is well documented among incarcerated individuals with schizophrenia. However, it is less clear that risk is also high for psychiatric hospital readmission after accounting for mediating influences such as psychopathology severity, functioning level, substance misuse, and demographic characteristics. Relative to counterparts without prior time in jail, this study therefore assessed whether formerly incarcerated individuals with schizophrenia were more likely to repeatedly use hospital care after controlling for level of functioning and symptomatology. Among 315 inpatients, former inmates had a greater mean number of previous hospital stays than other patients (t = -2.13; df = 305; p = 0.03) and were more likely to visit the emergency room or be rehospitalized within 3 months of discharge (chi2 = 8.83; df = 1; p = 0.003). They were twice as likely to be readmitted, moreover, even after accounting in logistic regression for age, sex, race, global functioning, psychopathology severity, alcohol abuse or dependence, and drug abuse or dependence (OR = .49; CI = .26-.95). Implications for community care are discussed, and the suggestion is made that jail diversion programs should be renamed and refocused as "jail and hospital diversion."     

Self-reported treatment adherence among psychiatric in- and outpatients

Abstract

Background: Poor adherence to psychiatric treatment is a common clinical problem, leading to unfavourable treatment outcome and increased healthcare costs.

Aim: The aim of this study was to investigate the self-reported adherence and attitudes to outpatient visits and pharmacotherapy in specialized care psychiatric patients.

Methods: Within the Helsinki University Psychiatric Consortium (HUPC) pilot study, in- and outpatients with schizophrenia or schizoaffective disorder (SSA, n = 113), bipolar disorder (BD, n = 99), or depressive disorder (DD, n = 188) were surveyed about their adherence and attitudes towards outpatient visits and pharmacotherapy. Correlates of self-reported adherence to outpatient and drug treatment were investigated using regression analysis.

Results: The majority (78.5%) of patients reported having attended outpatient visits regularly or only partly irregularly. Most patients (79.2%) also reported regular use of pharmacotherapy. Self-reported non-adherence to preceding outpatient visits was consistently and significantly more common among inpatients than outpatients across all diagnostic groups (p?<?.001). Across all groups, hospital setting was the strongest independent correlate of poor adherence to outpatient visits (SSA β?=?–2.418, BD β?=?–3.417, DD β?=?–2.766; p?<?.001 in all). Another independent correlate of non-adherence was substance use disorder (SSA β?=?–1.555, p?=?.001; BD β?=?–1.535, p?=?.006; DD β?=?–2.258, p?<?.000). No other socio-demographic or clinical factor was significantly associated with poor adherence in multivariate regression models.

Conclusions: Irrespective of diagnosis, self-reported adherence to outpatient care among patients with schizophrenia or schizoaffective disorder, bipolar disorder, and depression is associated strongly with two factors: hospital setting and substance use disorders. Thus, detection of adherence problems among former inpatients and recognition and treatment of substance misuse are important to ensure proper outpatient care.     

A collaborative rehabilitation approach to the improvement of inpatient treatment for persons with a psychiatric disability

With the growth of community support programs the role of the state psychiatric hospital has changed. Reduced funding levels have resulted in overcrowding, inadequate staffing and ineffective programming. In order to improve the quality of care and introduce more psychiatric rehabilitation-oriented activities into hospital programming, a large state hospital and a state health sciences university have entered into a time-limited collaborative partnership. This paper describes that partnership and its attempt to improve staff competencies, enhance service delivery and integrate a more rehabilitation-oriented philosophy of care into the hospital through undergraduate education, in-service training, program development, staff mentoring and organizational change activities.     

Promoting research in advanced dementia: early clinical results of the Alzheimer Center Reina Sofía Foundation

The Alzheimer Center Reina Sofía Foundation (ACRSF) was envisaged to address the complex and multi-disciplinary research and care needs posed by Alzheimer's disease (AD) and other neurodegenerative dementias. Patients may be admitted at ACRSF either as inpatients (i.e., nursing home) or outpatients (i.e., day-care center). The research program includes clinical, social, biochemical, genetic, and magnetic resonance investigations, as well as brain donation. We present the inception of the clinical research protocol for the ACRSF, the early results, and the amendments to the protocol. Foreseen as distinct populations, inpatient and outpatient results are presented separately. Data were collected from 180 patients (153 inpatients, 27 outpatients) (86% AD), with informed consent for participation in the research program of the ACRSF. Most patients (95%) had moderate to severe dementia. Nursing home patients were older, displayed marked gait dysfunction, and were significantly more dependent in the activities of daily living (ADL), compared to the day-care patients (p < 0.05). Some cognitive, ADL, and quality of life (QoL) scales were eliminated from the protocol due to floor effect or lack of specificity of contents for advanced dementia. New measurements were added for evaluation of cognition, apathy, agitation, depression, ADL, motor function, and QoL. The final assessment is expected to be sensitive to change in all the clinical aspects of advanced degenerative dementia, to promote multidisciplinary and, desirably, inter-center collaborative research and, eventually, to contribute to the improvement of treatment and care for these patients.     

Postdischarge treatment costs following closure of a state geropsychiatric ward: comparison of 2 levels of community care

Objectives: The purposes of this study were to (1) examine the cost of community-based health care services for geropsychiatric inpatients discharged into the community after the closure of an inpatient state geropsychiatric unit and (2) compare costs for patients treated with extra support through an Expanded Community Services (ECS) program to patients treated traditionally. Method: This study was a 6-month prospective, observational analysis of 30 patients discharged in conjunction with a ward closure in October 2002 (17 patients were nonrandomly assigned to the ECS program, and 13, to standard care). We analyzed costs of care, mortality, and rehospitalization rates derived from Medicaid paid claims and other data sources and compared costs to an estimate of hospital costs had the patients not been discharged. Patients were discharged to various community placements including long-term care facilities, assisted living facilities, and adult family homes in Eastern Washington State. Results: Costs for community care were approximately half of estimated costs for hospital care. Patients treated in the ECS program, representing the most severely in-need discharges, had costs of care that were nonsignificantly higher than non-ECS patients but still significantly lower than estimated hospital care. No differences in mortality or rehospitalization rates were found between ECS and non-ECS patients. Conclusion: Costs of community care were significantly lower than hospital care. Quality of life for patients in the community settings versus the hospital was not assessed. The ECS program was able to maintain high-risk geropsychiatric patients in the community comparably to less severely ill patients at less than hospital costs. Recommendations are provided for ways to establish community treatment programs for deinstitutionalized elderly patients with serious mental illness.     

"Big MAC": the role of consultation liaison psychiatry in hospital medical advisory committees

OBJECTIVES: The aim of this paper is to describe the participation of a consultation-liaison (CL) psychiatrist within a hospital medical advisory committee (MAC) and examine how this may generally contribute to improved patient care as well as assist in the development of governance within the hospital. CONCLUSIONS: Psychiatrists have a role in a MAC in enhancing the recognition of psychiatric care issues within the hospital, educating other members of the committee with respect to improved recognition of mental illness affecting hospital inpatients and enhanced care of patients requiring substitute decision-making. The psychiatrist also has a role in advising the committee on psychosocial issues generally affecting the hospital service as well as informing on psychological issues that impact on hospital staff performance. To an extent, CL psychiatry also encompasses issues involving all the other medical craft groups in hospitals, offering the opportunity for a "global" perspective that may be expressed through participation in a MAC.     

Inpatient psychotherapy compared with usual care for patients who have schizophrenic psychoses

The study examined whether some patients with schizophrenia benefit from intensive inpatient psychodynamic psychotherapy while others are harmed by it. Multiple regression analyses were conducted with combined data from a follow-up study of 25 inpatients who were treated in a psychotherapeutic program and a follow-up study of 71 patients who received standard hospital treatment. The mean duration of the follow-up period was seven years. The analyses showed that improvement in global mental health status from the index admission to follow-up was associated with the type of treatment and with the patient's clinical condition at the index admission. A strong interaction effect was found between these two variables. Psychotherapeutic inpatient programs may be beneficial to patients who have higher levels of global functioning at the start of treatment but detrimental to other patients.     

Child maltreatment: what we know in the year 2000.

This paper provides an overview of child maltreatment within a public health framework, based on the Closing Plenary Address presented at the 1999 Joint Meeting of the American Academy of Child and Adolescent Psychiatry and the Canadian Academy of Child Psychiatry. A brief historical perspective is followed by a discussion of the burden of suffering associated with child maltreatment. Evidence about the prevention and treatment of child abuse and neglect is reviewed. Evidence supports a program of nurse home visits as effective in preventing abuse and neglect among first-time, at-risk mothers. Sexual abuse education programs improve children's knowledge and prevention skills; whether such programs reduce the occurrence of child sexual abuse remains to be established. In the area of treatment, therapeutic day-care programs improve cognitive skills among physically abused and neglected children. Abuse-specific cognitive-behaviour therapy has been shown to be effective in reducing symptoms among sexually abused children in both preschool and older age groups. Further research is necessary across all subcategories of child maltreatment, particularly neglect and emotional abuse.     

A controlled trial of a predominantly psychosocial approach to BPSD: treating causality

BACKGROUND: The adverse effects of behavioral and psychological symptoms of dementia (BPSD) are well described but treatment remains problematical, including overuse of psychotropic medication. This study aims to compare the outcome of two approaches to BPSD, one focusing on causality and using predominantly psychosocial interventions, the other relying predominantly on psychotropic medication. METHODS: Thirty-three residential care clients manifesting BPSD who had been referred to a community psychogeriatric service (intervention group) were assessed and treated, with the focus placed on the causes of the behavior and why it was perceived as a problem by nursing staff. Cases were managed primarily by psychosocial means with psychopharmacology as an adjunct. A control group was made up of 22 referrals to an adjacent service, which used primarily psychopharmacology with psychosocial methods as an occasional adjunct. RESULTS: Measures of behavior and staff response showed significant improvement in both groups at two- and five-months' follow-up. Antipsychotic use in the intervention group decreased over time while in the control group it increased. Service measures showed both groups required approximately the same number of clinical visits but the intervention group experienced fewer medication changes, fewer drug side effects, and all but one case could be treated in situ. Five control group participants spent extended periods as inpatients in a psychogeriatric unit. Minor sampling differences did not affect the results, and neither they nor the nature of the behavior explained the difference in clinical approach. CONCLUSION: The causality-focused approach appears to be as effective as the more common predominantly pharmacological approach, and appears to involve lower human and financial costs.     

Examining attitudes, beliefs and knowledge of effective practices in psychiatric rehabilitation in a hospital setting

OBJECTIVE: This brief report presents a staff training program based on psychiatric rehabilitation principles used in a hospital setting. The training program intervention significantly promoted the belief that mental illness does not necessarily limit functioning and also improved awareness of research findings, evidence-based practices and community services. METHODS: A randomized controlled study assessed the impact of the program on the staff's attitudes regarding psychiatric rehabilitation and recovery. RESULTS: Findings suggest that in-service training programs within a hospital setting can change staff attitudes in order to support psychiatric rehabilitation. CONCLUSIONS: A psychiatric rehabilitation forum, made up of representatives from all disciplines, including the medical directors of every ward, was set up in the hospital following the training program and has become the main avenue to disseminate information, messages, and goals to the staff at large and to the hospital administration. It is the forum that creates the shared vision about psychiatric rehabilitation within the hospital and has the task of facilitating implementation of services according to that vision.     

Identifying risk factors and key strategies in linkage to outpatient psychiatric care

OBJECTIVE: The substantial failure of psychiatric patients to engage in outpatient specialty mental health care after an acute hospitalization at a time when managed care companies and others increasingly hold hospitals accountable for outcomes underscores the importance of identifying patients at high risk for not completing referrals. This study explored patient risk factors for not completing referrals and examined the success of several interventions targeted to achieving linkage with outpatient care. METHOD: A clinically detailed, structured form was used in abstracting information from the medical records of 229 inpatients with a primary psychiatric diagnosis. Clinicians and staff at outpatient programs were contacted to determine whether patients completed their referrals. RESULTS: Approximately two-thirds (65%) of the patients failed to attend scheduled or rescheduled initial outpatient mental health appointments after a hospital discharge. At high risk for unsuccessful linkage to outpatient care were patients with a persistent mental illness and those who had no prior public psychiatric hospitalization, were admitted involuntarily, and had longer lengths of stay. Controlling for risk factors, three clinical interventions used during the hospital stay more than tripled the odds of successful linkage to outpatient care: communication about patients' discharge plans between inpatient staff and outpatient clinicians, patients' starting outpatient programs before discharge, and family involvement during the hospital stay. CONCLUSIONS: Effective clinical bridging strategies can be used to avoid unnecessary gaps in the delivery of psychiatric services. Incorporating these strategies into routine care would enhance continuity of care, especially for some high-risk patients.     

A mental health center's aftercare specialty service for discharged state hospital patients

To serve discharged state hospital patients from its catchment area, a mental health and retardation center established an ambulatory community service that has total responsiblity for the community care of those patients. The service is staffed primarily by mental health workers and nurses. They become members of the neighborhood-based teams on the state hosptial unit and take part regularly in discharge planning with patients and hospital staff. They also provide a range of continuing outpatient and support services, including medication review, development of housing placements and recreational activities, and psychiatric follow-up. The service operates as a specialized, autonomous unit, which allows it to shift staff resources in line with changes in patient and program needs, to allocate time for program development, and to pressure other agencies to develop needed services.     

Outcomes and costs of two VA inpatient treatment programs for older alcoholic patients.

One hundred thirty-seven older alcoholic patients were randomly assigned to two different inpatient treatment programs at a Veterans Affairs medical center and followed for one year after discharge. The older alcoholic rehabilitation (OAR) program was operated by a tolerant staff that specialized in treating elderly alcoholics. Treatment included reminiscence therapy with goals of developing patient self-esteem and peer relationships. The traditional care program emphasized confrontation to focus on patients' past failures and present conflicts. Patient care costs were slightly lower (2.5 percent lower) in the OAR program than in the more traditional program, and OAR patients were 2.1 times more likely to report abstinence at one year. Response to the OAR program was best for patients over 60 years of age.     

General hospital psychiatry: Are its roles and functions adjunctive or pivotal?

General hospital psychiatric divisions are an important part of the mental health care delivery system; however, in Canada and the United States, their role and function have not been well defined. In most places, the general hospital is peripheral to the mental hospital, and is thus an adjunctive element in the resulting two-tier mental health care delivery system. The adjunctive type of general hospital psychiatric division provides brief treatment to highly selective types of patients, and is relatively inaccessible to a wide variety of patients. In contrast, the general hospital can be central to the mental health care delivery system--in a pivotal position to patients, other mental health facilities, and community agencies. Important features of the pivotal type are: defined catchment areas, broad admitting criteria and effective discharge planning, linkages with extramural and community programs, staff reorientation, appropriate architectural features, and the ability to hear and respond to the needs of the community. The pivotal type of general hospital psychiatric division can provide appropriate levels of inpatient care, as well as the linkages and backup to extramural and community programs for the long-term mentally ill. The mental hospital would no longer be used as a backup for general clinical disorders, involuntary patients, or patients usually rejected by adjunctive hospitals. There would be collaboration with other agencies in developing programs for special clinical groups (low prevalence disorders), as well as for alcoholism, psychogeriatrics, and adolescent disorders. This article reviews the current polemic on the role and function of the general hospital psychiatric division, as part of the mental health care delivery system.