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PubMed2002

Understanding those who seek frequent psychiatric hospitalizations.

In the period after deinstitutionalization, there has been a rise in hospital readmission rates. It is estimated that the readmission rate for individuals who are frequent users of psychiatric inpatient services is approximately 40% to 50% within 1 year of hospital discharge. Attempts to determine predictors of recidivism have identified multiple variables, some of which are mutually contradictory. Furthermore, comparison among studies is difficult given methodological and theoretical limitations. Despite such issues, however, one consistent predictor of frequent rehospitalization is a person's history of past psychiatric hospital admissions. It seems that those who have shown a pattern of seeking inpatient services in the past tend to repeat this treatment-seeking behavior. The aim of this report is to critically examine some of the predictors of rehospitalization. A better understanding of those who engage in the persistent pattern of seeking inpatient services may assist nurses in planning care that is more suited for their needs.

Canada↗
PubMed2002

[Subjective quality of life in severely disabled long-stay schizophrenic patients].

In the controversy about severely chronic mental patients, who still reside in the psychiatric hospital after decades of deinstitutionalization, their quality of life (QoL) has become a main topic. On the basis of a critique of the dominant, mere standardized approach to QoL this method is compared with a qualitative approach in such a schizophrenic "residual" patient group (n = 144). While in the standardized approach a high level of subjective QoL could be found that correlated positively with the duration of hospitalisation, the open interviews yielded specific experiences of deficiencies. The appraisal of the quality of life especially of chronic or hospitalized patients is reconsidered.

Adult↗
PubMed1983

Pediatric nursing homes. Implications of the Massachusetts experience for residential care of multiply handicapped children.

Pediatric nursing homes were established in Massachusetts in 1971, in response to the crisis created by the deinstitutionalization of children with multiple severe handicaps for whom care in the community was unrealistic. Although these residential beds provided short-term relief for the system, failure both to plan for the improved long-term survival of the children and to develop alternative community services for those whose functional and medical status changed has left fundamental problems unresolved. A review of the 421 residents of pediatric nursing homes since 1972 shows that most have been bedridden and nonverbal, requiring provision of basic care: feeding, dressing, maintaining hygiene, and sensory and motor stimulation. Three quarters of the residents were severely or profoundly retarded and had seizures. About 4 per cent died each year, and another 5 per cent were discharged; few beds were available for new admissions. Low standards of care and financial disincentives have resulted in less than optimal educational and rehabilitative services. Other states are facing similar problems, which can be resolved only through better funding and coordination of the relevant state agencies.

Certification↗
PubMed1989

Use of psychoactive medication and the quality of care in rest homes. Findings and policy implications of a statewide study.

Rest homes have become a major component of the health care system for frail elderly persons and deinstitutionalized psychiatric patients. Although psychoactive medications are frequently used in rest homes, there is little detailed information about the extent of such use, its supervision, or its effects. In a survey of a random sample of 55 rest homes in Massachusetts, we found that 55 percent of the residents were taking at least one psychoactive medication. Antipsychotic medications were being administered to 39 percent; of these, 18 percent were receiving two or more such drugs. In a follow-up investigation, we studied 837 residents in 44 rest homes with particularly high levels of antipsychotic-drug use. About half the residents had no evidence of participation by a physician in decisions about their mental health during the year of the study. A third of the residents had performance deficits on mental-status testing that indicated serious cognitive impairment, although the causal relation of such impairment to medication use could not be determined. Six percent had evidence of moderate or severe tardive dyskinesia, probably as a side effect of medication. An assessment of staff competence revealed a low level of comprehension of the purpose and side effects of commonly used psychoactive drugs. We conclude that psychoactive drugs are widely used in rest homes, with little medical supervision or understanding by staff members of their possible side effects.

Aged↗
PubMed2000

Orthodontics and the population with special needs.

During the past 30 years, more than three quarters of individuals with mental retardation/developmental disabilities have been deinstitutionalized and now reside in our communities, relying on community physicians and dentists (even orthodontists) for needed services. A presentation is made to increase orthodontic practitioner awareness of the magnitude and dimension of the increasing numbers of youngsters and adults with special needs who now reside in their communities and require their services, and to provide some insight and response for the query, "Why orthodontics?"

Adolescent↗
PubMed1993

On the perception of madness.

Since the beginning of recorded history, mental illness has been recognised as being primarily in the province of the healing profession. This view has continued, despite the fact that psychiatry left the mainstream of medicine with the development of asylums during the 19th century. With the advent of deinstitutionalization however, psychiatrists, particularly in Australia, have increasingly left public practice. As a result, the treatment of the severely and chronically mentally ill, especially those with behavioural disorder, has become neglected. It is argued that moves toward the mainstreaming of acute psychiatry to general hospitals offer a new opportunity for the profession to reassert itself in this essential but difficult area of psychiatric practice.

Australia↗
PubMed2005

The development of psychiatric care after the mental health care reform in Sweden. A case register study.

A process of deinstitutionalization and a series of mental health care reforms targeting severely mentally ill persons have taken place worldwide. The objective of this study was to follow-up the volume of psychiatric care after the 1995 Swedish reform and to study if the intended efforts of the reform were fulfilled. In a municipality, during the time-period 1994-2003, the development of number of days of inpatient care, inpatient care episodes, visits to outpatient facilities and the number of unique patients were studied using case registers. The number of persons staying in group homes and nursery homes was also studied. The number of days of inpatient care for persons given a diagnosis of schizophrenia was drastically reduced, but this reduction was quantitatively substituted by the persons staying in different kind of group homes. The implementation of new psychiatric field teams directed towards persons with psychosis and new social service field teams targeting this same group were reflected in the registers. Data supported that the intended efforts of the mental health care reform were in fact carried out, but the prioritizing of the target group of the reform may have influenced the care of persons with other kinds of psychiatric problems negatively.

Cohort Studies↗
PubMedDate not supplied

Residential transitions from nursing homes for adults with cerebral palsy.

PURPOSE: The impact of moving out of nursing homes into community-based settings for adults with cerebral palsy was assessed by comparing the health and community functioning of movers and non-movers at time 1 and 3 years later at time 2. SUBJECTS: The sample included 83 non-movers and 28 movers age 30 years and older who initially were living in nursing homes. The majority of residents had severe to profound mental retardation. The movers transferred to 15 community-based settings between 1 and 3 years (mean of 2 years) prior to the time 2 assessment. Assessments of residents at baseline and at follow-up included health measures (health status, health limits, mobility limits, days hospitalized and depression) and community functioning measures (adaptive functioning, maladaptive behaviour, community inclusion, day programme hours and monthly wages). RESULTS: Findings indicated that movers showed benefits in terms of improved health and community functioning. For movers, health status, mobility limitations, and community inclusion improved, while there were no significant changes for non-movers. This research corroborates previous research on the effects of deinstitutionalization and expands its implications to a group with severe disabilities.

Adult↗
PubMed2006

Radical redesign of nursing homes: applying the green house concept in Tupelo, Mississippi.

PURPOSE: We present the concept of the Green House, articulated by William Thomas as a radically changed, "deinstitutionalized" nursing home well before its first implementation, and we describe and discuss implications from the first Green Houses in Tupelo, Mississippi. DESIGN AND METHODS: Green Houses are small, self-contained houses for 10 or fewer elders, each with private rooms and full bathrooms and sharing family-style communal space, including hearth, dining area, and full kitchen. Line staff at the level of certified nursing assistants, called Shahbazim, are "universal workers," who cook meals, do laundry, provide personal care, assist with habilitation, and promote the elders' quality of life. Nurses, doctors, and other professionals comprise a visiting clinical support team for the residents and Shahbazim. Multiple Green Houses comprise a nursing home, meeting all nursing facility regulations and working within state-reimbursement levels. In 2003, four Green Houses were built on the campus of a retirement community; in June of that year, 40 residents relocated from the 140-bed nursing home to the Green Houses, including 20 residents previously living in the locked dementia unit. RESULTS: Experiences to date are positive for residents, family, and staff. The sponsor is converting the entire facility to Green Houses, and other providers around the country plan to implement Green House variants. IMPLICATIONS: Because nursing home stock is aging, many physical plants are or soon will be slated for major rebuilding, thereby providing sponsors with an opportunity to consider Green Houses. Early experience suggests that Green Houses are feasible and that outcomes are likely to be positive, and it also suggests that there are some potential issues to overcome in such a dramatic reengineering of nursing homes.

Assisted Living Facilities↗
PubMed1987

Reforming health care for the elderly--the example of Vorarlberg.

Vorarlberg--Austria's most western province with a population of about 325,000--has always implemented forms of social policy in which the principles of subsidiarity and solidarity play an important role. This is reflected in the structure of the organizations traditionally providing social services as well as in the more recent programmes the government has developed for social policy. This paper discusses two cases in point: the private associations for home care (Krankenpflegerverbände)--which now exist in 65 Vorarlberg communities and cover 85% of the population in the province--offering nursing services at home to members or to persons who are willing to join the organization when they need care, and the new organizational model, called Gesunder Lebensraum Vorarlberg (GLV), which is successfully operating in a few pilot communities. GLV has spawned umbrella organizations, run by volunteers, and offering a variety of social services relevant to the elderly, for example visiting services or neighbourhood help in case of emergencies. The volunteers get organizational help from a profit-making firm financed by the government. The Vorarlberg models can be interpreted as a step towards demedicalization and deinstitutionalization of health care for the elderly. Nevertheless, they also show the problems that arise when professionals and volunteers must cooperate. The models may lead to savings for the governments involved, although details are still subject to future empirical investigations.

Aged↗
PubMed1987

Boarding home residents: new underclass in the mental health system.

Boarding homes have proliferated in recent times, spawned by the deinstitutionalization movement. This study explored the realities of living in these homes by using a quantified assessment procedure to examine their programs and policies. Findings suggest an absence of support and stimulation for the residents of homes and a need for outreach and advocacy on the part of social workers in community mental health practice.

Activities of Daily Living↗
PubMed1991

Operating a member-employing therapeutic business as part of an alternative mental health center.

The promises of deinstitutionalization have not been kept for unemployed chronically mentally ill people. This article describes an innovative community support program--a nonprofit therapeutic member-run business. Rainbow Services provides opportunities for adults with chronic mental health problems to learn marketable job skills and necessary social skills through participation in various work settings. On-site job training, vocational education, socialization, and job counseling are offered. Thirteen years of business success demonstrate that chronically mentally ill people can function productively in the community. The features of the business are related to beliefs and values familiar to early settlement house workers and social activists and support social work's claim to leadership in working with this population.

Community Mental Health Centers↗
PubMed1983

Making cooperative living work for psychiatric outpatients.

In the wake of deinstitutionalization, the exploration of alternative placements and living arrangements in the community has come to the fore. After describing a program for cooperative apartment living for female psychiatric outpatients, this article assesses the program's economic cost and its benefits to clients and outlines the authors' recommendations concerning future efforts to develop cooperative living programs.

Activities of Daily Living↗
PubMed1997

Mortality in psychiatric hospital patients: a cohort analysis of prognostic factors.

BACKGROUND: This work followed a group of patients living in a psychiatric hospital in Central Italy in 1978 at the time of enforcement of the Italian reform law (No. 180) for closing down mental hospitals. The study had the following aims: a) to compare in terms of mortality patients discharged into the community with patients who did not experience deinstitutionalization; b) to determine the survival of the cohort of patients and to analyse prognostic risk factors for death; c) to analyse differences in mortality rates between psychiatric patients and the general population. METHODS: The study was designed as an historical follow-up investigation. Univariate (product limit) and multivariate (proportional hazards model) methods were used to estimate prognostic variables and related death risks. Mortality was assessed using standardized mortality ratios (SMR) on the entire cohort as well as after stratification according to age, sex, cause of death and discharge status, assuming the Abruzzo Region's population as standard. RESULTS: Length of hospitalization and discharge from hospital are prognostic variables for death risk, with relative risks respectively of 4.22 (95% confidence interval [CI]: 2.41-7.40) for a length of hospitalization of 10-25 years, and 8.13 (95% CI: 4.73-13.88) for non-discharge. The global SMR of the cohort was 2.68 (95% CI: 2.42-3.07). Non-discharged patients showed higher SMR than discharged. Excess mortality was found both in males and females for circulatory, respiratory and undefined diseases. A significantly lower mortality for cancer was observed in male patients. A strong excess mortality was observed in younger patients (20-29 years: SMRmales = 43.57; SMRfemales = 97.52). CONCLUSIONS: Longer periods of hospitalization and non-discharge from hospital are the main risk factors for death in psychiatric patients, who globally experience higher death rates than the general population for a wide spectrum of causes of death, whatever their diagnosis or gender. These findings strongly suggest positive actions in order to overcome the effects of institutionalization.

Adult↗
PubMed2003

Met and unmet needs of schizophrenia patients in a Spanish sample.

Deinstitutionalization of people with schizophrenia increases the importance of evaluating their needs. This study set out to identify the most common needs of people with schizophrenia who live in the community, analyze how those needs differ when evaluated by staff or by patients, describe the kind of help patients receive, and find out the variables that correlate with having unmet needs. A random sample of 231 outpatients with schizophrenia were evaluated with the Camberwell Assessment of Need and other predictor and outcome variables. Staff detected more needs than patients did. Mean number of needs as rated by patients was 5.36 and staff 6.6 (p < 0.001). Mean number of unmet needs was also greater when assessed by staff than by patients: 1.38 versus 1.82 (p < 0.001). The most frequently detected needs by patients involved psychotic symptoms, house upkeep, food, and information. Staff most often detected needs involving psychotic symptoms, company, daytime activities, house upkeep, food, and information. In a multiple regression model, needs were weakly associated with the clinical variables and quality of life. Needs assessment is complementary to clinical evaluation in schizophrenia.

Activities of Daily Living↗
PubMed1995

Vocational rehabilitation in schizophrenia.

Schizophrenia exacts a heavy toll on a person's capacity to work, and a variety of vocational rehabilitation interventions have been developed over the past few decades to enhance the vocational capacities of persons with this disorder. The research literature on outcomes of vocational rehabilitation during the era of deinstitutionalization for persons with schizophrenia is reviewed. Most vocational rehabilitation programs have a positive influence on work-related activities, but most have failed to show substantial and enduring impacts on independent, competitive employment. Recent advances in supported employment suggest that vocational rehabilitation offers greater promise than do transitional and sheltered employment approaches. Vocational rehabilitation intervention may also exert positive influences on such clinical outcomes as medication compliance, symptom reduction, and relapse.

Deinstitutionalization↗
PubMed1982

Assessment of outcomes in community support systems: results, problems, and limitations.

Assessment of outcomes in community support systems for chronic mental patients is associated with a number of difficulties, including the lack of an operational definition, the need to study synthesized programs as approximations to organic community support systems, ans severe methodological deficits within existing studies and in cross-study comparability. Although outcome studies indicate that community support programs show some apparent advantages in the treatment of patients, treatment gains are limited and tenuous. Moreover, interpretation of study results must be tentative because of methodological and programmatic limitations. Improved program evaluation and impact evaluation procedures are necessary to assess the efficacy of community support systems both in enhancing patient care and in providing solutions for the problems associated with deinstitutionalization.

Community Mental Health Services↗