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PubMed1976

Phasing out state hospitals -- a psychiatric dilemma.

Whether state hospitals have a role in caring for mentally ill persons has been intensely debated for the past decade. During this time the inpatient census of public mental hospitals has fallen dramatically from 490,000 to 215,000 owing to increasingly effective treatment programs for acutely and chronically psychotic patients. The vast majority of patients currently cared for in state hospitals could be adequately treated in the community if a comprehensive spectrum of psychiatric services and residential alternatives were established. The failure to establish this network of community services before the discharge of thousands of patients has discredited the deinstitutionalization programs in many states, including California and New York, and forced California to abandon its plan to phase out all its state hospitals. Thus, although phase out of state hospitals is clinically feasible, it is unlikely at present since the fiscal and ideologic commitment to shift to community-based treatment is lacking.

Acute Disease↗
PubMed1991

Service planning for chronic mental patients: some principles.

Services for chronic mental patients in this era of deinstitutionalization present a major challenge to clinicians and planners alike. The complexity of these patients' clinical and other programmatic needs requires that an array of viable comprehensive services be made available to them. Following certain established principles of service planning will help facilitate patients' longitudinal, psychological, financial, and geographical access to care.

Delivery of Health Care↗
PubMed1984

The risk of suicide in young psychiatric patients hospitalized out-of-state.

Long-term hospitalization is becoming an increasingly specialized form of psychiatric treatment. The specialization involves not only training and orientation but also geographical location. As more state hospital systems "deinstitutionalize" and more private hospitals concentrate on short-term treatment, a recommendation for long-term hospital treatment is coming to mean, in most areas of the country, a referral to an institution far from the patient's home. The consecutive deaths by suicide of two out-of-state patients in one hospital that offers long-term treatment led to an investigation of a possible connection between suicide and hospitalization at a distance from home.

Adolescent↗
PubMed1997

Comparison of health and functional ability between noninstitutionalized and least dependent institutionalized elderly in Finland.

Finland's active deinstitutionalization policy aims to reduce the number of elderly people in long-term residential care and to keep noninstitutionalized elderly people living at home as long as possible. As a contribution to the issue of the appropriateness of long-term institutional care, we compared the health and functional ability of elderly people living at home or in residential care to assess the theoretical possibility of discharging the least dependent elderly from residential homes. Findings from two separate data sets collected in 1992 were compared; one (n = 475) was obtained by computer-assisted telephone interview (elderly at home) and the other (n = 459) by postal survey (elderly in residential care). The direct method was used in age and gender standardization, and logistic regression analysis was applied. Elderly people living at home were found to be in better health and with better functional ability than those in residential care. However, a proportion of home-dwellers needing some help with Activities of Daily Living (ADLs) assessed their health as being even worse than those in care, and approximated that of institutionalized elderly judged by the personnel to be able to manage with home-based care. Compared with home-dwellers, those assessed as able to manage in-home care were mostly single and had less education and more restrictions in their Instrumental ADLs and medication. Our results indicate that one third of those assessed as able to manage in-home care could possibly be discharged if adequate servicers and housing were available.

Activities of Daily Living↗
PubMed1986

Are schizophrenics a burden to their families? Significant others' views.

Concern about the effects of deinstitutionalization has generally related to the plight of former mental patients rather than to that of patients' families. In examining whether schizophrenic clients attending a community mental health center were burdensome to their families, this study focused on the perceptions of clients' significant others and concluded that burden and social supports might be related in important ways.

Adolescent↗
PubMed1978

Institutions and alternatives for older people.

A major national priority for older people is the provision of systems of social and medical care that may be applied to individuals in an effort to extend residence in the community or avert institutionalization altogether. Data reviewed here suggest that goals must be modest in attemtping to deinstitutionalize or avert institutionalization.

Aged↗
PubMed1983

Characteristics of mentally retarded people in residential facilities.

Although deinstitutionalization of mentally retarded people has become established as a goal within the social service system, its continued momentum will depend on the careful planning of services for those now in institutions. This study, therefore, explored the physical and behavioral characteristics of a national sample of the mentally retarded in residential facilities to provide information on the needs that will have to be met by community policies and programs.

Adolescent↗
PubMed1987

"Is it functional?" A question for music therapists who work with the institutionalized mentally retarded.

The criterion of ultimate functioning is beginning to be the standard for treatment in institutions for the mentally retarded. The medical and developmental models are being replaced as standards because they are not considered sufficiently effective for deinstitutionalizing adult severely and profoundly retarded clients. Music therapists are being required to devise treatment plans to develop functional leisure time skills that clients can pursue independently in a community setting.

Adult↗
PubMed2004

Use of standardized patients to enhance a psychiatry clerkship.

Changes in psychiatric health care delivery driven by such major shifts as deinstitutionalization, community-based care, and managed care have greatly altered the educational milieu for third-year psychiatry clerkships. Students may be assigned exclusively to alcohol and substance abuse treatment units, consultation-liaison services, or outpatient clinics, and may not have as broad an exposure as is desirable to patients with a variety of psychiatric illnesses. The authors describe a pilot course they developed in 2001, Clinical Psychiatric Assessment and Diagnosis, for third-year medical students at the Uniformed Services University of the Health Sciences medical school. The course uses standardized patients (SPs) to help students gain broader clinical experience. In psychiatry, a growing body of literature supports the acceptability, reliability, and validity of objective structured clinical examination assessment using SPs for medical students. Only a few articles report the use of SPs to primarily teach psychiatry instead of evaluating student proficiency in clinical psychiatry. Since this course was developed, the National Board of Medical Examiners announced that all medical students will be required to pass a clinical skills test in order to practice medicine, beginning with the class of 2005. The examination will use SPs modeling different clinical scenarios. In light of this change, many medical schools may have to reevaluate and possibly revamp their curriculums to insure sufficient acquisition of clinical skills in different specialties. The use of SPs in psychiatry could provide an effective, primary clinical teaching experience to address this new requirement as well.

Clinical Clerkship↗
PubMed2002

Family needs and burdens of mentally ill offenders.

A growing number of research projects have been devoted to the study of needs, burdens and intervention programmes of families of psychiatric patients due to the emphasis on deinstitutionalization and community integration. Although it is noted that burdens for families when looking after a patient with a criminal history are even heavier and more complicated, studies on identifying family needs and burdens for mentally ill offenders have been very limited. This paper reviews literature on family burdens and studies on family needs for psychiatric patients with a forensic history. Methodological problems of available studies are discussed. In addition, a theoretical model that can be used as a conceptual guide for the study of burdens of families of mentally ill offenders is postulated. Directions for further research are discussed.

Cost of Illness↗
PubMed2005

Out-of-home placement of children with intellectual disability: Israeli-born parents vs. new immigrants from the ex-USSR.

Although the policy of deinstitutionalization encourages parents to raise a child with development disability at home, professionals are becoming increasingly aware of these parents' care-giving roles. Immigrant parents from the ex-USSR who have children with developmental disabilities are potential clients for placement, but to date, the tendency in Israel to out-of-home placement by immigrant parents, compared with Israeli-born parents, has not been studied. The placement variables were examined as a function of place of birth, emotional stress and social support. The sample was 100 parents who have children aged 6-21 years with mild to moderate mental retardation (according to the American Association on Mental Retardation definition) who live at home. Fifty parents were immigrants (arrived in Israel after 1990) and 50 were Israeli-born. They live in the region of Haifa and the north of Israel. The following measurements were carried out: (1) Demographic Questionnaire for data such as place of birth, age, socioeconomic status, etc., (2) Questionnaire of Resources and Stress, (3) Family Support Scale and (4) Out-of-Home Placement Questionnaire. The results showed that parents' readiness to apply for out-of-home placement proved to be related to their stress level and child's age, regardless of their origin (immigrants or Israeli-born) and regardless of social support resources. The older the children with mental retardation and the higher the stress levels felt by their parents, the higher was these parents' potential to apply for out-of-home placement. Immigrant parents tended to report a significantly higher level of stress than Israeli-born parents. No difference was found in the social support resources available to both research groups. Immigrant parents' stress level was higher as the child's mental retardation level was more moderate and their time in Israel was longer. Stress level among Israeli-born parents was higher among those who were religious, were of lower socioeconomic status and/or when, in addition to the mental retardation, the child suffered from other medical problems. In conclusion, families with children with mental retardation should be referred to services in an integrative way, regardless of the origin of the children's parents. Professionals must increase their own awareness of parents' level of stress and its impact on their readiness to apply for out-of-home placement. Recommendations for practical work and for future researches are made.

Adaptation, Psychological↗
PubMed1992

An analysis of treatment services provided in group homes for adults labeled mentally ill.

Although group homes for adults labeled mentally ill have been the focus of significant attention in deinstitutionalization discussions, substantive research on their operation has been lacking. The present study addresses past limitations by focusing on a well-defined sample of small group homes, with higher staffing levels and in-home treatment provided. Thirty homes were randomly selected; all home residents (N = 253) were studied. Data were collected from case managers, residents, and home staff to assess residents' functioning, services and treatments provided, and the environment of the home. The findings were examined in terms of adequacy and appropriateness of care provided in the home, using accepted guidelines. The results indicated that there are aspects of a homelike environment, emotional support from staff, and skill-development activities within the home. However, an institutional focus still seems prevalent, along with limited rehabilitation and socialization activities. Residents expressed high levels of satisfaction, which may reflect their dislike of the group home alternative, e.g., the state hospital. Policy implications are discussed vis-a-vis current efforts to move away from group homes toward supported housing initiatives.

Activities of Daily Living↗
PubMed2001

Lessons from the unexpected: the importance of data infrastructure, conceptual models, and serendipity in health services research.

In examining the importance of data systems, conceptual models, and serendipity in understanding health services, the case is made for a vigorous and responsive data infrastructure and more emphasis on conceptual development. Particularly important is the development of data systems that can keep pace with changes in health care organization and patterns of care. Three examples--from managed care, deinstitutionalization, and physician remuneration--demonstrate the need to empirically examine seemingly obvious assumptions about health patterns and trends, and the lessons to be learned when assumptions are proved incorrect. Major future challenges include incorporating patient preferences into outcomes research, meaningful communication about treatment options and health plan choices, and understanding how organizational culture and norms affect decision processes.

Health Maintenance Organizations↗
PubMed1989

The social reception of mainstreamed children in the regular classroom.

The purpose of the present study was to learn how a mainstreamed mentally retarded or emotionally disturbed child is received in a regular classroom by the other pupils in the class. Each of 36 fifth grade boys interacted with one of three male confederates and 36 eighth grade boys interacted with one of three other male confederates. In each case the confederate was of the same age and grade as the subjects. He was presented to the subject as an ordinary child, as a mentally retarded child, or as an emotionally disturbed child who might soon attend their school and the subject was asked to estimate how the confederate would fit into the school. The confederate was always blind to condition and, after the interaction, the subject was questioned about the confederate by an experimenter also blind to condition. Behavioural measures taken from the sound recordings of the interaction showed that the subjects in the mentally retarded and emotionally disturbed conditions behaved in a less friendly and more anxious manner than in the control condition. They also wanted more social distance from the 'retarded' and the 'disturbed' confederate and expected their peers to be more rejecting toward them relative to the control condition. Essentially the same results were obtained for fifth and eighth grade boys and little difference was found between the two types of mental handicaps. The implication of the study for deinstitutionalization are discussed.

Affective Symptoms↗
PubMed2006

Do staffing levels determine outcome in psychiatric inpatient care? - Factors related to the ratio of period hospitalized in Japan.

The aim of this study was to determine the factors related to outcome, as measured by the cumulative number of days hospitalized, of a cohort group of inpatients with a diagnosis of schizophrenia followed up for 6 years. Comprehensive data were obtained from 18 psychiatric hospitals from two surveys conducted in 1993 and 1999. Outcome was evaluated by calculating the cumulative number of days between the two surveys that the cohort group was hospitalized. Tree-based models analysis was used to explore the factors related to outcome. Patient characteristics at the time of the first survey that were related to outcome were the number of days hospitalized, cumulative number of years hospitalized, age, Global Assessment of Functioning score and relationship to the main visitor. The number of beds in each hospital and changes in their number were also related. Increasing staffing levels is not likely to impact on deinstitutionalization since their levels were not related to outcome.

Adult↗
PubMed1994

Environmental safety preparation for community-based nursing educational experiences: measurable indices.

Cities, formerly the hub of cultural activities and entertainment, are now more often associated with crime statistics and poverty. Students' emotional comfort and safety must therefore be prime considerations in planning community-based nursing education. This study piloted an instrument that promises to be useful in labeling situations that affect an individual's comfort level in an urban setting. Questions that guided the study included: (1) Does the Environmental Comfort Scale (ECS) score vary with the respondents' residential zone (urban = 1, suburban = 2, rural = 3)? (2) Is the instrument (Environmental Comfort [Fear] Scale) reliable? A one-shot, one-group, pre-experimental design was employed. Participants were self-selected from a junior baccalaureate nursing class (N = 79) that was a predominantly suburban-bred, relatively privileged population. The ECS contained nine specific environmental-situation items that could be construed as potentially threatening to safety. Respondents were to indicate on a five-point Likert scale the extent to which they would be fearful in each situation; 1 = least fearful and 5 = most fearful. Findings showed practically no difference in responses by residential zone and suggest a need for item refinement and a need to lengthen the tool to improve alpha coefficients. Further, the increasing demand for measurable outcomes underscores the need for continued work on instruments to produce such data. The deinstitutionalization of health care from contained grounds to uncontained community-based settings makes it imperative that nursing education attend to the challenges of safety education.

Community Health Nursing↗
PubMed1992

Does case management reduce the rehospitalization rate?

It was expected from deinstitutionalization that outpatient care could replace hospital care. But many empirical studies proved that the number of admissions to psychiatric hospitals rose when community-based care developed. This might be due to the lack of coordination and cooperation of extramural services. The concept of case management therefore originated in the last few years. In this study the effect of case management on the rehospitalization rate is examined by analyzing the data of 4 social-psychiatric services responsible for defined catchment areas. During the evaluation period of 2.5 years, 162 patients dismissed from psychiatric hospitals were referred to those services. For each of these index patients a matched control patient was identified, each identical in diagnosis, sex, age, living conditions and number of previous inpatient episodes. The results of a survival analysis show that there are no significant effects of case management on the rate of rehospitalization nor on the length of time in hospital in case of a rehospitalization.

Adult↗
PubMed1999

Continuity of care and readmission in two service systems: a comparative Victorian and Groningen case-register study.

OBJECTIVE: We compared service consumption, continuity of care and risk of readmission in a record linkage follow-up study of cohorts of patients with schizophrenia and related disorders in Victoria (Australia) and in Groningen (The Netherlands). These areas are interesting to compare because mental health care is in a different stage of deinstitutionalization. More beds are available in Groningen and more community resources are available in Victoria. METHOD: The cohorts were followed for 4 years, since discharge from inpatient services using record linkage data available in the psychiatric case-registers in both areas. Survival analysis was used to study continuity of care and risk of readmission. RESULTS: Available indicators showed a higher level of continuity of care in Victoria. While the relative risk of readmission was the same in both areas and not affected by aftercare contact after discharge, the number of days spent in hospital was much higher in the Groningen register area. CONCLUSION: These findings provide further support for earlier reports that the risk of readmission is predominantly affected by attributes of mental illness. However, the duration of admissions, is strongly affected by service system variables, including the provision of continuity of care.

Adolescent↗