Assertive community treatment: organizational adaptation.
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Community Mental Health Services↗
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PRISM: the Psychiatric Rehabilitation Integrated Service Model--a public psychiatric hospital model for the 1990s.
The Massachusetts Department of Mental Health's Metro South Area developed an inpatient psychosocial rehabilitation model called PRISM (The Psychiatric Rehabilitation Integrated Service Model) which emphasizes skill development and patient participation. This article describes the transformation of a state hospital into a rehabilitation treatment facility using the PRISM model. This approach has the potential to improve quality of life, decrease relapse, and increase the efficiency and responsiveness to patient needs of public sector hospitals.
Deinstitutionalization↗
[Decentralization--a social psychiatric key idea: experiences at the St. Gallen Canton].
In the St. Gallen county community care was not only organised in a decentralized way but also was anchored regionally by political means. Regional societies and community politicians are responsible for organizing and funding community care. After 17 years of experience, some of the consequences of this direct political influence on community care are reported.
Community Mental Health Services↗
The 'ward-in-a-house': residential care for the severely disabled.
This paper is concerned with the care of the most difficult and severely disabled new patients presenting to mental health services in the U.K. Questions of definition will be examined and the clinical and social characteristics of the population discussed. Since the defining characteristics (and prevalence) of this group are strongly affected by the overall service context, the range of community provisions within one health district (Cambridge) will be described. Examples of a new kind of institutional solution-the 'ward-in-a-house'-will then be presented, together with the underlying principles of management and care. The benefits and limitations of the model will be discussed.
Activities of Daily Living↗
Two modes of case management: assessing their impact.
This is a study of two strategies of case management-Community Treatment Teams (CTTs) and Intensive Case Management Teams (ICMTs). A random sample of 30 cases from the CTT group were matched with 30 cases from the ICMT group using 4 criteria. Data were collected from case records and verified with case managers. The analysis revealed that although the CTTs engaged in more case management activities, there were few significant differences in the outcomes of the two approaches. The results are discussed in relation to a possible "ceiling effect" of case management, cost effectiveness, and limitations in the sample.
Activities of Daily Living↗
The closure of a mental hospital in Sweden. 5 years of transition to district-based long-term care.
A political decision to decentralize psychiatric care in a county of Sweden was made in October 1984. This will lead to the closure of the county's only large psychiatric hospital. Short-term psychiatric care will be provided by three smaller hospitals in the county, while long-term care in hospital will cease completely and be replaced by district-based psychiatric services. All patients (n = 199) in the large hospital's long-term unit were studied over 5 years of the transition period. The results showed that 42% of patients were discharged during the period, mainly to other institutions. Only 8 patients were provided with alternative types of care, such as group homes. Sixty-eight per cent of all patients died, most of them before being discharged (80% of the organically demented patients and 51% of the others). The mortality rate for patients with severely impaired activities of daily living (ADL functioning) was 92% for those who were also organically demented and 84% for the others. The patients who survived the 5-year period were mainly (80%) nondemented patients with relatively well-preserved ADL functioning, but with behavioural disturbances.
Activities of Daily Living↗
The costs of accommodation and care. Community provision for former long-stay psychiatric hospital patients.
The development of community services to replace two long-stay psychiatric hospitals in the North East Thames Health Authority region of the UK has been the subject of a research programme since 1985. The economic evaluation is conducted by the Personal Social Services Research Unit; research results relating to the first five cohorts of hospital leavers are reported in this paper. When followed up 1 year after discharge, almost half of the sample were living in highly supported residential care units, most of which were managed by district health authorities. More than 40 services provided outside the accommodation facility were used by clients and, although contact with certain professionals remained constant, some changes in service use over time were marked. The average total cost of community care for this group was 493 pounds per week (1992-93 prices), accommodation facility costs comprising approximately 85% of the total. In the new service configuration, district health authorities fund half of the costs of supporting the hospital leavers, 50% less than when they funded long-stay hospital placements. The rest of the funding burden is borne by a range of agencies, resulting in pressure on budgets and staff case loads.
Adult↗
The future of children is now.
A community resource network, Annie Sullivan Enterprises, Inc., is described as a system for community integration of children and youth who have developmental disabilities and mental health problems. A brokerage model is espoused for accessing and delivering services. The model is based on Hobb's (1975) view that organization of human services must be based primarily on the client's needs rather than on the needs of the service agency. Lessons and recommendations based upon 7 years of successful operation are described.
Autistic Disorder↗
Normalization and its relevance today.
Historically, the normalization principle has been influential in promoting a comprehensive community-based service delivery system for people with developmental handicaps. However, its effects were more positive a decade ago when the issues were simply inhumane institutions or more individualized community-based alternatives. Issues in community-based programs for developmentally handicapped people have become more diverse and the choices more complex. In the current climate, the effects of the normalization principle have polarized issues for several reasons: The theory works better than current practice, the criteria are vague and the goals unattainable, normalization takes the focus away from individual client needs, the theory discourages diversity, normalization has become a rallying point for inappropriate practices, overzealousness of normalization advocates has polarized issues, normalization promotes an undesirable value system, and normalization ignores handicapped clients' deficits. What is needed to replace the normalization principle today are guiding concepts that are clearer, more responsive to client needs, and more reflective of value systems that are in the best interests of handicapped people.
Adult↗
Discharge-ready patients who remain hospitalized: a re-emerging problem for mental health services.
There is evidence that mentally ill patients nationwide are retained in state hospitals in spite of the fact that they are discharge-ready. New Jersey provided a unique opportunity to study this phenomenon, since it has been using specific procedures to identify discharge-ready patients in state hospitals. An analysis of New Jersey state hospital data found that about 45% of the state hospital patients were designated by either the legal or the clinical system, or both, as discharge-ready. Although a substantial number of these patients were disabled, they were assessed as being able to manage in the community with appropriate support. Characteristics and service needs of these patients are described, and the differences between those designated as discharge-ready and those who were not are examined. Recommendations are made for future research addressing the legal, clinical and social processes that affect discharge readiness.
Adolescent↗
The closure of a mental hospital in Sweden: characteristics of patients in long-term care facing relocation into the community.
A political decision to decentralize psychiatric care in a county of Sweden was made in October 1984, leading to the closure of the only large mental hospital in the area (290,000 inhabitants). The hospital is of the traditional type, with 490 beds and 1,294 staff members. It has units for long-term care, short-term care and rehabilitation and a unit for research and education. The long-term care is to cease completely and be replaced by community-based alternative types of care. In this study, the long-term population (n = 199) was characterized and their levels of functioning were measured. The results showed that 91% of the patients were 65 years old or more and that more than half of them were organically demented. Only 20% were chronic schizophrenics. All patients were cognitively impaired and 80% were also impaired in ADL functioning. A correlation between length of stay in hospital and ADL functioning was found in the organically demented group, but not in the group of chronic psychiatrically ill patients. Thirty-nine per cent of the population were severely impaired in ADL functioning and needed nursing care around the clock; 34% were moderately impaired and needed help and support that could be given in alternative types of care; 27% were not impaired at all to mildly impaired and could be relocated to some type of service apartment. Thus, all patients needed sheltered living arrangements and care provided by staff with adequate training.
Activities of Daily Living↗
Needs-based planning: evaluation of a level-of-care planning model.
With the closure of a number of provincial psychiatric hospitals planned, the Ministry of Health of Ontario has commissioned a series of planning projects to identify alternative placements for current hospital patients. The goal is to match need to care in the least restrictive setting. A systematic, clinically driven planning process was implemented that involved three steps: development of a continuum of levels of care representing increasingly intensive and more restrictive supports, development of criteria and decision rules for placement, and comprehensive needs assessment of current patients using the Colorado Client Assessment Record. Results showed that only 10% of current inpatients need to remain in the hospital, and over 60% could live independently in the community with appropriate supports. Evidence supports concurrent validity of the planning model, but further work is needed to assess whether recommended levels of care effectively meet consumer needs in the least restrictive setting.
Aged↗
The closing of Central State Hospital: long-term outcomes for persons with severe mental illness.
This study examined the clinical/community functioning of long-stay patients following closing of a large state psychiatric hospital. Two overlapping samples were followed: (1) the tracking project collected information on patient location, treatment provision, legal contacts, and level of functioning (LOF) and followed all discharged patients and (2) the research study subsample, drawn from the final group of discharged patients, gathered information on quality of life (QOL), LOF, and general physical and mental health. At follow-up, patients were functioning equal to or better than prior to discharge. There were consistent improvements in QOL (especially safety and occupational satisfaction) and LOF (especially housing and income/benefits). Fewer than 27% of patients discharged into the community were rehospitalized, and fewer than 4% were either in jail or homeless after 24 months. The study demonstrates that even persons who have been hospitalized for extremely long periods can do well in the community.
Adult↗
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.
Cost of Illness↗
The changing hopes, worries, and community supports of individuals moving from a closing long-term care facility.
This study examines client's hopes, worries, and social networks before, one year, and two years following release from a long-term care facility. More clients expressed hopes than worries before closure but, over time, hopes decreased and worries increased significantly. Before closing, independence was cited most often as a hope, followed by work and finances. Criminal opportunities headed up concerns, followed by mental health treatment, finances, living arrangements and independence. Over time, respondents were less excited about independence and living arrangements but more hopeful about social opportunities and everyday practicalities. Worries relating to family increased while concerns about deviance decreased. Respondents reported an average increase in network ties but the proportion of family members decreased while professional supports and ties with former CSH patients increased. The trends highlight particular vulnerability at the one-year point, the necessity of viewing movement into the community as a nonlinear process, and the importance of marking outcomes periodically.
Adaptation, Psychological↗
"Stakeholder" attitudes over time toward the closing of a state hospital.
For four groups--patients (N = 80), their families or lay caregivers (N = 120), hospital workers (N = 124), and the public (N = 108)--attitudes toward the decision to close the only long-term, urban state hospital are traced over time. Initially, patients were most supportive of the closing decision (65.4%), followed by family members (39.8%), the general public (27.8%), and workers (10.4%). A majority of all groups favored fixing the hospital. Almost half of the clients and more than half of other stakeholders expressed concerns about homelessness. Most attitudes were consistent despite respondents' sociodemographic characteristics. The overall profile of group attitudes remained remarkably stable, although there was a good deal of change in individuals' positions. Public support for fixing the hospital decreased significantly, and differences among stakeholders regarding homelessness disappeared. These findings reinforce the importance of ascertaining different constituencies' positions and recognizing the slowly changing response of stakeholders even under massive and successful policy change.
Adult↗
State mental hospitals and their host communities: the origins of hostile public reactions.
This article examines the hostile public reactions of a community that, through a state policy to consolidate all long-term behavioral health services, was to become the site of the state's only mental hospital. A telephone survey conducted in the host community (n = 800) and a matched community (n = 800) was used to test whether the origins of hostility toward consolidation were related to the public's negative attitudes toward mental illness and homelessness or to the beliefs about the discharge and supervisory behavior of the hospital. The host community was not found to have more negative views of mental illness, although it did have significantly more negative views about the homeless. Disapproval of consolidation was unrelated to negative views of mental illness or homelessness but was strongly related to the expected "bad" behavior of the hospital. These results suggest that the best way to improve relations between hospitals and their host communities is for hospitals to behave like "good" neighbors.
Attitude to Health↗
Length of stay for psychiatric inpatient services: a comparison of admissions of people with and without developmental disabilities.
This study investigated associations between the presence of developmental disabilities and length of inpatient stay for mental health care. All psychiatric admissions of people with developmental disabilities over a 5-year period were selected (n = 294), and were compared using survival analysis to a random sample of admissions from the general psychiatric population (n = 287). Overall, people with developmental disabilities stayed in hospital longer than those without developmental disabilities, and this extra stay was partially attributed to casemix differences between the cohorts. Subanalysis in both cohorts showed that those going back to their usual living arrangement stayed a shorter period than those who were discharged elsewhere, and that people with developmental disabilities were less likely to be discharged to their usual living arrangement than were people without the disability. This study highlighted the importance of specialized residential and personal supports for people with developmental disabilities and a coexisting mental disorder.
Adult↗