Patterns of care in the field of mental health. Conceptual definition and research methods

Predicting patterns of service utilization within children's mental health agencies

BACKGROUND

Some children with mental health (MH) problems have been found to receive ongoing care, either continuously or episodically. We sought to replicate patterns of MH service use over extended time periods, and test predictors of these patterns.

METHODS

Latent class analyses were applied to 4 years of visit data from five MH agencies and nearly 6000 children, 4- to 13-years-old at their first visit.

RESULTS

Five patterns of service use were identified, replicating previous findings. Overall, 14% of cases had two or more episodes of care and 23% were involved for more than 2 years. Most children (53%) were seen for just a few visits within a few months. Two patterns represented cases with two or more episodes of care spanning multiple years. In the two remaining patterns, children tended to have just one episode of care, but the number of sessions and length of involvement varied. Using discriminant function analyses, we were able to predict with just over 50% accuracy children's pattern of service use. Severe externalizing behaviors, high impairment, and high family burden predicted service use patterns with long durations of involvement and frequent visits.

CONCLUSIONS

Optimal treatment approaches for children seen for repeated episodes of care or for care lasting multiple years need to be developed. Children with the highest level of need (severe pathology, impairment, and burden) are probably best served by providing high intensity services at the start of care.

Defining Episodes of Care in Children's Mental Health Using Administrative Data

Criteria to define an episode of care in children's mental health services are needed. Various criteria were applied to 5 years of visit data from children 4-11 years (N = 5,206) at their first visit to 1 of 3 children's mental health agencies. A minimum of 3 visits with 180 days between episodes optimized agreement with other dates (e.g., telephone intake assessment) marking the start and end of an episode, and clinician-rated number of episodes. Grouping visits into episodes provides a clearer representation of how services are distributed over extended periods of time, facilitating research and enhancing accuracy in service planning.

Il contributo dell'epidemiologia alla valutazione dei servizi psichiatrici

A discussion of epidemiologic researches for the evaluation of psychiatric care is presented. With regard to the Italian context the author stresses the importance of analytical studies over the descriptive ones. The main design options for the evaluation of quality of care are then considered in the psychiatric framework.

The mental health system in Lombardy, Italy: access to services and patterns of care

PURPOSE

The psychiatric reform in Italy devolved to the regions the responsibility of implementing community psychiatric care. The aim of this paper is to evaluate the mental health system in Lombardy by assessing changes in accessibility and patterns of care occurred between 1999 and 2009.

METHODS

Data on mental health services were collected through the regional mental health information system and analyzed in terms of treated prevalence, treated incidence, continuity of care and packages of care.

RESULTS

Both treated incidence and treated prevalence in Lombardy increased between 1999 and 2009. There was an increasing access to psychiatric services of people with a better social integration. Incidence of schizophrenic and personality disorders decreased and that of affective and neurotic disorders increased dramatically, while increase in prevalence concerned all diagnostic groups. The percentage of patients in continuous care remained stable and was generally low. The majority of cases, even those with schizophrenia, are cared for on outpatient basis. The percentage of patients receiving integrated multiprofessional care declined. Rates of admission to inpatient services remained low and within the inpatient sector a shift from hospital towards residential care emerged, with decreasing hospital utilization and an increase in size of patient population entering community residences. Treatment gap is still a problem in schizophrenic disorders.

CONCLUSIONS

The Lombardy mental health system is strongly based on community care. However, it is reaching a turning point and it needs to be improved in some key areas: the shifting balance towards the care of common mental disorders, in the absence of resource allocations targeted to severely mentally ill, may hinder the system ability to deal with more disabled people. A focus on early intervention and an improvement of continuity of care for people with severe mental disorder, by strengthening community teams, is a priority.

Reconstructing continuity of care in mental health services: a multilevel conceptual framework

Continuity of mental health care is a key issue in the organization and evaluation of services for patients with disabling chronic conditions. Over many years, health services researchers have been exploring the conceptual boundaries between continuity of care and other service characteristics. On the basis of papers published over the past decade, we argue that while conceptual consensus is growing, there is room to improve continuity measures, and the development of practical interventions is still at an early stage. There is growing consensus that continuity of care is a multidimensional concept. We identified four core elements: continuous care; care of an individual patient; cross-boundary care; and care recorded objectively. These elements help clarify conceptual boundaries, and incorporate measurement guidelines. With reference to these core elements, we define types of continuity of care, including informational continuity, management continuity, relational continuity and contact continuity. In order to improve continuity of care, better understanding is needed of the complex inter-relationship of core elements and types of continuity. A multilevel perspective on continuity of care can guide research to develop and evaluate new interventions. Achieving continuity of care is hindered by the lack of standard measures and administrative data appropriate to assessing continuity. Account should be taken not only of the nature of the patient population, but also of local conditions. To address these topics and identify best practices, research should be multidisciplinary and take a comparative, naturalistic form.

The Addiction Severity Index as a predictor of the use of mental health care

The Addiction Severity Index (ASI) has been extensively used in the United States and Europe as an indicator of the problems of substance abuse patients. Several studies have shown the ASI to be a reliable and valid instrument, but lately doubt has arisen regarding its validity and reliability. The article focuses on a specific scale of the ASI--the Psychiatric Status scale--and its strength in predicting the use of mental health care. A group of 1,027 heroin patients in Rotterdam, the Netherlands, who participated in a methadone program were the subjects. Three indices have been used: the evaluation index, the clinical index, and the composite scores. It appears that no matter which indices are used, the Psychiatric scale does discriminate between those who will have contact with mental health care and those who will not. However, the percentage of false positives is high. None of the indices predicts the intensity and duration of the mental health care treatment.

[Packages of care in the departments of mental health in Lombardy]

OBJECTIVE

The analysis aims to study the packages of care in the public Departments of Mental Health by diagnosis and service utilisation intensity.

DESIGN

Data on community, hospital and residential contacts were provided by the Regional Psychiatric Information System. The sample has been composed by 55,518 patients residents in Lombardy and treated in public Departments of Mental Health.

SETTING

The public Departments of Mental Health in Lombardy.

MAIN OUTCOME MEASURES

Fifteen packages of care were defined according to researchers' experience; the package "community care only" has been divided in five sub-packages; for every package the care weight has been attached.

RESULTS

Four packages of care ("community care only", "hospital care plus community care", "hospital care only" "community care plus day centre care") represented 95% of the patients. Three quarter of the patients were treated only in the community setting, without hospital, residential and day centre contacts in the year. Heavier patients (patients with more than 5000 care weight) represent only 4%. Residential care is the heavier setting (36% of the total weight), while schizophrenia is the diagnosis with mayor impact on the community services (59% of the total weight). Of the patients treated only in the community setting one third receives only psychological and psychiatric visits, while two thirds integrated community care. Conclusions in community care the mixed packages represent the exception not the rule. More complex or heavier packages are addressed to severe mental illness patients.

Analysis of patterns of mental health care with three different approaches (cross-sectional, longitudinal and dynamic)

OBJECTIVE

This article attempts to provide an overview of different methods of analysis of information on service utilization from different approaches.

METHODS

A systematic review of the studies of pattern of care is done. The analysis of pattern of care has been divided into three different approaches: cross-sectional, longitudinal and dynamic.

RESULTS

In cross-sectional studies, information on utilization is based on the total number of contacts with mental health services during a given period. In the second approach, called longitudinal, survival analysis is applied considering the interval of time between each contact. The third type of analysis, called here the "dynamic" approach, involves the application of mathematical models based on the Markov chain to analyse the probability of change from one type of contact to another.

CONCLUSIONS

We emphasise the need for further studies designed to analyse data from psychiatric case registers with standardised models for mental health services utilization analysis.

A way of obtaining isoresource consumption care episodes

The purpose of this study is to identify groups of care episodes that involve pneumologic and cardiologic problems and that exhibit homogeneous patterns of frequentation and diagnostic test consumption in an ambulatory consulting room. A 1-year prospective study of care content was done, and the episodes were retrospectively analyzed 2 years later. Data were collected in an ambulatory cardiologic and pneumologic consulting room in Spain. Nonlinear principal components analysis was applied before cluster analysis. Five typologies with a homogeneous pattern of resource consumption were obtained: three related to acute episodes of care and two to chronic ones.

[Patterns of care in community mental health services in Lombardy]

OBJECTIVE

The analysis aims to study patterns of care of patients in contact with 5 Psychiatric Services in Lombardy. Four patterns have been identified long term-high users, non long term-high users, long term-non high users, non long term-non high users.

DESIGN

Data were provided by the regional Psychiatric Information System. The cohort of patients have been composed by 5,670 patients included in 1994 one year prevalence.

SETTING

Five Psychiatric Services (Merate, Treviglio, Crema, Desio, Castano Primo) with a total population of 610,184 inhabitants aged over 14. MAIN UTILISED MEASURES: Some sociodemographic and clinical variables have been taken into consideration for a descriptive analysis; a multinomial logistic regression model was used to identify the characteristics of patients associated with different patterns.

RESULTS

Long term-high users were 5.3%, i.e. a mean rate of 4.9/10,000 residents over 14, and absorbed 60% of resources, the absence of a partner was associated in regression analysis with this pattern. Non long term-high users were 1.2%, i.e. a mean rate of 1.1/10,000 residents over 14, and absorbed 7.8% of resources; age below 45, unemployment, absence of a partner, severe mental illness and first contact with Psychiatric Services in the period 1985-1989 were predictive variables. Long term-non high users were 23.4%, i.e. a mean rate of 21.6/10,000 residents over 14, and absorbed 18.1% of resources; age below 45, unemployment, living alone, absence of a partner, severe mental illness and first contact with Psychiatric Services before 1990 were predictive variables. Non long term-non high users were 70.1%, i.e. a mean rate of 64.8/10,000 residents over 14 and, absorbed 18.1% of resources.

CONCLUSIONS

Data show that on the whole the activity of Psychiatric Services is addressed to most serious patients, though considerable differences between Psychiatric Services utilisation may be found. This study highlights the importance of a regional Psychiatric Information System, that allows the monitoring in time and in the regional territory of patterns of care.

Service utilization: a pivotal measure in assessing service needs and service outcome

In past years the study of service utilization has given a great contribution to the evaluation of mental health services. Nowadays, the challenge that must be faced is to obtain from service utilization research useful knowledge for clinical practice and service planning.

Psychiatric care organization should be based on coherent and comprehensive assessments of the population's morbidity and needs for care, and take into account costs and benefits of different forms of treatments in relieving mental disorders and meeting mental health needs. While the former issue has been widely studied, the last two are mostly unexplored. Specifically, there is limited amount of information available on the significance that certain patterns of service utilization, or changes in service utilization, may have for the patient, his/her relatives and the community, and on the correlation between certain characteristics of service utilization and the overall quality of care.

In this perspective, service utilization must not be considered an isolated step in the patient's career; the causal link betweenneeds, use, andoutcomeof services should be identified. A full understanding of the role of service utilization in psychiatry thus necessitates taking into consideration events occurring at various steps of a person's history:

step 1: a person develops a mental disorder;

step 2: in certain cases this will determine a mental health service need;

step 3: in certain cases the service need will determine mental health service utilization;

step 4: use of mental health services will have a certain outcome.

Service utilization by schizophrenic patients in Groningen and South-Verona: an event-history analysis

The question addressed to in this paper is whether severely mentally ill patients are treated differently in a community mental health service without the back-up of a mental hospital (south-Verona, Italy) compared with an institution-based system in which mental hospitals, although highly modernized, are still predominant (Groningen, The Netherlands). Using the psychiatric case-registers in both areas, the patterns of care in 2 years of follow-up of schizophrenic patients were constructed. Survival analysis was used to analyse in-, day- and out-patient episodes of care. Three-quarters of the Groningen and half of the south-Verona patients experienced at least one episode of hospitalization; 20% of the Groningen and 5% of the south-Verona patients were long-stay patients at the end of the observation period. The south-Verona patients had more episodes of in-patient and especially of day-patient and out-patient care. Cox's regression showed that the duration of episodes controlled for the history of events and sociodemographic characteristics, was significantly shorter in south-Verona. One of the main conclusion was that hospitalizations for the severely mental ill are also needed in a community-based system of care, supporting the assumption of a 'bed-rock' of mental illness. However, the south-Verona community mental health service seems to be able to reduce the duration of hospitalizations considerably.

The consequences of an open referral system to a community mental health service

The first 590 patients referred to a community mental health service (the Early Intervention Service) in an inner-city district were separated into groups based on their referral source. The service has an open referral system allowing any agency (including patients) to contact the service by letter or by telephone, and priority is given to patients with serious mental illness. The results of open referral showed that the number of referrals was adequate for the service to process, the proportion of inappropriate referrals was similar in all referral agencies, and milder cases of mental illness were referred more often from doctors than from other agencies. It is concluded that an open referral system is likely to be more sensitive to need and has some advantage over closed referral arrangements in inner-city areas.

Utilization and patterns of care in comprehensive psychiatric care organizations. A review of studies and some methodological considerations

This article reviews and analyzes studies on the utilization of care and patterns of care in psychiatric care organizations with a defined catchment area responsibility. Eight studies fulfilled the inclusion criteria. The main results of the studies were reviewed with regard to distribution of utilization, typical patterns of care, sociodemographic characteristics, clinical characteristics and, when appropriate, organizational characteristics related to utilization. The results show that a small proportion of patients use a large proportion of resources. Sociodemographic factors such as living alone or having no occupation in some of the studies predicted a higher utilization. Only one study reported sex differences, men being more common among heavy users. In most of the studies a psychosis diagnosis predicted a higher utilization. A history of prior contacts with psychiatric care predicted a higher utilization in 2 studies. It is concluded that future studies should make efforts to develop standardized models of classification of patterns of care to enhance possibilities of comparisons. Cost, as a common unit for summarizing and comparing resource utilization, has not been used, but is viewed as a highly relevant measure. Furthermore, measures of utilization should be separated from evaluations of outcome or quality of care. However, the latter is a neglected area that should also be promoted in studies of utilization of psychiatric care to create knowledge of the relationship of utilization to outcome.

Patterns of psychiatric care in south Verona and Groningen. A case-register follow-up study

The pattern of utilization of mental health services in south Verona (Italy) and in Groningen (the Netherlands) was studied. The local psychiatric case registers were used to select patients aged 15 years or more who had at least one contact in 1982 and no contacts in the previous 365 days. Each patient was followed for 36 months after the first contact in 1982. The 2 cohorts differed in size (373 in south Verona and 590 in Groningen), age, diagnosis and pattern of care, whereas the sex distribution was similar. The cohort in Groningen was characterized by a higher number of elderly people, suffering from organic psychoses. Drug dependence prevailed in south Verona, while alcohol dependence was predominant in Groningen. The pattern of care was classified according to 2 basic measures, the gross duration of care and the net duration of care. In south Verona single consulters were almost 3 times more common than in Groningen. In general, patients in Groningen tended to depend more on the mental health services. Linear regression analysis was used to determine the extent to which the pattern of care was predicted by the sociodemographical and clinical characteristics of the patients. Only the site where the contacts were made (south Verona or Groningen) and the diagnosis were significantly associated with the pattern of care.

Use of mental health services in south Verona and Groningen. A comparative case-register study

A comparison was made of the utilization of mental health services in a psychiatric case register area in Italy (south Verona) and one in the Netherlands (Groningen). All residents living in these areas who contacted a mental health service in 1982 were traced and followed for a period of one year. The year prevalence rates differed considerably (110/10,000 in south Verona and 329/10,000 in Groningen). Rates of single consulters were similar in both areas, while those of chronic inpatients were more than 11 times higher in Groningen than in south Verona. After excluding both single consulters and chronic inpatients, when comparing service consumption according to fixed classes of scores, the category of highest service use accounted for 60% of care provided in Groningen as compared with less than 30% in south Verona. The proportion of total service consumption due to inpatient care was about the same in both areas, but brief admissions were more common in south Verona. Moreover, when service use was considered as a relative construct, about 10% of patients in both areas could be called high users. Finally, long-term patients were more prevalent in Groningen (26%) than in south Verona (13%).