Dilemmas and choices in facing the drugs problem. "Being truthful about drugs...must remain the foundation of drug policy"

Effects of Home Visit Intervention on Re-hospitalization Rates in Psychiatric Patients

To examine the home visit intervention (HoVI) effects on the re-hospitalization rate and medical costs in patients with schizophrenia or other psychiatric disorders. The subjects who received more than 3 HoVIs were defined as the HoVI group, whereas the subjects who received equal to or less than 3 HoVIs were defined as the HoVI < 4 group; the subjects who had never received an HoVI were defined as the non-HoVI group. Differences in the re-hospitalization rates and National Health Insurance (NHI) costs among the three groups were examined. The re-hospitalization rate of the HoVI group was significantly lower than that of the non-HoVI group. The hospitalization days and the NHI costs of the HoVI group were also lower than those of the non-HoVI group. However, the HoVI < 4 group was not different than the non-HoVI group regarding the re-hospitalization rate or the hospitalization days. The re-hospitalization rate was significantly higher before compared with after the HoVIs. The NHI costs were significantly higher before compared with after the HoVIs. HoVIs (More than 3 HoVIs) produced a lower re-hospitalization rate, number of hospitalization days, and NHI costs in patients who received care through the Home Visit. Project to strengthen the Community Rehabilitation Program.

Resolving the psychiatric bed crisis: a critical analysis of policy

The National Service Framework (NSF) for Mental Health in 1999 was central to the modernisation of mental health services under the New Labour government of 1997. It placed an emphasis on universal clinical standards and set out a vision for service developments over the next 10 years. One such proposal was the development of crisis resolution teams, aimed at reducing the psychiatric admissions rate by providing care at home. This article provides a critical analysis of policies relating to the provision of 24-hour access to mental health services, focusing on the specifications for creating crisis resolution teams, as laid out in the NSF for Mental Health and the NHS Plan. First, it looks at the historical context surrounding the policy, examining the content of the NSF and NHS plan and how policy was disseminated and implemented nationally and locally. Then it examines the effects and changes this policy brought about and, specifically, whether it has achieved its aims of reducing the nationwide acute psychiatric inpatient admission rate.

Crisis resolution teams in the UK and elsewhere

BACKGROUND

Crisis resolution and home treatment teams (CRTs) and home treatment teams have been established nationwide in the UK to reduce admissions to psychiatric hospitals. However, the evidence for CRTs was limited at the time of their introduction.

AIMS

Review of the literature accumulated since the national rollout of CRTs in 2000.

METHOD

Systematic narrative literature review utilising British Nursing Index, Cinahl, Embase, Medline and PsyINFO.

RESULTS

The search revealed one randomised controlled trial and a number of naturalistic studies. The balance of evidence suggests that CRTs can reduce hospital beds and costs with similar symptomatic outcome and service user satisfaction, but there is no evidence that CRTs are the only way to do so. There is no conclusive evidence that CRTs cause an increase in serious and untoward incidents (SUIs) or compulsory admissions.

CONCLUSIONS

Currently, there is no compelling evidence for the widespread implementation of CRTs. In the future, the incidence of compulsory admissions and SUIs needs to be studied at a national level, CRTs have to be compared with other methods to reduce hospital admissions and studies need to specify sample and treatment characteristics with greater detail.

How effective is a hospital at home service for people with acute mental illness?

OBJECTIVE

Hospital at home (HAH) services have been developed to replace traditional inpatient care but there is little recent published data about their efficacy. This study evaluates HAH treatment for people with an acute episode of psychiatric illness who would otherwise have been admitted to hospital.

METHOD

The staffing and operation of the service is described, along with admission criteria. Patients could be visited by the HAH team up to three times a day, 7 days a week. Data were collected for 1 year. Demographic data, diagnoses, referral, discharge pathways, and outcomes are presented.

RESULTS

One hundred and eleven people were admitted to HAH. The most common diagnoses were mood disorders and non-affective psychoses. The mean length of stay was 17 days with an average of 22 home visits to each patient. Twenty percent of patients were transferred to inpatient services. For those who completed their treatment with HAH, symptom improvement and length of stay were comparable to inpatient services. There was only one adverse event, an episode of self harm.

CONCLUSIONS

HAH services can provide a safe, effective alternative to inpatient care for suitable patients. Home treatment has the potential to reduce costs, reduce the pressure on inpatient services and provide care that is acceptable to patients and their families.

Ambulatory care provision versus first admission to psychiatric hospital: 5 years follow up

OBJECTIVE

Ambulatory care for subjects with severe mental problems has been clearly shown to be a valid alternative to hospitalisation. However, very few studies have considered the fate of patients over several years. Ambulatory care services are often experimental set-ups, for small groups, and their impact on subsequent treatment has only been assessed over the first few months of treatment. The value of developing this practice therefore remains unclear. We investigated the possible consequences of generalising ambulatory care services by a mobile crisis intervention team (ERIC) to all requests for the first hospitalisation in a psychiatric department. The principal aim was to determine whether systemic intervention by the crisis intervention team could provide a true alternative to hospitalisation. We also investigated whether problem-resolving approaches and ambulatory care led, in the long term, to fewer prolonged or repeated periods of hospitalisation than practices in which hospitalisation was considered as an ordinary solution.

METHODS

We carried out a prospective, comparative, cohort study over a 5-year period beginning with the creation of ERIC by one of the hospital departments. All patients arriving at this department for the first time were offered immediate ambulatory care by this team for 1 month. Their hospitalisation record (duration of hospital stay, number of days in hospital) was compared with that of subjects hospitalised in the same conditions but in other departments of the hospital.

RESULTS

This study included most of the subjects referred for the first time to the psychiatric hospital, in our department. Regardless of their diagnosis, intensive follow-up at home, based on systemic crisis intervention work, was found to be an effective and well-accepted alternative to hospitalisation. Indeed, a highly significant immediate decrease in both the number of admissions and the duration of hospital stay was observed for the experimental group, with no subsequent increase in the number of days of hospitalisation. From the second year onwards, the use of hospitalisation did not seem to be influenced by the type of care initially given to the patient. Rehospitalisation was rare in both groups. One third of the patients in the experimental group benefited from another intervention of the ambulatory emergency team from the second year onwards, highlighting the value placed on this type of care by the patients and their families.

CONCLUSION

Our results support the development of ambulatory crisis intervention services, including those from psychiatric hospitals. Clinical studies following the treatment paths of patients in a more exhaustive manner would almost certainly distinguish more precisely between the "natural" course of the disease and the impact of the care provided. In any case, the prevention of hospitalisation must be based as much on a possible alternative at the time of the crisis as on subsequent access to ambulatory care.