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Zarzar T, Sheitman B, Cook A, Robbins B. Reducing Length of Acute Inpatient Hospitalization Using a Residential Step Down Model for Patients with Serious Mental Illness. Community Ment Health J 2018; 54:180-183. [PMID: 28233137 DOI: 10.1007/s10597-017-0111-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Accepted: 01/30/2017] [Indexed: 11/29/2022]
Abstract
Psychiatric inpatient bed numbers have been markedly reduced in recent decades often resulting in long emergency department wait times for acutely ill psychiatric patients. The authors describe a model utilizing short-term residential treatment to substitute for acute inpatient care when the barrier to discharge for patients with serious mental illness (SMI) is finding appropriate community placement. Thirty-eight patients (community hospital (n = 30) and a state hospital (n = 8)) were included. Clinical variables, pre-/post-step down length of stay, and adverse outcomes are reported. Thirty of the 38 patients completed treatment on the residential unit and were discharged to the community. Five of the patients required readmission to an inpatient unit and the other three had pre-planned state hospital discharges. The majority of patients with SMI awaiting placement can be stepped down to residential treatment, potentially freeing up an inpatient bed for an acutely ill patient. Reforms in healthcare funding are necessary to incentivize such an approach on a larger scale, despite likely cost savings.
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Affiliation(s)
- Theodore Zarzar
- Department of Psychiatry, University of North Carolina School of Medicine, 101 Manning Drive, Chapel Hill, NC, 27514, USA.
| | - Brian Sheitman
- Department of Psychiatry, University of North Carolina School of Medicine, 101 Manning Drive, Chapel Hill, NC, 27514, USA
| | - Alan Cook
- Central Regional Hospital, 300 Veazey Road, Butner, NC, USA
| | - Brian Robbins
- Department of Psychiatry, University of North Carolina School of Medicine, 101 Manning Drive, Chapel Hill, NC, 27514, USA
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Meiser-Stedman C, Howard L, Cutting P. Evaluating the effectiveness of a women's crisis house: a prospective observational study. PSYCHIATRIC BULLETIN 2018. [DOI: 10.1192/pb.30.9.324] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Aims and MethodTo investigate the effectiveness of the Women's Service crisis house in Croydon we performed an observational study prospectively measuring functioning, symptom severity and unmet needs before and after admission. Use of mainstream mental health services was also measured.ResultsWomen using the service had high use of mainstream mental health services, with 137 out of 269 (51%) requiring admission to a mainstream acute ward in the 4 years studied. The service was effective with an improvement in Global Assessment of Functioning scores from a median of 48 on admission to 67 on discharge (P<0.001).Clinical ImplicationsThe women's crisis house was effective in providing for women who required high levels of mainstream mental health services, suggesting that it provides a valuable alternative to standard in-patient care.
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Afilalo M, Soucy N, Xue X, Colacone A, Jourdenais E, Boivin JF. Characteristics and Needs of Psychiatric Patients With Prolonged Hospital Stay. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2015; 60:181-8. [PMID: 26174218 PMCID: PMC4459245 DOI: 10.1177/070674371506000405] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2014] [Accepted: 07/01/2014] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To describe the characteristics and needs prior to, on admission, during the first month in hospital, at the thirtieth day of hospitalization and posthospital discharge of psychiatric patients occupying acute beds. METHODS This prospective observational study was conducted in 2 tertiary care hospitals. Adult patients hospitalized on a psychiatric unit for 30 days were identified. Data was collected from their medical charts and interviews with their health care team. The categorization of acute and nonacute status at day 30 was based on the health care professional's evaluation. Descriptive and univariate analyses were performed. RESULTS A total of 262 patients were identified (mean age 45 years), 66% lived at home and 11% were homeless. More than one-half were cognitively impaired and a few had special medical needs. Ninety-seven per cent had been admitted from the emergency department. At day 30, 81% of patients required acute care, while 19% (95% CI 15% to 24%) occupied an acute care bed, despite the resolution of their acute condition. The main reason preventing discharge of nonacute patients was the difficulty or inability to find appropriate resources that met patients' needs. As for patients who required acute care, the most common psychiatric issues were delusions or hallucinations (34%), inability to take medications independently (23.6%), and inadequate control of aggression or impulsivity (16.5%). CONCLUSIONS Prevention of the discharge of nonacute patients is largely due to the difficulty in finding appropriate resources that meet patients' needs. Improved access to community and subacute care resources could potentially facilitate the hospital discharge of psychiatric nonacute patients.
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Affiliation(s)
- Marc Afilalo
- Associate Professor, Department of Medicine, McGill University, Montreal, Quebec; Director, Emergency Department, Jewish General Hospital, Montreal, Quebec
| | - Nathalie Soucy
- Clinical Research Associate, Emergency Department—Research Division, Jewish General Hospital, Montreal, Quebec
| | - Xiaoqing Xue
- Statistician, Emergency Department—Research Division, Jewish General Hospital, Montreal, Quebec
| | - Antoinette Colacone
- Research Coordinator, Emergency Department—Research Division, Jewish General Hospital, Montreal, Quebec
| | - Emmanuelle Jourdenais
- Director, Emergency Department, Centre Hospitalier de L’Université de Montréal, Notre-Dame Hospital, Montreal, Quebec
| | - Jean-François Boivin
- Professor, Department of Epidemiology and Biostatistics, McGill University, Montreal, Quebec
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Abstract
Community homes for the treatment of the acutely psychiatrically ill have been established in several places in the world as alternatives to inpatient hospitalizations. We reviewed sources from the psychiatric and psychological literature which examine these models. Several features are common to this treatment setting: fewer residents in comparison with hospital wards; a supportive and caring milieu including intense and regular therapeutic contact with staff; a de-emphasis of medication; and a destigmatization of the therapeutic treatment of psychosis. The models differ with respect to use of psychotropic medication, emphasis upon first admissions, and composition of staff. The varying models are comparable to inpatient treatment in terms of clinical and psychosocial outcome, and generally cost less. For most patients requiring psychiatric hospitalization, residential treatment can be a viable alternative to inpatient hospitalization. Issues of cost, therapeutic effectiveness, and long-term outcomes still need to be studied.
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Affiliation(s)
- Pesach Lichtenberg
- Department of Psychiatry, Herzog Hospital, School of Medicine of the Hebrew University of Jerusalem, POB 3900, Jerusalem, 90135, Israel.
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Improving Risk Adjustment of Self-Reported Mental Health Outcomes. J Behav Health Serv Res 2009; 37:291-306. [DOI: 10.1007/s11414-009-9196-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2008] [Accepted: 10/06/2009] [Indexed: 10/20/2022]
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Lloyd-Evans B, Slade M, Jagielska D, Johnson S. Residential alternatives to acute psychiatric hospital admission: systematic review. Br J Psychiatry 2009; 195:109-17. [PMID: 19648539 DOI: 10.1192/bjp.bp.108.058347] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Reducing use of hospital wards and improving their quality are central aims of mental health service policy. However, no comprehensive synthesis is available of evidence on residential alternatives to standard acute psychiatric wards. AIMS To assess the effectiveness and cost-effectiveness of and satisfaction with residential alternatives to standard acute in-patient mental health services. METHOD A systematic search identified controlled studies comparing residential alternatives with standard in-patient services. Studies were described and assessed for methodological quality. Results from higher quality studies are presented and discussed. RESULTS Twenty-seven relevant studies were identified. Nine studies of moderate quality provide no contraindication to identified alternative service models and limited preliminary evidence that community-based alternatives may be cheaper and individuals more satisfied than in standard acute wards. CONCLUSIONS More research is needed to establish the effectiveness of service models and target populations for residential alternatives to standard acute wards. Community-based residential crisis services may provide a feasible and acceptable alternative to hospital admission for some people with acute mental illness.
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Affiliation(s)
- Brynmor Lloyd-Evans
- Department of Mental Health Sciences, University College London, Charles Bell House, London W1W 7EJ, UK.
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Abstract
PURPOSE OF REVIEW To provide a brief overview on trends in common substances of abuse in adolescents, a summary of tools to evaluate adolescent substance abuse in an outpatient setting, and an update of outpatient and inpatient treatment options. RECENT FINDINGS Recent national data suggest an overall slight decline in the use of tobacco, crystal methamphetamine, heroin, and club drugs. No significant change was noted in the use of alcohol, marijuana, and cocaine. Yearly screening of all adolescents for substance use is recommended. This can be accomplished in an office setting using mnemonics, structured interview techniques, and brief screens for substance abuse. If a problem is identified, various outpatient and inpatient treatments are available. Individual, family, and group therapy methods are available. Other options include acute detoxification programs, partial hospitalization, acute residential treatment, residential treatment centers and wilderness programs. Pharmacological treatments are available for nicotine, alcohol, and opioid addiction. SUMMARY Tobacco, alcohol, marijuana, and other drugs remain a significant problem among adolescents in the United States. Pediatricians should screen and assess all adolescents on a yearly basis. If a problem is identified, there are many options for treatment, including pharmacologic treatment as well as individual, family, or group therapy in an inpatient or outpatient setting.
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Affiliation(s)
- Mary E Fournier
- Division of Adolescent/Young Adult Medicine, Children's Hospital Boston, Boston, Massachusetts 02115, USA.
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Abstract
There has been no comprehensive history of the scope and roles of private psychiatric hospitals in the USA. This paper documents the origins, functions, support, and contributions of private psychiatric hospitals from their beginnings in the eighteenth century through 2003. An interesting feature of nineteenth century psychiatry was the interplay between private and public institutions which reveals a pattern of the public purchase of private beds that is conceptually much like what we have today. From the early twentieth century through 1970, advancements in somatic treatments, new ways of using the hospital milieu, the introduction of antipsychotic medications, the shift from institution-based to noninstitution-based loci of acute and long-term treatment and care, the beginnings of day hospitals and a shortage of psychiatrists and nurses, all impacted upon the private psychiatric hospital. While the private psychiatric hospitals expanded in number and in responsibilities during these decades, at the end of the 1960's their future was a matter of serious debate. A comprehension of the history of the private psychiatric hospital since 1970 is based on an understanding of the impact of for-profit hospital chains, managed care, the privatization of traditionally public services, the requirement for "treatment in the least restrictive alternative," further erosion of the use of any form of inpatient treatment, and an overall decrease in expenditures for mental health services. The future of the private psychiatric hospital may well be based on its ability both to maintain its traditional, patient-centered approach and to create innovative, effective, efficient, novel systems of care and treatment.
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Affiliation(s)
- Jeffrey L Geller
- Department of Psychiatry, UMass Medical School, Worcester, Massachusetts01655, USA.
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Abstract
Systems of crisis intervention are frequently difficult to operationalize; they are often described as crisis components rather than systems, fail to differentiate levels of crisis acuity, provide very limited fundamental utilization data, and are almost exclusively implemented in urban areas. A system of rural crisis intervention differentiating levels of acuity and fundamental utilization information was profiled. Implications for clinicians and administrators are presented. This system of crisis intervention was highly effective in reducing inpatient utilization with the help of crisis residential beds and partial hospitalization. Mobile response was infrequently used in this setting. Age and gender were important variables in mental health emergency situations. Use of acute crisis level services was rarely more than once. More systematic descriptions of crisis systems of care were encouraged.
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Eisen SV, Normand SL, Belanger AJ, Spiro A, Esch D. The Revised Behavior and Symptom Identification Scale (BASIS-R). Med Care 2004; 42:1230-41. [PMID: 15550803 DOI: 10.1097/00005650-200412000-00010] [Citation(s) in RCA: 173] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND To assess outcomes of health services, providers need brief, responsive, reliable, and valid measures that can be implemented in clinical settings with minimal cost and burden. The Behavior and Symptom Identification Scale (BASIS-32) is a self-report measure developed in 1984 to assess mental health treatment outcomes. During the past 3 years, multiple methods were used to revise the instrument to improve reliability, validity, and applicability to diverse groups of mental health service recipients. OBJECTIVE The objective of this study was to field test the revised instrument, make further changes based on analysis of the field test data, and assess reliability and validity of the final version (BASIS-24). METHODS A field test was implemented at 27 treatment sites across the United States. A total of 2656 inpatients and 3222 outpatients participated. Factor analytic methods, classic test theory, and item response theory modeling were used to select the most discriminating, nonredundant items for inclusion in the final version of the instrument and to assess its reliability and validity. Item response theory modeling was used to score the instrument. RESULTS The final instrument includes 24 items assessing 6 domains: depression/ functioning, interpersonal relationships, self-harm, emotional lability, psychosis, and substance abuse. Test-retest and internal consistency reliability were acceptable. Tests of construct and discriminant validity supported the instrument's ability to discriminate groups expected to differ in mental health status, and its correlation with other measures of mental health. CONCLUSIONS Analyses of the BASIS-24 supported its reliability and validity for assessing mental health status from the patient's perspective.
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Affiliation(s)
- Susan V Eisen
- Center for Health Quality Outcomes and Economics Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts, USA.
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Biancosino B, Barbui C, Pera V, Osti M, Rocchi D, Marmai L, Grassi L. Patient opinions on the benefits of treatment programs in residential psychiatric care. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2004; 49:613-20. [PMID: 15503733 DOI: 10.1177/070674370404900907] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To assess patients' opinions on the perceived benefit of treatment delivered during their stay in a residential facility. METHOD We administered the Opinions on Curative Factors Questionnaire (OCFQ), which was developed from previous studies and assesses several treatment modalities and therapeutic factors, to a sample of 157 severely ill psychiatric patients admitted to a residential facility. RESULTS All therapeutic factors tested by the OCFQ were considered helpful or very helpful by most of those sampled. The item with the highest score was "talking to doctor," followed by "free pass," "medication," "visitors," "nonhospital setting," "making friends with patients," "structure of daily life," "support from team," and "talking to nurses." The least-valued item was "group activities." CONCLUSION Psychiatric patients consider several treatment factors to be helpful, especially those based on individual approaches or on a less restrictive therapeutic milieu that allows interactions with the outside world. These results may be a valuable contribution to improving treatment planning in residential facilities.
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Affiliation(s)
- Bruno Biancosino
- Department of Mental Health, Local Health Agency, Ferrara, Italy
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Timko C, Sempel JM. Short-term outcomes of matching dual diagnosis patients’ symptom severity to treatment intensity. J Subst Abuse Treat 2004; 26:209-18. [PMID: 15063915 DOI: 10.1016/s0740-5472(04)00002-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2003] [Revised: 12/07/2003] [Accepted: 01/11/2004] [Indexed: 11/30/2022]
Abstract
This study evaluated a patient-treatment matching strategy intended to improve the effectiveness of hospital-inpatient and community-residential treatment for dual diagnosis patients. Matching variables were the severity of patient disorders and the program's service intensity. Each of three high-intensity hospital programs was paired with a nearby high-intensity community program; there were also four low-intensity pairs. Patients (N=230) were randomly assigned to hospital or community care at intake, and followed at discharge (96%) and at 4 months (90%). Support was found for the matching strategy at discharge in that severely ill patients treated in high-intensity programs improved more on substance abuse outcomes, and moderately ill patients treated in low-intensity programs improved more on psychiatric outcomes. The benefits of matching held at 4 months in that high-severity patients had better alcohol outcomes when they were treated in high-rather than low-intensity programs. High-and moderate-severity patients did not show differential outcomes in hospital-based or community-based programs. Dual diagnosis patients should be matched by symptom severity with program service intensity, but matching with hospital or community care may not enhance treatment outcomes.
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Affiliation(s)
- Christine Timko
- Center for Health Care Evaluation, Department of Veterans Affairs Health Care System, 795 Willow Road, Menlo Park, CA 94025, USA.
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McCabe L, Butterill D, Goering P. Residential Crisis Units. Are We Missing Out on a Good Idea? ACTA ACUST UNITED AC 2004; 23:65-74. [PMID: 15920883 DOI: 10.7870/cjcmh-2004-0005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Residential Crisis Units (RCU) are non-hospital-based facilities that provide mental health crisis intervention. This paper reviews the RCU literature base and finds good evidence of the ability of RCUs to function as alternatives to hospitalization for many consumers, with equivalent effectiveness and for significantly less cost. Despite this promising research, the RCU model has not been widely adopted. Using two crisis units as case examples as well as key informant interviews, this paper explores factors affecting the lack of dissemination and potential barriers to the growth of the RCU model.
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Affiliation(s)
- Laura McCabe
- University of Toronto, Sunnybrook and Women's College Health Sciences Centre
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Durbin J, Prendergast P, Dewa CS, Rush B, Cooke RG. Mental health program monitoring: towards simplifying a complex task. Psychiatr Rehabil J 2003; 26:249-61. [PMID: 12653447 DOI: 10.2975/26.2003.249.261] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Finding measures that can assess areas of expected program impact, provide valid results, and be easily integrated into routine program practices is a significant challenge. This paper is intended to assist program staff by providing an accessible inventory of measures appropriate for routine monitoring of the status and outcome of individuals using mental health outpatient and community programs. The inventory is not exhaustive, but rather includes examples of solid measures for assessing outcomes in four key domains--symptoms, functioning, quality of life, and satisfaction. These can provide a core of information, to which measurement of more in-depth issues can be added to address specific concerns.
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Affiliation(s)
- Janet Durbin
- Health Systems Research & Consulting Unit, Centre For Addiction & Mental Health, and Department of Psychiatry, University of Toronto, Ontario.
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