The effects of hospital closure on mental health workers: an overview of employment, mental and physical health, and attitudinal outcomes

This article examines the physical, psychological, and attitudinal impact of the closure of Central State Hospital (CSH) on its former employees. Eighty-five former CSH employees were interviewed at two points in time, preclosure and postclosure. Data on the psychological and physical health and employment attitudes of workers were collected prior to and eight months after organizational closure. Over time, workers had more positive attitudes about the hospital closure as well as reporting less depression, less work stress, and use of more coping strategies at postclosure. However, at post-closure, they also reported increased work conflict, lower income, and a more pessimistic outlook toward their future. Implications for hospital closure are discussed.

Closing of a state hospital: an overview and framework for a case study

This article introduces the trends in deinstitutionalization, the limitations of previous research, and the design and research questions of the Central State Hospital (CSH) closing studies. Previously, the central engine of deinstitutionalization has been the downsizing, and not the closing, of facilities to decrease available beds. Only 14 state hospitals closed between 1970 and 1990. However, since 1990, 40 hospitals have closed. Moreover, beginning in 1993, for the first time since deinstitutionalization began, funding for state psychiatric facilities was less than for community-based services. Previous research on both the downsizing and closing of hospitals has focused predominantly on relatively short-term clinical and social outcomes of patients. The current study is a multidisciplinary, longitudinal, multiple-stakeholder study of the closing of a state-run, long-term care facility in Indiana. The articles that follow focus on the clinical, psychological, social, and attitudinal outcomes for patients, workers, families, and the public following the closing of CSH.

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.

Critical ingredients of assertive community treatment: judgments of the experts

Twenty experts on assertive community treatment (ACT) rated the importance of 73 program elements, also indicating ideal model specifications (e.g., minimum time commitment for psychiatrist) when appropriate. Interexpert agreement on ratings of importance was high (intraclass r = .94), although there was less agreement for some areas--for example, team structure (intraclass r = .70). Survey responses suggested several areas of increasing emphasis (e.g., vocational and addictions specialists) and of decreasing emphasis (e.g., the avoidance of office visits). Two subgroups of experts were identified--those who advocated large multidisciplinary teams (100 or more clients) and day and evening shifts, and those who advocated smaller, often generalist, teams (approximately 50 clients). Experts also reported ideal staffing for an ACT team. The most frequently identified disciplines were psychiatrist, nurse, and social worker. Implications for mental health policy--for example, quality assurance and program standards--are discussed.

Assertive outreach for frequent users of psychiatric hospitals: a meta-analysis

A meta-analysis was conducted on nine studies of an assertive outreach model for frequent users of psychiatric hospitals. Four studies used experimental or quasi-experimental designs and five used pre-post designs. Findings at one-year follow-up were examined for retention in community mental health services, psychiatric inpatient days, quality of life, and client level of functioning. Eighty-four percent of assertive outreach clients were still receiving mental health services after one year, compared to 54% of controls. In two thirds of the programs, the mean annual rate of inpatient days declined by 50% or more. The overall experimental effect size for quality of life was negligible, although changes over time for assertive outreach clients were more encouraging. Similarly, improvement in level of functioning was found for assertive outreach clients. The study examining experimental differences in level of functioning obtained a nonsignificant moderate effect.

Implementing assertive community treatment programs in rural settings

The authors present a controlled evaluation of a rural adaptation of the assertive community treatment (ACT) model for clients with serious and persistent mental illness (SPMI). Four community mental health settings adopted an ACT model, while a fifth site blended ACT principles with those of the Rhinelander model, another approach to case management for persons with SPMI. A broad array of client and system outcomes were evaluated at 6, 12, and 24 months into the intervention. Twelve-month findings alerted us to potential problems in implementing the treatment model in study year 1; the implementation was qualitatively evaluated and weaknesses were addressed at the beginning of the second treatment year. Small, positive findings at 24 months suggested that the mid-study course correction may have had an impact. We present these findings along with descriptive data on the challenges of implementing complex services models. We give particular attention to describing implementation barriers to mental health services provision that are uniquely rural.

The association between program characteristics and service delivery in assertive community treatment

The authors describe the relationship between service intensity and staffing, organizational, client, and site characteristics in 19 programs based on the Thresholds Bridge adaptation of the assertive community treatment (ACT) model. Pearson correlations were examined between 14 program characteristics and intensity of ACT services. Several staffing and organizational attributes were related to service intensity: larger team size, shared caseloads, greater supervisor involvement in direct client services, and assignment of primary responsibility for the client to the team. The potential facilitating relationship between several aspects of team operation and intensive services is discussed as are implications for local implementation of ACT.

A multisite study of client outcomes in assertive community treatment

OBJECTIVE

This study examined outcomes of clients admitted to assertive community treatment programs simultaneously implemented at six sites in northeastern Indiana.

METHODS

A total of 212 clients at risk for psychiatric rehospitalization were assessed at baseline and at six-month intervals for 18 months after admission to assertive community treatment programs. Data on rehospitalization, quality of life, and level of functioning were compared using t tests. Progressive improvement was also examined by linear trend analysis.

RESULTS

Frequency of psychiatric hospitalization was reduced by one-third and the number of inpatient days by 50 percent after admission to the program. Improvements were progressive, with continued reductions over the 18-month period. Progressive improvements also occurred in quality of life as measured by both client and staff ratings. Case managers rated clients as having improved family and social support, increased self-reliance and independence, and improved daily living skills. Clients reported significantly more legal problems, which may have been an artifact of increased monitoring during treatment. A key element of the programs' success was the position of clinical coordinator, important functions of which are described.

CONCLUSIONS

Results of this study provide support for wide-scale dissemination of assertive community treatment as an effective form of community care for persons with serious mental illness.

Measuring the fidelity of implementation of a mental health program model

A fidelity index of program implementation for assertive community treatment (ACT) was developed. In Study 1, 20 experts rated the importance of 73 elements proposed as critical ACT ingredients, also indicating ideal model specifications for elements. Agreement among experts on ratings of importance was high (intraclass r = .98). In Study 2, a 17-item subset of the expert-identified critical ingredients was used to construct a fidelity index with three subscales: Staffing, Organization, and Service. Internal consistencies ranged from .50 to .72, with a .81 reliability for the total scale. Fidelity was linearly related to program "generations," suggesting "program drift." In 18 ACT programs, fidelity also was associated with measures of reduction in days in psychiatric hospitals. The correlation was significant for the total scale and for the Organization and Staffing subscales but not for the Service subscale.

Measuring the fidelity of implementation of a mental health program model

A fidelity index of program implementation for assertive community treatment (ACT) was developed. In Study 1, 20 experts rated the importance of 73 elements proposed as critical ACT ingredients, also indicating ideal model specifications for elements. Agreement among experts on ratings of importance was high (intraclass r = .98). In Study 2, a 17-item subset of the expert-identified critical ingredients was used to construct a fidelity index with three subscales: Staffing, Organization, and Service. Internal consistencies ranged from .50 to .72, with a .81 reliability for the total scale. Fidelity was linearly related to program "generations," suggesting "program drift." In 18 ACT programs, fidelity also was associated with measures of reduction in days in psychiatric hospitals. The correlation was significant for the total scale and for the Organization and Staffing subscales but not for the Service subscale.