Care Of Chronic Mental Patients Research Articles

Case management revisited.

Although little consensus exists about the precise meaning of case management in the care of chronic mental patients (1-3), the concept is widely endorsed and has assumed a central role in service planning. In this article I expand on an earlier discussion of the semantics of case management (1) by suggesting a conceptual approach for synthesizing various current definitions. I also discuss some trends in case management practice that support this approach. Unlike other specialties concerned with the care of chronic mental patients, case management lacks a specific disciplinary focus. The field draws personnel from the full array of service delivery professions. Case management must thus be defined in terms of its functions, not on the basis of the professional training its practitioners undergo. Functionally, case management may be viewed as a vehicle for implementing continuity in the care of mentally ill persons (4-7). It focuses on individualized rather than mass approaches to patient care and is

Financing case management: making the money work.

AbstractThe financing of case management for persons with chronic mental illness represents a particularly interesting and important challenge for the system of care.In promoting the goals of comprehensive case management, capitation payment systems offer some clear advantages over existing systems of reimbursement for units of service or episodes of care, which reinforce service fragmentation. Capitation, an integrative approach to funding the functions of case management within the context of all services, differs sharply from current fee‐for‐service approaches, which simply create new staff positions for “case managers.” There are, however, barriers to achieving a comprehensive prospectively funded case management model, which include inadequate data to project appropriate capitation rates accurately, vague standards of care for the chronically mentally ill, ongoing ambivalence about what levels of service effort and outcomes are acceptable, and a wide variety of resistances within existing service agencies. If these barriers can be overcome—a highly formidable task— then the mutually supportive concepts of comprehensive case management and capitation may lead to a far more cost‐effective system of care for chronic mental patients.

Capitation financing for the chronic mentally ill: a case management approach.

The method chosen for financing mental health care has profound implications for how that care will be delivered. Fee-for-service methods of reimbursement impede the implementation of certain essential program components. Capitation financing, in contrast, holds the promise of promoting an integrated system of care for chronic mental patients. The authors present data from a case management program that incorporates capitation financing. Discussion focuses on factors that planners need to consider when instituting a capitated financing system.

Care of chronic mental patients in The Netherlands.

While the Dutch Government is actively planning to reduce the number of mental hospital beds, particularly those for long-stay patients, it takes little notice of the reality of mental health care in The Netherlands, cherishing various misconceptions regarding institutionalism and community care. On the basis of a case-register study the population of chronic mental patients is estimated, including their current discharge rate from mental hospital without any aftercare. The burden of the mentally disabled on the community is discussed.

Integrated services for chronic mental patients: Theoretical perspective and experimental results

The theoretical basis of an integrated service approach to the care of chronic mental patients is discussed. An experiment testing the Treatment Network Team (TNT) program, based on that approach, is described and results are reported. Although TNT and control patients exhibited minimal differences in symptomatology and psychopathology, those in the experimental group showed substantive improvement in psychosocial functioning. The authors conclude that flexible service systems that deemphasize locus of care and offer a range of treatment modalities have the potential for enriching the social lives of chronic mental patients.

General hospital psychiatry and deinstitutionalization: A systems view

The shift in responsibility for the care of chronic mental patients has generated a variety of problems for general hospital psychiatry. In response to these new demands, general hospital psychiatry has evolved a variety of effective strategies. Nevertheless, widespread concern over the appropriateness of serving chronic patients in an acute care setting persists. The level and direction of general hospital psychiatry's involvement with chronic mental patients will vary according to the specific characteristics of a community's patient population, its goals for those patients, and the resources at its disposal for realizing those goals. General hospital psychiatry must make a serious effort to minimize its being forced into a reactive position by deinstitutionalization policies generated by distant authorities. It must assume, instead, its rightful position as an autonomous, but fully cooperative, element within the psychiatric service system. Only then can its responsibility to the chronically mentally ill, to other patients, and to its own integrity be assured.

Mental health professionals' knowledge in the field of caring for chronic mental disorders.

A national sample of 246 Canadian mental health professionals was given a knowledge test concerning principles of care for chronic mental patients. Results showed that: (1) mental health professionals were moderately knowledgeable on this topic (mean score 66%), (2) errors made were more commonly in the direction of over-enthusiastic support for the community approach and (3) there were no differences in knowledge scores by a demographic or professional status variables included in this study.

The community residential treatment service: developing a continuum of prosthetic environments for the chronically disabled.

Among the many issues regarding the care of chronic mental patients, none is more pressing than the need for administrative and clinical models designed to organize and systematize the efforts of diverse community service providers. This paper describes the functioning of the Community Residential Treatment Service of the South Beach Psychiatric Center, a large-scale project of a state facility created to respond to this tissue. By blending sophisticated clinical and administrative technology, programs operated by the state, voluntary, and proprietary health care sectors have been integrated to form a balanced service delivery system. This system provides a broad continuum of inpatient and outpatient residential settings developed in accordance with social learning principles. The components of the system, with the Community Residential Treatment Service as the major integrative force, are linked together by detailed contracts as well as common behavioral clinical and behavioral administrative language. The treatment successes f this system have been significant enough to suggest that a positive synergistic effect is generated by this programming combination.

Chronic mental patients: the quality of life issue.

Quality of life issues must be addressed more vigorously in the care of chronic mental patients. In a survey of 30 large board-and-care homes in Los Angeles, 278 mentally disabled residents described their life conditions and satisfaction in eight areas: living situation, family relations, social relations, leisure activities, work, finances, safety, and health. Residents were less satisfied than the general population in most life areas, especially finances, unemployment, safety, and family and social relations (p less than .001). Of particular concern was the finding that 34% had been recent victims of crime. The results underscore the need for better social programs for these patients.

Continuity of care for chronic mental patients: a conceptual analysis.

The author discusses seven dimensions of continuity of care, a basic concept in planning services for chronic mental patients. Continuity of care in psychiatry is distinguished from that in other medical specialties by the unique needs of chronic mental patients. Different approaches to continuity must be used for chronic mental patients with different institutional histories and specialized service needs.

Nursing home care for mental patients: descriptive data and some propositions.

Nursing homes play an important role in the community-based care of chronic mental patients, yet there is little research in that setting. The present study gathered and analyzed descriptive data on 20 nursing homes in a large urban area, including data about structure, staffing, policy, treatment, residents, discharge, psychosocial climate, and neighborhood characteristics. Results suggested a clear difference between skilled nursing versus intermediate care facilities, with the latter playing a larger role in caring for mental patients. More important, data suggested such facilities play primarily a custodial rather than treatment role, and that managers expect patients in nursing homes to stay indefinitely. In view of this, our justifications for community care, such as social integration, need to be examined anew.

Long-term community care: mental health policy in the face of reality.

Nursing homes play an important role in the care of chronic mental patients, and they could be used as one base on which to build a better system of care. Carling, in his article "Nursing Homes and Chronic Mental Patients: A Second Opinion," appears to question aspects of this contention. His efforts in this regard are interesting but unconvincing, though his thoughtful comments usefully elaborate the problems inherent in trying to incorporate nursing homes into the mainstream of mental health care. He more successfully uses his article to describe the National Plan for the Chronically Mentally Ill, a recent policy proposal of great merit that may some day significantly benefit metal patients. Meanwhile, mental health policy must face the reality that nursing homes are providing useful services to many chronic mental patients who have been inadequately served by current community care programs. This is not likely to change in the foreseeable future. Policy advocates need to attend to practical alternatives, not just to idealized possibilities.

Nursing homes and chronic mental patients.

Nursing homes play an important and controversial role in the community-based care of chronic mental patients. Confronting the reality of this role can help us recognize problems in the rationales for deinstitutionalization and community care. Problems with three concepts that were central to deinstitutionalization are examined--the total institution, institutional neurosis, and social reintegration. Furthermore, two concepts are presented that were overlooked in the haste to initiate deinstitutionalization--custody, asylum, and treatment functions in society; and the role of patient expectations. Finally, suggestions are made about how nursing homes can play a more constructive role in mental health policy.

Community Care for Chronic Mental Patients: The Need for a Reassessment

The release of chronic mental patients from the hospital to the community has been prompted more by political and economic considerations than by any planned treatment strategy. Large numbers of former patients have gone to live in privately operated boarding houses and nursing homes, where staff have had little experience with mental illness, and where conditions are not much different from the back wards of state hospitals of past decades. New models for caring for chronic, dependent patients should be developed; they should incorporate the precepts of an open social system and should be built around the needs of such patients as they themselves perceive them. To date, few state mental hospitals, have had the funding, staff, or support to adequately explore the possibilities of an optimal environment.

Impressions of Soviet psychiatry. The chronic care system.

In the U.S.S.R., care of chronic mental patients is divided between mental hospitals, under the health authorities, and homes for invalids, under local ministries of social welfare. While there seemed to be some ambivalence in time Soviet attitude toward chronicity, the U.S. team felt that the system provides humane, dignified treatment which maximizes the patient's productivity and contribution to society.