Community-based Care System Research Articles

Mortality and cause of death among psychiatric patients: a 20-year case-register study in an area with a community-based system of care

Mortality and cause of death among psychiatric patients: a 20-year case-register study in an area with a community-based system of care

Psychiatric Discharges in Community Hospitals With and Without Psychiatric Units: How Many and for Whom?

Psychiatric Discharges in Community Hospitals With and Without Psychiatric Units: How Many and for Whom?

Psychiatric Discharges in Community Hospitals With and Without Psychiatric Units: How Many and for Whom?

This study sought to describe the extent to which community hospitals, in a sample of states, are caring for patients with psychiatric disorders in medical-surgical beds (scatter beds) and to compare the characteristics of patients treated in scatter beds with those of patients treated in psychiatric units in community hospitals. Information on hospital discharges in 12 states for patients with a principal psychiatric diagnosis was gathered from the Healthcare Cost and Utilization Project State Inpatient Databases. Discharges of patients who were treated in community hospital psychiatric units (N=370,984) were compared with those of patients who were treated in scatter beds (N=26,969). Overall, only 6.8% of discharges were from scatter beds. The rate of total psychiatric discharges per 10,000 total state population ranged from a high of 62.3 in one study state to a low of 9.6 in another. The average rate of scatter bed discharges per 10,000 state population ranged from 1.6 to 5.8, whereas the average rate of psychiatric unit discharges ranged from 7.4 to 58.9. A comparison of discharges of patients treated in scatter beds with discharges of patients treated in psychiatric units indicated that patients in scatter beds were more likely to have somatic conditions and were half as likely to have an accompanying substance use disorder. Discharge codes indicated that almost 40% of patients from scatter beds had a diagnosis of schizophrenia, episodic mood disorder, or depression; about two-thirds were admitted from emergency rooms; and about one-fifth were transferred to another facility. More research is needed to determine the optimal supply of psychiatric unit beds across regions and whether and how scatter beds should be used to address the lack of psychiatric beds.

Scaling up community-based services and improving quality of care in the state psychiatric hospitals: the way forward for Ghana

This paper aims to explore the options available for developing community-based care and improving the quality of care in psychiatric hospitals in Ghana. Semi-structured interviews (SSIs) and focus group discussions (FGDs) were conducted: with a cross-section of stakeholders including health professionals, researchers, policy makers, politicians, users and carers. The SSIs and FGDs were recorded digitally and transcribed verbatim. Apriori and emergent themes were coded and analysed with NVivo version 7.0, using a framework analysis. Psychiatric hospitals in Ghana have a mean bed occupancy rate of 155%. Most respondents were of the view that the state psychiatric hospitals were very congested, substantially compromising quality of care. They also noted that the community psychiatric system was lacking human and material resources. Suggestions for addressing these difficulties included committing adequate resources to community psychiatric services, using psychiatric hospitals only as referral facilities, relapse prevention programmes, strengthening psychosocial services, adopting more precise diagnoses and the development of a policy on long-stay patients. There is an urgent need to build a credible system of community-based care and improve the quality of care in psychiatric hospitals in Ghana.

Mortality among people with mental disorders

Mortality among psychiatric patients has been found to be higher than the general population, not only in those long-term residents in old-fashioned psychiatric hospitals or attending hospital-based psychiatric services (Harris & Barraclough, 1998) but also in those treated in modern community-based systems of care (Amaddeo et al., 1995; Grigoletti et al., 2009).

Combined Interventions May Improve Success When Treating Sudden Cardiac Arrest

Recently, emphasis has been placed on the simultaneous implementation of resuscitation interventions currently recommended within the 2005 American Heart Association (AHA) guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiac care (ECC). The rate of successful outcomes from out-of-hospital cardiac arrest remains relatively low in most U.S. communities. Accurate measures of these rates are difficult to determine because of ineffective reporting mechanisms. In many cases of acute myocardial infarction, the initial presentation of symptoms is quickly followed by sudden death. Little information exists regarding the system-of-care components most likely to result in successful outcomes. Inconsistent application of these components may be responsible in part for the variability of survival rates among communities. We present a case of acute myocardial infarction followed by sudden cardiac arrest benefiting from the application of coordinated, community-based systems of care.

Mortality and cause of death among psychiatric patients: a 20-year case-register study in an area with a community-based system of care

Most mortality studies of psychiatric patients published to date have been conducted in hospital-based systems of care. This paper describes a study of the causes of death and associated risk factors among psychiatric patients who were followed up over a 20-year period in an area where psychiatric care is entirely provided by community-based psychiatric services. All subjects in contact with the South Verona Community-based Mental Health Service (CMHS) over a 20-year period with an ICD-10 psychiatric diagnosis were included. Of these 6956 patients, 938 died during the study period. Standardized mortality ratios (SMRs) and Poisson multiple regressions were used to assess the excess of mortality in the sample compared with the general population. The overall SMR of the psychiatric patients was 1.88. Mortality was significantly high among out-patients [SMR 1.71, 95% confidence interval (CI) 1.6-1.8], and higher still following the first admission (SMR 2.61, 95% CI 2.4-2.9). The SMR for infectious diseases was higher among younger patients and extremely high in patients with diagnoses of drug addiction (216.40, 95% CI 142.5-328.6) and personality disorders (20.87, 95% CI 5.2-83.4). This study found that psychiatric patients in contact with a CMHS have an almost twofold higher mortality rate than the general population. These findings demonstrate that, since the closure of long-stay psychiatric hospitals, the physical health care of people with mental health problems is often neglected and clearly requires greater attention by health-care policymakers, services and professionals.

Multiple Imputation With Large Data Sets: A Case Study of the Children's Mental Health Initiative

Multiple imputation is an effective method for dealing with missing data, and it is becoming increasingly common in many fields. However, the method is still relatively rarely used in epidemiology, perhaps in part because relatively few studies have looked at practical questions about how to implement multiple imputation in large data sets used for diverse purposes. This paper addresses this gap by focusing on the practicalities and diagnostics for multiple imputation in large data sets. It primarily discusses the method of multiple imputation by chained equations, which iterates through the data, imputing one variable at a time conditional on the others. Illustrative data were derived from 9,186 youths participating in the national evaluation of the Community Mental Health Services for Children and Their Families Program, a US federally funded program designed to develop and enhance community-based systems of care to meet the needs of children with serious emotional disturbances and their families. Multiple imputation was used to ensure that data analysis samples reflect the full population of youth participating in this program. This case study provides an illustration to assist researchers in implementing multiple imputation in their own data.

Goals of Inpatient Treatment for Psychiatric Disorders

The purpose of the psychiatric hospital changed dramatically during the twentieth century. Formerly the primary location for psychiatric treatment, the hospital now plays a more circumscribed role within a community-based system of care. Crisis stabilization, safety, and a focus on rapid discharge are the critical components of the acute inpatient stay. Subspecialized units focus on geriatrics, children, adolescents, dual diagnosis (substance abuse and mental illness), trauma disorders, eating disorders, and forensics. When integrated with the general medical system and a comprehensive base of community-delivered day treatment, residential services, and outpatient services, psychiatric hospitalization is a humane alternative to long-term institutional care.

Current role of acute hospitals in community-based stroke care system in Japan

背景および目的：脳卒中では緊密な連携の重要性が強調されている．脳卒中地域医療における急性期病院の実態を明らかにする． 方法：急性期病院2,185施設に対しアンケート調査を行った． 結果：有効回答46%で，うち52%が脳卒中患者を診療していた．多くが，地域医療圏は二次医療圏（45%）であるとし，その中心的役割は急性期病院（69%）と回答した．他の急性期病院，回復期リハ病棟，一般診療所，維持期施設事業所，周辺地域全体，自治体との連携が良好は75%，75%，74%，69%，73%，34%であった．医療（介護）情報を既に共有しているのは20%（14%）で，共有する予定51%（51%），共有する予定なし25%（30%）であった．医療保険と介護保険のシステムでは十分なリハビリを提供しにくいとの回答が67%に達した． 結論：脳卒中連携において中心的役割を担う急性期病院でも，地域での情報共有は未だ十分ではなかった．

Planning for Health Care Transitions: Results From the 2005–2006 National Survey of Children With Special Health Care Needs

Many youth with special health care needs have difficulties transferring to adult medical care. To address this, the Maternal and Child Health Bureau has made receipt of transition services a core performance outcome for community-based systems of care for youth with special health care needs. In this article we describe the results for the transition core outcome from the 2005-2006 National Survey of Children With Special Health Care Needs. We also describe changes in the measurement strategy for this outcome since the first National Survey of Children With Special Health Care Needs in 2001. In the nationally representative, cross-sectional 2005-2006 National Survey of Children With Special Health Care Needs, parent or guardian respondents of 18198 youth with special health care needs (aged 12-17) were asked if they have had discussions with their child's health care providers about (1) future adult providers, (2) future adult health care needs, (3) changes in health insurance, and (4) encouraging their child to take responsibility for his or her care. All 4 components had to be met for the youth to meet the overall transition core outcome. Those who had not had transition discussions reported if such discussions would have been helpful. Overall, 41% of youth with special health care needs met the core performance outcome for transition. Forty-two percent had discussed shifting care to an adult provider, 62% discussed their child's adult health care needs, and 34% discussed upcoming changes in health insurance. Most (78%) respondents said that providers usually or always encourage their child to take responsibility for his or her health. Non-Hispanic black or Hispanic race/ethnicity, lower income level, not speaking English, and not having a medical home reduced the odds of meeting the transition core outcome. Current performance on the transition core outcome leaves much room for improvement. Many parents feel that having transition-related discussions with their health care providers would be helpful. Future clinical and policy-level research should be directed at identifying barriers to, and recommending content for, health transition discussions.

Thirtieth birthday of the Italian psychiatric reform: research for identifying its active ingredients is urgently needed

In 2008 Italian psychiatry celebrates 30 years since the passing of Italian Law Number 180, the reform law that marked the phasing out of psychiatric hospitals and the gradual development...

Uganda edges closer to AIDS treatment for all

Uganda has seen the number of those accessing antiretroviral (ARV) drugs jump from 45 000 in 2004 to 121 200 in September 2007--a bit more than one-third of some 312 000 who need it. Although drug supplies have increased in volume, the national programme faces delays in procurement and distribution, poor storage and weak quality control, stock-outs and a chronic lack of manpower. management of the whole supply chain is very weak and problematic, Dr Elizabeth Madraa, manager of Uganda's AIDS Control Programme in the health ministry, told the Bulletin. We are now moving slowly as a result of the stock-outs because if we spread out rapidly and ran out of drugs, it would be disastrous. I think Uganda is making a lot of progress with regard to access to ARVs, the World Health Organization (WHO) Representative Dr Melville George says, adding that: in itself calls for a number of things like a good and reliable supply of drugs ... because if patients run out of ARVs they may develop resistance. George suggested that Uganda needs to put in place a good community-based care system that will look at a comprehensive package to include nutrition, social support for patients, management of other opportunistic infections and other social responsibilities. One of the beneficiaries of the government ARV programme is Elinah Kasubo. Access to ARVs has enabled the primary school teacher to live longer and continue working. But she complains of irregular drug supplies and a lack of antibiotics to fight infections that are a constant risk to people like her with weakened immune systems. We want a stable and consistent supply of ARVs and treatment for opportunistic diseases. Kasubo also complains of the queues teachers face when they fetch the drugs from government hospitals. It takes a whole day lining up for ARVs in government hospitals because we are many. As if that is not enough, pupils missing their teacher for a whole day is too much. AIDS and malaria are the biggest threats to the health of Ugandans and account for over 50% of the national health budget, according to the health ministry. The Ugandan government has committed itself to providing free ARVs and--to treat malaria--free artemisinin combination therapy to all those who need them. This is only possible if these remedies are available at prices the government can afford. Uganda imports most of its drugs. But that may be about to change, q-he first batch of locally produced generic ARVs and antimalarial drugs are expected to be delivered to the health ministry this year in a move that will see the cost of these life-saving remedies dropping from between USS 15 and USS 9 to between USS 9 and USS 2 per patient per month, Ugandan officials say. The drugs are to be produced by a pharmaceuticals factory in Kampala, a joint venture between Quality Chemical Industries Ltd. (QCIL), a local company, and Indian generics manufacturer, Cipla. The plant--the first of its kind in east Africa--opened in October 2007 in Luzira, a suburb of the city, to manufacture mainly ARV and antimalarial drugs. In time, the plant is expected to lower the cost of these drugs and make them more widely available in Uganda. At one time, ARVs cost USS 1500 per month, far beyond the pocket of the average Ugandan. The Ugandan government and QCIL signed an agreement in 2006 committing the government to buy ARVs and antimalarial drugs from the Luzira-based company. Approved in March 2008 by the National Drug Authority on behalf of the Uganda government, the new plant aims to produce two million tablets a day, once it achieves full capacity. This year the government budgeted for an extra 50 000 patients out of the expected production in Luzira. Uganda's ARV programme is 95% donor funded which raises the issue of sustainability. The programme is funded by the Global Fund to fight AIDS, Tuberculosis and Malaria, and the USA President's Emergency Plan for AIDS Relief. …

Use and Predictors of Out-of-Home Placements Within Systems of Care

This article examines out-of-home placements for youth with mental health problems in community-based systems of care. Longitudinal data come from the national evaluation of the Comprehensive Community Mental Health Services for Children and Their Families Program. One third of youth residing at home when they enrolled in the system of care were placed out of home during the 2-year follow-up period. As expected, youth who were placed out of home displayed more problems, fewer strengths, and more risk factors than youth who remained at home. However, results suggested few differences between youth placed in foster care and those placed in more restrictive settings. In addition, there was increased placement instability for Hispanic and older youth. Findings suggest that out-of-home placements remain a common component in systems of care. This suggests the immediate need for additional work on effectiveness of these settings for youth within systems of care.

Children and Youth with Special Health Care Needs: Partnering with Families for Effective Advocacy

Currently, 10.2 million children (13.9%) from birth through 17 years of age in the United States have special health care needs (SHCN); these children represent 29% of households (Child and Adolescent Health Measurement Initiative [CAHMI], 2007). The umbrella term “special health care needs” was officially adopted by the U.S. federal government in the Omnibus Balanced Budget Act of 1989 due to the efforts of an advocacy coalition led by the federal Maternal and Child Health Bureau (MCHB). A child has SHCN if he or she “has or is at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also requires health and related services of a type or amount beyond that required by children generally” (McPherson et al., 1998). Noncategorical terminology such as SHCN is useful because it groups children across many diagnoses and categorizes them by needs and functional difficulties. A recent survey using 2005-2006 data found that 85% of children with SHCN had functional difficulties, 57% had difficulty with bodily functions, 49% had difficulty with participation in any activity, and 42% had emotional or behavioral difficulties (CAHMI, 2007). This report found that needs of children with SHCN are complex: 86% needed prescription medications, 52% needed specialist care, 25% needed mental health care, 23% needed specialized therapies, and 11 % used durable medical equipment (CAHMI). The MCHB (2007) has issued a call to action to urge service providers, communities, states, families, and federal partners to develop and improve community-based systems of care for children with SHCN and their families. Linking information systems, coordinating care, and identifying children with SCHN through ongoing screening are key priorities of the MCHB. Tiedje

Avoidable mortality of psychiatric patients in an area with a community‐based system of mental health care

To ascertain the existence of an excess of avoidable mortality among psychiatric patients in an area with a community-based system of care, to identify predictors of higher risk of avoidable mortality and to provide some possible indication to reduce avoidable mortality in modern psychiatric services. All patients with an ICD-10 psychiatric diagnosis, living in a catchment area of about 75,000 inhabitants, seeking care in 1982-2001 were included (n = 6956). Mortality and causes of death were ascertained using linkage procedures with other local health databases. Standardized mortality ratios (SMRs) were calculated for each avoidable cause of death. The observed number of deaths for those causes considered avoidable by the European Community was four times greater than the expected (P < 0.01). SMR was higher for deaths preventable with adequate health promotion policies than for those preventable with appropriate health care. Males, alcohol/drug addicted and young patients have the highest avoidable SMRs. These findings urgently call for the implementation of health promotion and preventive programs targeted to psychiatric patients. Moreover, mental health services should improve the capacity to manage medical health problems of their patients.

Educational Profiles of Students at Enrollment in a System of Care

Systems of care have demonstrated improved outcomes for students and families in a variety of domains. However, more information is needed about how these approaches can be used to support positive school functioning. In an effort to articulate and better understand how systems of care might be used in ways that complement the educational system, this article examines the educational profiles of a cohort of students at the time they entered a community-based system of care. Educational variables of interest included attendance, discipline, and grades. Logistic regression models revealed differences in terms of grades and discipline at enrollment. Implications for collecting data at entry and future research on systems of care and school functioning are presented.

Families, Work, and an Aging Population

This article examines the intersection of family caregiving, work, and long-term care. Supporting families who provide care in order to minimize negative work effects while enhancing the acceptability of care options is of common concern to employers, state and federal policymakers, and the homecare professionals in the community-based care system. The contribution of families to the long-term care system, how employer policies have developed, how the public policy agenda has addressed family caregiving, and the importance of a more effective partnership on the state level are discussed.

Factors associated with clinicians’ dispositions in an out-patient psychiatric department

This cross-sectional study attempted to identify factors associated with clinicians' dispositions of patients after the first visit in an out-patient psychiatric department. Over a 33-month period, all new episodes of care with the department were included in the study. For each patient, socio-demographic, clinical information and contact characteristics were prospectively collected in relation to the first visit, as was information on case disposition. Factors associated with clinicians' disposition were analysed. Of the 1,138 patients who met the study criteria, 848 (75%) were followed up by the department, 150 (13%) were referred to other services and 140 (12%) were discharged. Suffering from a major psychiatric disorder, being younger and not living in an institution influenced clinicians' disposition to follow-up patients. Older age increased the chances of being referred to other services rather than discharged. Examining decision-making behaviour in out-patient psychiatric departments is a worthwhile endeavour because this setting represents the main entry point of modern and accessible community-based systems of care. The findings confirmed the importance of psychiatric determinants in the dispositional process and contribute to make clinicians more aware of other factors related to their decision-making.

The Kids Oneida Project: What Happened to Services When the Payment Rules Changed

Community-based systems of care may provide high quality, cost-effective alternatives to institutional care for children and adolescents. This report examines Kids Oneida (KO), a not-for-profit managed care entity established in upstate New York in 1998 to serve such children and their families. Changes in payment rules that established the program allowed KO to contract with a wide array of providers to provide and be reimbursed for non-traditional and formerly unreimbursable services, such as mentoring and supervision. By design, emphasis was on highly individualized plans of care in which traditional office-based services played only a small part. During the first 30 months of KO's operation, 228 children, whose severity of emotional disturbances was comparable to those of children placed in residential treatment centers, had average monthly expenditures for first admissions of 2,734 dollars for services and 228 dollars for administrative fees. Median length of stay in the program was 13.5 months, yielding an estimate of 39,987 dollars for typical length of stay. Length of stay and treatment costs were not related to children's gender or race. Length of stay was significantly longer for children with diagnoses indicating attention deficit hyperactivity disorder and behavior disorders. Treatment costs were significantly higher for children with behavior disorders and/or substance use and children who had had prior contact with the juvenile justice system.