Community-based Residential Services Research Articles

Life is better but not without challenges: experiences following discharge from community-based residential mental health rehabilitation-a qualitative content analysis.

Community-based residential mental health rehabilitation units for people experiencing severe and persistent mental illness are increasingly available in Australia. Research completed 20 years ago suggested that people leaving these services often experienced impoverished social lives and other challenges in the community. It is unclear whether contemporary consumers experience similar difficulties. This qualitative study explored contemporary consumers' experiences after leaving community-based residential services. An inductive qualitative content analysis of individual interviews was completed with consumers 12-18 months following discharge from three community care units (CCUs) in Queensland, Australia. The interview schedule explored three questions: (1) What does life look like after leaving the CCU, (2) Has the CCU impacted their life, and (3) How could the CCU experience be improved? A convenience sample was used, with sampling continuing until thematic saturation was achieved. A member of the research team who had relevant lived experience actively supported the analysis and interpretation. Seventeen interviews were completed. Three themes were identified: 'life is better but not without challenges', 'the CCU helps you get ready to go out into the world', and 'strict rules are important but rigid expectations can be hard; things could be better'. Consumers reflected positively on their lives post-discharge from a community-based residential rehabilitation unit and viewed the service as having supported improvements in their lives. The findings suggest the appropriateness of optimism about the possibility of sustained improvements in quality of life after leaving community-based transitional residential rehabilitation support.

Comparative Effectiveness of Integrated Peer Support and Clinical Staffing Models for Community-Based Residential Mental Health Rehabilitation: A Prospective Observational Study

This observational study compared the outcomes of consumers receiving community-based residential mental health rehabilitation support in Australia under a clinical staffing model and an integrated staffing model where Peer Support Workers are the majority component of the staffing profile. Reliable and clinically significant (RCS) change between admission and discharge in functional and clinical assessment measures were compared for consumers receiving care under the clinical (n = 52) and integrated (n = 93) staffing models. Covariate analyses examined the impact of known confounders on the outcomes of the staffing model groups. No statistically significant differences in RCS improvement were identified between the staffing models. However, logistic regression modelling showed that consumers admitted under the integrated staffing model were more likely to experience reliable improvement in general psychiatric symptoms and social functioning. The findings support the clinical and integrated staffing models achieving at least equivalent outcomes for community-based residential rehabilitation services consumers.

Cross-Sectional Comparison of Treatment Provided Under the Clinical, Integrated, and Partnership Staffing Models for Community-Based Residential Mental Health Rehabilitation.

In Queensland (Australia), community-based residential mental health rehabilitation services have three distinct staffing profiles. The traditional 'clinical' staffing model has nursing staff occupying most staff roles. The 'partnership' approach involves collaboration between the health service and a Non-Government Organisation. Under the 'integrated' staffing approach, Peer Support Workers reflect the majority staffing component. This study compares the treatment received by consumers (N = 172) under these staffing models using cross-sectional administrative data. Staffing models were generally comparable on demographic, diagnostic, and symptomatic/impairment measures. However, statistically significant differences were present on a range of treatment variables. Differences mainly occurred between the clinical and integrated approaches, with the integrated staffing model having lower rates of involuntary treatment, antipsychotic polypharmacy, depot use, and chlorpromazine dose equivalence levels. These findings indicate the need to carefully examine the impact of staffing configuration on rehabilitation processes to understand whether differences in approaches are likely to impact rehabilitation outcomes.

Evaluating client experience of rehabilitation following acquired brain injury: a cross-sectional study

ABSTRACT Objective: To implement a service-wide approach in the collection of data to evaluate client experience of brain injury rehabilitation. Methods: Mixed methods study. Clients with brain injury and family members of the Liverpool Brain Injury Rehabilitation Unit completed a purpose-designed Patient Experiences Survey for Brain Injury Rehabilitation (PES-BIR) which included closed and free-text responses, as well as the Client Services Questionnaire-8 (CSQ-8). The survey was completed by clients across the inpatient, community rehabilitation, vocational rehabilitation and community-based residential services. Results: 118 questionnaires were completed in relation to 102 clients. The majority of respondents were clients (n = 79, 66.9%) with a small proportion of family members represented (n = 39, 33.1%). High levels of satisfaction were reported (CSQ-8 28.4 ± 3.8) and positive patient experience (PES-BIR total, 37.2 ± 5.5) across all services. Themes identified from the free-text responses suggested that client experience was influenced by communication with the client about their progress and within the team, tailoring of rehabilitation, access to specialist services, integration of care across the rehabilitation continuum and the rehabilitation environment. Implications for practice: Routine collection and evaluation of client experience data in brain injury rehabilitation can be used to evaluate service delivery quality and guide further service improvements.

Diary of a Mental Health Peer Worker: Findings From a Diary Study Into the Role of Peer Work in a Clinical Mental Health Setting.

Introduction: The importance of peer support workers in mental health care delivery has been extensively advocated for in mental health policy frameworks. However, there has been limited research examining the implementation of paid peer workers in clinical settings. This study explores the experience of paid peer support workers integrated within a clinically-operated community-based residential rehabilitation service for people diagnosed with a mental health disorder experiencing challenges living independently in the community.Methods: A general inductive approach was taken in the analysis of diaries completed by a newly employed peer workforce. These diaries focussed on what they viewed as significant interactions in fulfilling their role. Composite vignettes were generated to illustrate key themes.Findings: Thirty-six diaries were provided; these reported unplanned and spontaneously occurring interactions. Peer workers emphasized the importance of connecting with people while they were engaging in everyday activities as an opportunity for personal growth of the residents. The diaries also focussed on the peer workers' ability to connect and establish trust by sharing similar experiences with residents or family members. Peer workers also believed that they brought a different perspective than clinical staff and were able to refocus attention from clinical diagnoses and symptoms to other aspects of the resident's lives.Discussion: Peer support workers described their work as flexible, responsive, and adaptable to the resident's needs. They believed that their roles brought a different lens to interactions on the unit and fostered a more inclusive and personal way of working for the team.Conclusion: To ensure that peer workers can engage authentically with residents and family members, it is critical that the role and principles of peer work are valued and understood by all.

Transitioning from child to adult mental health services: what role for social services? Insights from a European survey

PurposeYoung people transitioning from child to adult mental health services are frequently also known to social services, but the role of such services in this study and their interplay with mental healthcare system lacks evidence in the European panorama. This study aims to gather information on the characteristics and the involvement of social services supporting young people approaching transition.Design/methodology/approachA survey of 16 European Union countries was conducted. Country respondents, representing social services’ point of view, completed an ad hoc questionnaire. Information sought included details on social service availability and the characteristics of their interplay with mental health services.FindingsService availability ranges from a low of 3/100,000 social workers working with young people of transition age in Spain to a high 500/100,000 social workers in Poland, with heterogeneous involvement in youth health care. Community-based residential facilities and services for youth under custodial measures were the most commonly type of social service involved. In 80% of the surveyed countries, youth protection from abuse/neglect is overall regulated by national protocols or written agreements between mental health and social services, with the exception of Czech Republic and Greece, where poor or no protocols apply. Lack of connection between child and adult mental health services has been identified as the major obstacles to transition (93.8%), together with insufficient involvement of stakeholders throughout the process.Research limitations/implicationsMarked heterogeneity across countries may suggest weaknesses in youth mental health policy-making at the European level. Greater inclusion of relevant stakeholders is needed to inform the development and implementation of person-centered health-care models. Disconnection between child and adult mental health services is widely recognized in the social services arena as the major barrier faced by young service users in transition; this “outside” perspective provides further support for an urgent re-configuration of services and the need to address unaligned working practices and service cultures.Originality/valueThis is the first survey gathering information on social service provision at the time of mental health services transition at a European level; its findings may help to inform services to offer a better coordinated social health care for young people with mental health disorders.

A Comprehensive Cohort Description and Statistical Grouping of Community-Based Residential Rehabilitation Service Users in Australia.

Background: Community Care Units (CCUs) are a model of community-based residential rehabilitation support available in Australia that assists people affected by severe and persistent mental illness to enhance their independent living skills and community involvement. These services have been subject to limited evaluation, and available descriptions of consumer cohorts lack relevance to the understanding of their rehabilitation needs. Method: A clinical assessment battery covering a broad range of relevant domains was completed with consumers commencing at three CCUs in Queensland, Australia, between December 2014 and December 2017 (N = 145). The cohort was described based on demographic, diagnostic, treatment-related variables, and the assessment battery. The comparability of included sites was assessed. This contemporary cohort was also compared to the pooled cohort of Australian community-based residential rehabilitation services emerging from a previous systematic review. Additionally, cluster analysis (CA) was completed in two stages based on the clinician-rated assessments: hierarchical CA (Wards method) to identify the optimal number of clusters, followed by K-means clustering. Results: Dominant features of the cohort were male sex and the primary diagnoses of schizophrenia spectrum disorders. The average consumer age was 31.4 years. Most consumers were referred from the community, had been living with family, and were not subject to involuntary treatment orders. No site-based differences were observed on demographic, diagnostic and treatment-related variables. However, some site-based variation in levels of symptoms and functional impairment emerged. Overall, the cohort was comparable with the Transitional Residential Rehabilitation (TRR) cohort defined in a previous systematic review. Through CA, a three-cluster solution emerged: Cluster 1 (15%) was characterised by higher levels of substance use comorbidity; Cluster 2 (39%) was characterised by higher levels of disability and symptoms; and Cluster 3 (46%) was distinguished by lower levels of general psychiatric symptoms. Conclusions: The cohort was generally comparable to the TRR cohort. Site-based variability in the characteristics of admitted consumers was minimal. The CA solution suggested that three different sub-groups of consumers are admitted to CCUs, which have implications for adapting the approach to rehabilitation. Recommendations include ensuring early availability of interventions to address co-morbidities and pacing rehabilitation expectations to consumers stage of recovery.

Integrated staffing model for residential mental health rehabilitation

Purpose – A novel integrated staffing model for community-based residential rehabilitation services is described. The purpose of this paper is to achieve synergistic gains through meaningful integration of peer support and clinical workers within rehabilitation teams. Key features include the majority of roles within the team being held by persons with a lived experience of mental illness, the active collaboration between peer and clinical workers throughout all stages of a consumer’s rehabilitation journey, and an organizational structure that legitimizes and emphasizes the importance of peer work within public mental health service delivery. This staffing model is not anticipated to alter the core rehabilitation function and service models. Design/methodology/approach – The emergence of the integrated staffing model is described with reference to the policy and planning context, the evidence base for peer support, and the organizational setting. A conceptual and contextualized description of the staffing model in practice as compared to a traditional clinical staffing model is provided. Findings – There is a potential for synergistic benefits through the direct collaboration between horizontally integrated peer and clinical specialists within a unified team working toward a common goal. This staffing model is novel and untested, and will be subjected to ongoing evaluation. Originality/value – The integrated staffing model may provide a pathway to achieving valued and valuable roles for peer workers working alongside clinical staff in providing rehabilitation support to people affected by serious mental illness.

The Setting is the Service: How the Architecture of Sober Living Residences Supports Community Based Recovery.

The architecture of residential recovery settings is an important silent partner in the alcohol/drug recovery field. The settings significantly support or hinder recovery experiences of residents, and shape community reactions to the presence of sober living houses (SLH) in ordinary neighborhoods. Grounded in the principles of Alcoholics Anonymous, the SLH provides residents with settings designed to support peer based recovery; further, these settings operate in a community context that insists on sobriety and strongly encourages attendance at 12-step meetings. Little formal research has been conducted to show how architectural features of the recovery setting - building appearance, spatial layouts, furnishings and finishes, policies for use of the facilities, physical care and maintenance of the property, neighborhood features, aspects of location in the city - function to promote (or retard) recovery, and to build (or detract from) community support. This paper uses a case-study approach to analyze the architecture of a community-based residential recovery service that has demonstrated successful recovery outcomes for its residents, is popular in its community, and has achieved state-wide recognition. The Environmental Pattern Language (Alexander, Ishikawa, & Silverstein, 1977) is used to analyze its architecture in a format that can be tested, critiqued, and adapted for use by similar programs in many communities, providing a model for replication and further research.

Interview with Charles R. Evans, FACHE, president of the International Health Services Group and senior advisor at Jackson Healthcare.

Charles R. Evans, FACHE, is president of the International Health Services Group (IHSG), based in Alpharetta, Georgia, and senior advisor at Jackson Healthcare, in Atlanta, Georgia. IHSG is a social enterprise he founded in 2007 to support health services development in underserved areas of the world. Its mission is to work with established organizations to enhance their healthcare management and development capabilities as they seek to attain their broader missions. Jackson Healthcare is a consortium of companies that provide physician and clinician staffing, anesthesia management, and healthcare information technology solutions.Mr. Evans's previous professional experience includes positions at HCA (Hospital Corporation of America), where he managed a number of company divisions and, in 2004, was named president of HCA's Eastern Group. Prior to his work at HCA, he held executive positions in a number of not-for-profit community hospital settings.A Fellow of the American College of Healthcare Executives (ACHE) since 1999, Mr. Evans served on ACHE's Board of Governors from 2004 to 2007 and as its ChairmanElect, Chairman, and Immediate Past Chairman from 2008 to 2011. He currently serves on the organization's Counselors Committee. In 2014, he received ACHE's Gold Medal Award in the nondelivery healthcare organization category. The Gold Medal Award is the highest honor bestowed by the American College of Healthcare Executives on outstanding leaders who have made significant contributions to the healthcare profession.Mr. Evans, a native of West Virginia, earned an undergraduate degree from West Virginia Wesleyan College; he received his MA from Indiana University of Pennsylvania and his MBA from Indiana University.Dr. O'Connor: Congratulations on winning the Gold Medal Award! You have had an exceptional career. Tell us about your beginnings and what attracted you to the field of healthcare management.Mr. Evans: My early career was in community mental health services and programming for emotionally disturbed children. I directed the Columbia-MontourSnyder-Union Mental Health, Mental Retardation, Drug and Alcohol Program, a four-county board of county commissioners in rural central Pennsylvania (the term mental retardation in the commission's name has since been changed to intellectual disability). In that role I worked closely with Geisinger Medical Center, which provided our inpatient hospital services. I loved my work with physicians and administrators and my involvement with the hospital. Through that experience, I decided that hospital administration was my calling. I went back to school to recredential for a hospital administration career.Dr. O'Connor: What is the greatest challenge you have confronted during your career?Mr. Evans: This question affects me on two levels. First, on a personal competency level, 1 have felt challenged in terms of-and have worked my whole career on improving-my listening skills. Most of us are much better at talking than at really listening effectively to what others are saying. I have given a lot of effort to this. In fact, I took a 50-hour course that was mostly about listening skills and listening more effectively.A second challenge was an experience I faced early on in central Pennsylvania. One of the programs we created and managed was a community-based residential service for deinstitutionalized intellectually disabled women who had previously been institutionalized for many years. At that time, the state had initiated a major program to transition these women into more appropriate settings than institutions; in today's world, they would not have been institutionalized in the first place. I was shocked at the tremendous community resistance to creating the programs. These were small, three-person apartment programs that were staffed, so it was a very safe and wellmanaged environment. But misinformation was circulated, and continued to circulate, indicating a great need for community education and for systematic, ongoing communication to effectively counter the misinformation. …

Train the trainer? A randomized controlled trial of a multi‐tiered oral health education programme in community‐based residential services for adults with intellectual disability

To assess the impact of a multi-tiered oral health education programme on care staff caring for people with intellectual disability (ID). Postal questionnaires were sent to all care staff of a community-based residential care service for adults, randomly assigned to control and intervention groups. A specifically developed training programme was delivered to residential staff nominees, who then trained all staff within the intervention group. The control group received no training. Post-test questionnaires were sent to both groups. Paired-samples t-test was used to compare oral health-related knowledge (K) and behaviour, attitude and self-efficacy (BAS) scores. Of the initial 219 respondents, 154 (response rate between 40% and 35.8%, with attrition rate of 29.7% from baseline to repeat) returned completed questionnaires at post-test (M=8.5 months, range=6.5-11 months). Control and intervention groups were comparable for general training, employment and demographic variables. In the intervention group, mean Knowledge Index score rose from K=7.2 to K=7.9 (P<0.001) and mean BAS scale score rose from BAS=4.7 to BAS=5.4 (P<0.001). There was no statistically significant increase in mean scores from test (K=7.0, BAS=4.7) to post-test (K=7.2, BAS=4.9) for the control group. Mean scores regarding knowledge, attitude, self-efficacy and reported behaviour increased significantly at 8.5 months in staff where training was provided. The results indicate that a multi-tiered training programme improved knowledge, attitude, self-efficacy and reported behaviour amongst staff caring for people with ID.

Should Government Subsidize Caregiver Wages? Some Evidence on Worker Turnover and the Cost of Long-Term Care in Group Homes for Persons With Developmental Disabilities

High rates of worker turnover have been a persistent problem in the long-term care industry. Spending on individuals with developmental disabilities represents 20 percent of all long-term care spending and 40 percent of Medicaid spending on long-term care. Using detailed data on the providers of long-term community-based residential services for persons with developmental disabilities, this research examined the consequences of high worker turnover for long-term care costs and whether a wage-subsidy policy to reduce worker turnover would have been cost-effective in this sector. Higher turnover increased state-reimbursed training expenditures, the share of workers engaged in training, and workers’ compensation costs. Turnover had no effect on training expenditures that were not reimbursed by the state, nor did it affect residential vacancies. The findings indicated that providers were unlikely to reduce turnover on their own, since its associated costs were either tolerably small or borne by others. An analysis indicated that it was likely socially beneficial for the government to reduce turnover through wage subsidization in this sector.

Causes of Caregiver Turnover and the Potential Effectiveness of Wage Subsidies for Solving the Long-Term Care Workforce 'Crisis'

Abstract Detailed data on private providers of long-term community-based residential services for persons with developmental disabilities permit investigation of the causes of frontline worker turnover. The endogeneity of turnover with compensation variables is accounted for in the estimation using instrumental variables. Turnover is determined by resident characteristics, frontline-worker compensation, and establishment characteristics. The share of higher-need residents and agency size predict higher turnover, while compensation and non-profit status are associated with lower turnover. Our findings indicate that public policies to reduce turnover through compensation subsidization can be effective. Our preferred estimates suggest an approximate one-quarter increase in total compensation would cut turnover by one-third.

Residential alternatives to acute psychiatric hospital admission: systematic review

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. To assess the effectiveness and cost-effectiveness of and satisfaction with residential alternatives to standard acute in-patient mental health services. 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. 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. 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.

Deinstitutionalization of People With Developmental Disabilities: A Review of the Literature

Ontario has recently closed its last 3 institutions for persons with developmental disabilities. Very little research has been conducted on Canadian deinstitutionalization projects, and the impacts and bona fides of such endeavours have not been well documented in Canada. However, the closing of institutions has occurred in most Western jurisdictions and has been the subject of much research in Australia, the United Kingdom, and the United States. Although community services are of variable quality, this literature review suggests that the Ontario plan to close institutional facilities in favour of community-based residential services will be of general benefit to former institutional residents.

‘It's pretty hard with our ones, they can't talk, the more able bodied can participate’: staff attitudes about the applicability of disability policies to people with severe and profound intellectual disabilities

The level of resident's adaptive behaviour and staff facilitative practices are key sources of variation in outcomes for residents in community-based residential services. The higher the resident support needs the poorer their outcome. Although substantial investment has been made in values-based training for staff, their attitudes and the impact of these on practice is largely unexplored. The first study used ethnographic and action research methods to examine the daily lives of 25 residents with severe and profound intellectual disabilities (ID), who lived in five small group homes, and the attitudes of the staff supporting them. Thematic analysis of the data led to a proposition that although staff accept principles of inclusion, choice and participation for people with ID in general, they do not consider it feasible to apply these to the people with severe and profound ID to whom they provide support. The findings from a second study that used a group comparison design and administered a short questionnaire about staff attitudes to 144 direct-care staff and first-line managers working in disability services confirmed this hypothesis. The study suggests more focused attention is needed to staff understanding the values embedded in current policies and their application to people with more severe disabilities.

Ethical Challenges

The Ethical Challenges scenario in the June 2004 issue of the American Journal of Evaluation focused on an evaluator-client disagreement concerning the wisdom of having consumer representation on a steering committee that would help plan and oversee an evaluation in an agency providing community-based residential services to the chronically mentally ill. In her response to the commentaries on this case, Gillian Kerr encourages us to explore in greater depth the implications of using steering committees, advisory groups, and related strategies for soliciting stakeholder input in evaluation.

Hospital and community-based care for patients with chronic schizophrenia in Hong Kong--quality of life and its correlates.

There have been few studies on the impact of de-institutionalization on psychiatric patients' lives in Chinese culture. The objectives of the present study were: (1) to compare quality of life (QOL) of Chinese patients with schizophrenia living in three different treatment settings (hospital, long-stay care home and half-way house) in Hong Kong, and (2) to identify factors associated with patients' subjective well-being. A matched-group design was used. Subjects (n = 204) living in the three treatment settings were matched according to age, sex, educational level, marital status, length of psychiatric illness and number of previous psychiatric admissions. Multiple measures for the evaluation of QOL included the Satisfaction With Life Scale (SWLS), WHO Quality of Life Measure-Abbreviated version-Hong Kong (WHOQOL-BREF-HK), Life Event List (LEL) and the Global Assessment Scale (GAS). Psychiatric symptoms were evaluated with the Brief Psychiatric Rating Scale (BPRS). Significant differences in objective QOL indices (global level of functioning, number of life events and income) between subjects staying in hospital and community-based residential services were found in favour of the less restrictive community settings. However, with respect to global life satisfaction, subjects preferred the more secure settings despite their restrictiveness. Predictors of subjective well-being were educational level, negative life events and the BPRS items of somatic concern, anxiety and guilt feelings. The impact of negative life events on subjective well-being decreased over time. In a cohort of Chinese patients with chronic schizophrenia, community-based treatment settings had a positive impact on objective QOL indices but not on subjective well-being. Negative life events, education level, and the BPRS items of somatic concern, anxiety and guilt feelings were predictors of subjective well-being which seemed to adapt to external circumstances over time.

Living with support in a home in the community: predictors of behavioral development and household and community activity.

The purpose of this article was to review studies of behavioral development and household and community activity among adults with mental retardation living in community residential services and to distill knowledge about the factors that influence outcome. Research points to behavioral development occurring across the full spectrum of disability but influenced by mental retardation syndrome and the acquisition of pivotal skills. However, engagement in household and community activities has been found to be strongly related to individual adaptive behavior. People with more severe mental retardation are vulnerable to leading lives characterized by underoccupation and lack of community involvement. Moving from institutional to community-based residential services may be accompanied by significant increases in adaptive behavior, but a plateau effect on subsequent development has also been reported. There is substantial evidence to suggest that key aspects of effective teaching technology may be absent in community-based residential environments. Community settings support greater engagement in household and community activities than institutions. Ordinary housing stock and normative architecture and standards of material enrichment are to be preferred. The use of normative housing constrains group living to relatively small scale, but there is little evidence that smaller size within this range is to be preferred to larger size. There is little evidence to suggest that higher staff-to-resident ratios lead to uniformly better outcomes, but staff orientation, working methods, and performance are important influences. Little is known about what precise characteristics of community location give rise to greater community integration. MRDD Research Reviews 7:75-83, 2001.

People Living in Community Homes: Their Views

The study investigated the views of people with learning disabilities in community-based residential services. Six people in different services took part in detailed case studies. Views were assessed using two interview approaches: a Service User's Interview Questionnaire was completed, and secondly, interviews took place on at least six occasions covering selected topics. The use of qualitative analysis is outlined. Four of the six people in the study wanted to leave their residential service. People's views were strongly influenced by the following factors: knowledge of alternative living arrangements, identified friend(s) to live with, dislike of the behaviour of other people in the service, and dislike of a member of staff. Managers and carers in community services may need to give more attention to the interpersonal issues highlighted by the study.