Heavy Service Users Research Articles

What Becomes of the Frequent Hospital Attenders with Centrally Mediated Gastrointestinal Pain Syndrome?

Objective: Centrally mediated gastrointestinal pain syndrome (CAPS) is an infrequently diagnosed functional condition. A small number of patients do, however, become heavy service users due to difficulty in controlling severe symptoms. We aim to review the outcomes of patients who required frequent hospitalisation with CAPS. Methods: Medical records of patients with multiple CAPS presentations during 2015 (n = 18) were further analysed and reviewed until January 1st, 2019. Results: Patients (female 15; male 3) had a median age of 33 (IQR 12) years. Gastrointestinal co-diagnosis was common (88.9%), most frequently irritable bowel syndrome (50%), cyclical vomiting syndrome (27.8%) or gastro-oesophageal reflux disease (16.7%). 66.7% were prescribed regular opiate analgesics. Psychiatric co-morbidity was present in almost all: depression (88.9%); anxiety/panic disorders (38.9%) and post-traumatic stress disorder (27.8%). Social stressors were cited in 33.3%. 27.8% were employed, frequently in healthcare. Over the 4-year study period, 18 identified patients accounted for 2,048 nights in hospital and 672 A+E attendances. In 2015, these patients spent a median of 19 (IQR 34) nights in hospital each with median hospitalisations of between 7 and 10 nights over the following 3 years. Median A+E attendance was 8 per patient (IQR 8) in 2015, remaining relatively constant between 5 and 6 A+E presentations per patient per subsequent year. Conclusion: CAPS is a complicated heterogenous condition resulting from an interplay of physical stimuli with cognitive and emotional factors. As such, management is difficult and requires a multidisciplinary approach with considerable patient ownership of the condition, which is often difficult to achieve.

Supported Employment Helps Patients, Cuts Costs

Supported Employment Helps Patients, Cuts Costs

Consumption of Mental Health Services by People with Intellectual Disabilities

Background Although research is starting to identify those factors that predict contact with mental health services in individuals with intellectual disabilities, very little is known about the patterns of service use following referral. Yet, this information is vital for effective service planning and development. We therefore examined the factors associated with service consumption.Methods We constructed a service consumption index based on the number of outpatient clinics attended, contacts with the community psychiatric nurses, home visits by a psychiatrist and the number of admissions. This consumption index was used to divide the sample (n = 115) into two groups: heavy and light service users.Results and conclusions Logistic regression analysis indicated that, after controlling for the length of service contact, individuals with a diagnosis of schizophrenia spectrum disorder and those with a greater number of affective/neurotic symptoms were more likely to be heavy service users. Age, living situation and the degree of intellectual disabilities were not found to be significant predictors of service consumption. The results also suggest that a small proportion of service users consumed almost half of the service resources.

Heavy use of acute in‐patient psychiatric services: the challenge to translate a utilization pattern into service provision

There is an inequality in resource utilization among acute psychiatric in-patients. About 20-30% of them absorb 60-80% of the total resources allocated to this form of treatment. This study intends to summarize findings related to heavy in-patient service use and to illustrate them by means of utilization data for acute psychiatric wards. Longitudinal assessment of consecutive acute in-patients hospitalized for the first time. Analysis of individual utilization patterns by using latent class cluster analysis. Four groups with different utilization patterns were found all including heavy service users. In most cases heavy service use was temporary and could only be poorly predicted. Specific preventive interventions to contain heavy service use seem to be out of reach for the majority of high utilizing patients. However, services that have proven effective in reducing admissions to in-patient treatment and length of stay may nevertheless help to reduce heavy service use.

Rethinking Mental Health and Disorder: Feminist Perspectives

Back to table of contents Previous article Next article Book ReviewsFull AccessRethinking Mental Health and Disorder: Feminist PerspectivesMargaret Chaplin, M.D.Margaret ChaplinSearch for more papers by this author, M.D.Published Online:1 Jan 2004https://doi.org/10.1176/appi.ps.55.1.97AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail Rethinking Mental Health and Disorder: Feminist Perspectives is an edited volume consisting of five chapters of feminist theory and six chapters examining psychopathology from a feminist perspective. The book's editors, Mary Ballou and Laura S. Brown, have a long-standing professional background in feminist psychology.The first section, "Developing Feminist Theories," is, as billed, devoted to theoretical discussion. Not having much background in feminist thought, I found this section jargon laden and slow going. However, although dense, these chapters do provide a background and some general principles with which to understand feminist psychology. Perhaps most interesting is the senior editor's own chapter, "Toward a Feminist Ecological Theory of Human Nature: Theory Building in Response to Real-World Dynamics," in which Ballou and coauthors propose a model of human nature that incorporates everything from individual factors to the influence of the earth's climate and time in history. By including the "macrosphere" of societal forces, they hope not only to better understand the individual experience but also to "impel us to work towards a transformation of society by linking the personal, the political and action."Lofty goals indeed! It is hard to argue against the notion that individuals are shaped by all sorts of external factors that are traditionally overlooked by mainstream psychology. And it is not difficult to accept the fact that our efforts as clinicians to help individuals may be limited by social realities. As we are all sometimes painfully aware, treating an individual's depression won't relieve the person's poverty or oppression. Ballou and associates, however, seem to suggest that mental health professionals should become social activists in order to better serve their patients. Although this view is admirable, it seems a tad idealistic, impractical, and presumptive to expand the role of the mental health provider to include fighting for social justice. Nonetheless, the chapter is provocative, well reasoned, and a good prelude to the second half of the book.The second section, entitled simply "Psychopathology," is much more accessible to general mental health providers. It covers both female-dominated diagnoses, such as chronic fatigue syndrome, and common diagnoses, such as depression and addictions. Also included is an intriguing chapter called "Raging Hormones?: Feminist Perspectives on Premenstrual Syndrome and Postpartum Depression," which evaluates the extent to which stereotypes influence the diagnosis of these conditions. The highlight for me was the chapter titled "The Chrysalis Program: A Feminist Treatment Community for Individuals Diagnosed as Personality Disordered," which describes a day treatment program in Ontario developed for patients—mostly women with a diagnosis of borderline personality disorder—who were heavy users of services but did not obtain significant benefit from them. By incorporating feminist principles, the program manages to empower the clients to gain control over their lives.In general, these chapters demonstrate a real-world framework for putting the "ecofeminist" model to practical use by underscoring the role of environmental causes in the development of psychopathology and the importance of listening to the individual woman's story.In summary, this volume is a bit heady at times, a bit ethereal at others, but nevertheless thought-provoking and stimulating. The book is worth at least a perusal, if only to open one's mind to another perspective.Dr. Chaplin is staff psychiatrist at Community Mental Health Affiliates in New Britain, Connecticut.edited by Mary Ballou and Laura S. Brown; New York, Guilford Press, 2002, 314 pages, $38 FiguresReferencesCited byDetailsCited ByNone Volume 55Issue 1 January 2004Pages 97-97 Metrics PDF download History Published online 1 January 2004 Published in print 1 January 2004

Specialist service use following psychiatric emergency presentation: an 18-month follow-up study.

The aim of the present study was to identify the subsequent use of specialist psychiatric services by a group of 170 individuals referred as psychiatric emergencies. Hospital and community mental health team (CMHT) records and databases were used to identify specialist contact in an 18-month follow-up period. Out of the total of 170 people, 169 were traced. The majority (60.9%) had had some specialist psychiatric contact in the follow-up period. Those with severe mental health problems formed a minority of presenters, but were heavy users of services. Coverage by CMHT services was insufficient to prevent crisis in many cases. Improved access to broader community services is needed for those with life crises. This study suggests some important gaps in coverage by wider mental health services, which the current mental health agenda goes some way towards addressing.

The measurement of a case manager's workload burden

Objective: The aim of this activity was to develop an appropriate scale to accurately assess the level of clinical load carried by each case manager at the Royal Brisbane Hospital Integrated Mental Health Service. Method: A survey of, and consultation with, case managers over a period of 15 months was used to gather data and modify the monitoring tool for future use in the service. Results and Conclusion: Analysis of the data gathered revealed the level of case managers' work load burden and the depth of need required by clients. Professionally the Clinical Load Monitoring scores have been used in the allocation of additional cases for case management and in the supervision by discipline seniors. Service management has used the Clinical Load Monitoring Scale by dividing individual caseloads into low, medium and heavy service users – with low service users being further investigated for discharge from the service. Heavy service users were assessed for entry into more intensive treatment areas.

The measurement of a case manager's workload burden.

The aim of this activity was to develop an appropriate scale to accurately assess the level of clinical load carried by each case manager at the Royal Brisbane Hospital Integrated Mental Health Service. A survey of, and consultation with, case managers over a period of 15 months was used to gather data and modify the monitoring tool for future use in the service. Analysis of the data gathered revealed the level of case managers' work load burden and the depth of need required by clients. Professionally the Clinical Load Monitoring scores have been used in the allocation of additional cases for case management and in the supervision by discipline seniors. Service management has used the Clinical Load Monitoring Scale by dividing individual caseloads into low, medium and heavy service users - with low service users being further investigated for discharge from the service. Heavy service users were assessed for entry into more intensive treatment areas.

Community Treatment for Heavy Users of Private Mental Health Services: Who Benefits?

Much attention has been paid recently to the possibilities offered by the development of integrated services across the public and private sectors. In mental health a variety of models have been proposed and trials implemented. This article describes the advantages of a model of public-private integration that addresses the needs of private heavy service users. The model takes advantage of the increasing expertise within the public sector in managing complex and severe mental health problems in community settings and seeks to address the lack of availability of this type of resource for private sector patients.

Rates of health services utilization and survival in patients with heart failure in the Department of Veterans Affairs medical care system.

The objective of this study was to describe patterns of hospital and clinic use and survival for a large nationwide cohort of patients with heart failure. A retrospective cohort study of patients treated in the Veterans Affairs medical care system was conducted using linked administrative databases as data sources. In 1996, the average heart failure cohort member had 1-2 hospitalizations, 14 inpatient days, 6-7 visits with the primary physician, 15 other visits for consultations or tests, and 1-2 urgent care visits per 12 months. The overall risk-adjusted 5-year survival rate was 36%. Hospital use rates in the cohort fell dramatically between 1992 and 1996. One-year survival rates increased slightly over the period. Patients with heart failure are heavy users of services and have a very poor prognosis. Utilization and outcome data indicate the need for major efforts to assure quality of care and to devise innovative ways of delivering comprehensive services.

Who is a heavy service user? Preliminary development of a screening instrument for prospective consumers of a mobile intensive treatment team.

The mobile intensive treatment team (MITT) of the Valley Integrated Adult Mental Health Service in Brisbane, Australia, aims to provide services in the community to people with severe and persistent mental illness who have traditionally been heavily reliant on inpatient services (i.e. heavy service users). The MITT screening instrument (MITTSI) was developed to provide an objective measure to appropriately identify patients for referral to the service. A literature review and a panel of multidisciplinary clinicians were consulted to identify a list of specific attributes that would assist in the detection of heavy service users. These attributes were then formulated into an easy-to-administer screening instrument entitled the MITTSI. The MITTSI was administered in an interview format to MITT case managers (intensive case management) and to case managers in standard case management with prospective MITT patients (prospective heavy service users). Analyses of the responses indicated support for the MITTSI as a valid screening instrument in identifying heavy service users and for determining appropriate patients for referral to the MITT. The MITTSI is an easy-to-administer screening instrument which provides clear guidelines for inclusion and exclusion, and is an objective measure regarding the patients' urgency for referral to the MITT. Follow-up of the MITTSI within a broader, longer-term project will attempt to further refine the MITTSI and to further determine its validity. Outcomes will be published at a later stage.

Heavy utilization of inpatient and outpatient services in a public mental health service.

The purpose of the study was to develop a descriptive profile of heavy users of services in the South Australian Mental Health Services. Case notes for 50 heavy users were reviewed to obtain demographic and diagnostic information and data on service use over a three-year period. To supplement and verify this information, 35 of the patients were given structured interviews. The mean age of the 50 patients was 34.9 years, and there was a slight predominance of females. Most patients had never married and had been unemployed for a long time. All had a low income. The mean number of years of education was ten. The group was seriously disabled by psychiatric illness. The most common diagnosis was schizophrenia, followed by schizoaffective disorder and bipolar disorder. Comorbid axis I disorder and personality disorder or physical illness was common. Drug and alcohol abuse often complicated patient management and patients' ability to live successfully in the community. The average annual cost per patient was $13,598 (Australian), largely from inpatient care. This study contributes to an emerging global profile of the heavy service user. Such a profile may help service systems identify patients in this subgroup and target management strategies to these often very disadvantaged and challenging patients.

A review of studies of heavy users of psychiatric services

This paper reviews studies of patients who are heavy users of psychiatric services and identifies areas in which further research and evaluation are indicated. Extensive searches were conducted of the English language psychiatric and psychological literature before 1994. Important references from initially identified studies were followed up. More than 200 articles were reviewed, 72 of which are described in this review. The 72 papers were selected because they dealt with three questions: What is heavy service use? What patient characteristics contribute to it? What service delivery characteristics contribute to it? Criteria for identifying and defining heavy users of psychiatric services vary among studies. Few studies of heavy service users have attempted to examine use of all psychiatric services, both inpatient and community based. In most studies, 10 to 30 percent of patients are identified as heavy users, those who utilize between 50 and 80 percent of service resources. This group consists of a constantly changing cohort of patients who generally have psychotic illnesses as well as comorbid personality disorders and high levels of drug and alcohol misuse. Few studies have examined social issues such as isolation, homelessness, and social support, although these factors appear to contribute significantly to heavy service use. Few attempts have been made to define heavy-user groups in fiscal terms. More research on heavy users of psychiatric services is clearly needed to improve providers' ability to plan appropriately targeted mental health services for this disabled group of patients who use expensive resources.

The relationship between social factors and frequent use of psychiatric services.

The purpose of the study was to develop a comprehensive demographic, diagnostic and social profile of patients who are heavy service users of hospital and community based services within the South Australian Mental Health Services (SAMHS). This paper concentrates on the relationship of social issues to heavy service use. The 50 heaviest users of public adult acute psychiatric services in a defined catchment area of Adelaide were identified. Data were obtained retrospectively from the case notes over a 3 year study period. All patients' primary therapists were interviewed, as were 35 of the patients. These structured interviews included a variety of psychosocial rating scales investigating disability and social networks. The 50 patients studied were found to be seriously disabled by chronic psychiatric illness, with substance abuse often complicating their management and their ability to live successfully in the community. The study confirms the emergence in the literature of a valid global profile of the heavy service user patient, and indicates that social factors are strongly related to heavy service use.

Psychiatric and social reasons for frequent rehospitalization.

The authors attempted to identify factors that commonly contributed to the decision to rehospitalize patients who made heavy use of mental health services. The case notes of 50 patients with frequent readmissions to the South Australian Mental Health Services over a three-year period were examined to identify which of 15 factors most frequently contributed to hospital readmission. Lack of insight or denial of illness was cited in 62.2 percent of the patients' 442 total admissions, followed by relationship problems (61.1 percent), suicidal ideation (44.8 percent), and noncompliance with medication (43.2 percent). When the 15 factors were combined into four major categories, social factors were found to contribute to 38.9 percent of admissions, followed by factors related to psychiatric and physical illness (31.1 percent), dangerousness to self or others (20.3 percent), and substance abuse (9.7 percent). The substantial contribution of social factors to the readmission of patients to acute mental health services is strong evidence that the mental health system must provide appropriate targeted resources and assertive, continuous case management to avoid social crises. Issues surrounding drug and alcohol abuse among heavy users of services must be actively addressed.

Patterns in the delivery of psychiatric care in Saskatchewan 1971-1972 (II). Types of contacts and some patient career characteristics.

A previous paper dealt with an overview of service sectors and patient volumes (2), whereas this one concentrates on types of contacts and some patient career characteristics. Analysis of a comprehensive psychiatric care utilization data file for Saskatchewan for the 1971-1972 period shows that 'public' sector patients were hospitalized for a greater average length of time than were 'private' sector patients. This may reflect differences in the styles of practice, exigencies of the demand for hospital beds in the 'private' as opposed to the 'public' sector and/or intrinsic differences in the nature of the problem treated in each sector. Some interesting facts regarding patterns of contact were uncovered. The bimodal nature of the 'psychiatric population' was further evident from the data which show that the majority of patients used relatively few services whereas a few used a large number of services. This suggests that the majority of the people seen for psychiatric reasons by medical practitioners were suffering from relatively minor psychiatric disorders. Heavy users of services were much more likely to have had some'public' or University Hospital-based contact. Conversely, light users were predominantly private sector patients. In the 'public' sector, those who had had some in patient treatment were consistently higher users of all services. It is evident that psychiatrists held a dominant position in this community-oriented public sector, having seen a large number of patients, but having had a low average rate of services per patient. In contrast, community nurses saw relatively few patients but saw them very often. This no doubt reflects their role in providing 'maintenance' services to chronic patients in approved homes in the community. In the 'private' sector, 69 percent of the services were delivered by GPs and 23 percent by psychiatrists were more likely to have had 'public' sector activity than were those seen only by GPs; also once in the 'public' sector, they were likelier to have had in patient as well as outpatient treatment. This suggests a 'sifting' of the more "difficult" patients through the private specialist sector into the public sector.