Long-term Wards Research Articles

Descriptive outcomes for a cohort of high-frequency psychiatric service users in the Western Cape, South Africa after 10 years

BackgroundAssertive community treatment (ACT) is an intervention implemented to manage the effects of deinstitutionalisation. South African studies have reported decreased admissions at 12 and 36 months when a modified ACT intervention is compared with standard care. However, costs associated with the intervention have raised the question of its feasibility in developing countries.AimThis study aimed to describe the long-term demographic and clinical outcomes of a group of psychiatric high-frequency users (HFUs) included in the first South African ACT study.SettingStikland Psychiatric Hospital, Cape Town, South Africa.MethodsData from 55 HFUs participating in the first South African ACT trial, including both the intervention and control groups, were retrospectively reviewed 10 years after the patients’ inclusion.ResultsOf the 55 HFUs initially included, nine remained in the formal ACT programme whilst 16 received standard care over the full 10 years. Five patients died and two were admitted to long-term wards. The mean number of admissions was 3.73 and the mean number of admission days was 261.11 over the 10 years. Twelve patients were never re-admitted; of these, nine came from the original study intervention group.ConclusionsThis was the first study looking at the long-term outcomes of a group of psychiatric HFUs in an under-resourced setting receiving either a modified ACT intervention or standard outpatient care. Reflecting broadly on the group, there were a larger number of patients in the original ACT group who had no re-admissions and a comparatively higher utilisation of available services during the 10-year follow-up period.

Perceived barriers and facilitators in providing palliative care for people with severe dementia: the healthcare professionals\u2019 experiences

BackgroundDementia has become a major public health issue worldwide due to its rapidly increasing prevalence and an increasing number of dementia-related deaths in long-term care facilities. The aim of this study was to examine health professionals’ experiences of potential barriers and facilitators in providing palliative care for people with severe dementia in long-term care facilities.MethodsThis was a qualitative descriptive study. The data were collected from four focus groups and 20 individual in-depth interviews with healthcare professionals from four Norwegian nursing homes. The data were analysed by thematic text analysis, as described by Braun and Clarke.ResultsThe major findings indicate that healthcare professionals experience a lack of continuity as the main barrier to facilitating palliative care. Time pressure and increased efficiency requirements especially affect the weakest and bedridden residents with dementia. The healthcare professionals feel conflicted between wanting to spend more time caring for each individual resident and feeling pressure to help everyone. Although resources are scarce, dying residents are always given priority by healthcare professionals, either by the hiring of extra personnel or the reorganization of tasks in a way that facilitates someone staying with the terminal resident. Advanced care planning was highlighted as a facilitator in providing palliative care, but the extensive use of temporary staff among nurses and doctors and the relocation between the sheltered and long-term wards threaten the continuity in planning and providing palliative care.ConclusionsThe findings indicate that healthcare professionals experienced several structural barriers that prevented the provision of palliative care to people with severe dementia in long-term care facilities. Increasing demands for economic rationality lead to a lack of continuity of care. Organizational changes, such as measures to increase the competence and the proportion of permanent employees and the prevention of burdensome end-of-life transitions, should be implemented to improve continuity and quality of care.

Quality of care in long-term care departments in mental health facilities across the Czech Republic.

In the region of Central and Eastern Europe, long-term departments at psychiatric hospitals provide a large proportion of the care for people with complex mental health needs. The System of United Psychiatric Rehabilitation (S.U.P.R.) project focussed on the implementation of a complex set of interventions of psychosocial rehabilitation to increase the quality of care. The aim of this study was to assess the effect of the S.U.P.R. psychosocial rehabilitation programme on the quality of care at the longer-term inpatient psychiatric departments. All 12 psychiatric hospitals in the Czech Republic were asked to participate in the study. A 'before and after' design was adopted to evaluate the impact of the S.U.P.R. programme. Quality of care was assessed using the internationally validated, web-based tool, QuIRC (Quality Indicator for Rehabilitative Care), which provides percentage scores (0-100%) on seven domains of care and an overall mean quality score. Fourteen long-term wards of 12 psychiatric hospitals for adults in the Czech Republic participated in the S.U.P.R. project. The mean total QuIRC scores were relatively low at the start of the project (range 33% to 53%) but all domain scores increased two years after the S.U.P.R. programme was implemented (range 44% to 62%). Staff feedback was generally positive about the programme, but inadequate staffing was an impediment to its success. Implementing a modern concept for psychosocial rehabilitation aimed at progressing the recovery of people with complex mental health problems can improve the quality of care in longer term inpatient settings.

Potentially inappropriate medication use in nursing homes: an observational study using the NORGEP-NH criteria

BackgroundFrail residents in the nursing home sector call for extra care in prescribing. The Norwegian General Practice Nursing Home (NORGEP-NH) list of 34 explicit criteria for potentially inappropriate medication use in nursing homes was developed explicitly for this population. The aim of this study was to employ the NORGEP-NH Criteria to study the extent of potentially inappropriate medication use among nursing home residents and explore possible associated factors.MethodsCross-sectional observational pharmacoepidemiological study from residents in nursing homes in the county of Vestfold, Norway. Data collected 2009–11 included residents’ demographic and clinical status and all medications, regular and on demand.Results881 patients from 30 institutions (mean 85.9 years, 68.6% female), were included. According to NORGEP-NH, 43.8% were prescribed at least one potentially inappropriate regular medication, and 9.9% regularly received three or more potentially inappropriate medications. When also including a) the NORGEP-NH Deprescribing Criteria and b) including drugs prescribed for use as needed, 92.7% of all residents received medication that needs particular surveillance according to the NORGEP-NH. 69.7% of the nursing home residents used at least one psychotropic drug regularly. Female residents received more often than males at least one potentially inappropriate regular medication (OR 1.60, p=0.007). Regarding the prescription of three or more concomitant psychotropic medications, odds ratio for females was 1.79 (p=0.03) compared to males. Residents with the best performance in activities of daily living, and residents residing in long-term wards, had higher risk of using three or more psychotropic drugs. Use of multiple psychoactive drugs increased the risk of falls in the course of an acute episode of infection or dehydration (odds ratio 1.70, p=0.009).ConclusionsPrevalence of potentially inappropriate medications in nursing homes according to the NORGEP-NH was extensive, and especially the use of multiple psychotropic drugs. The high prevalence found in this study shows that there is a need for higher awareness of medication use and side effects in the elderly population.Trial registrationRetrospectively registered. Data obtained from clinical trial NCT01023763 registered with ClinicalTrials.gov 12/01/2009.

Exploring the need for an expertise centre for challenging behaviour

In a case study (N=1) a 78-year-old woman of Indonesian origin was referred for admission to the psychiatric hospital because there were increasing behavioural problems in the nursing home where she was staying. The challenging behaviour consisted of screaming; name calling, pinching, hitting and throwing food. The multidisciplinary team in the nursing home did not cope with the behaviour of the patient. This patient has an extensive history in psychiatry; she was diagnosed with bipolar disorder, anger management disorder and cognitive impairment. Because of cognitive impairment the patient lived in a nursing home because her husband was no longer able to care for her because of his own health problems. The medical team of the nursing home wanted her transfer to GGz centraal with the purpose to treat her provocative behaviour and to lead her to a permanent place to live in a setting appropriate to her problems. Also, the family of the patient supported this. They were very dissatisfied with the care offered in the nursing home. They indicated that they were very overburdened by the challenging behaviour of this patient in the nursing home. They also said that they felt that the nurses tried to solve the behavioural problems themselves without enlisting the help of experts in psychiatry. The patient was admitted to the geriatric psychiatry ward for a multidisciplinary evaluation of condition and challenging behaviour. Through the efforts of the team and the involvement of the family it was clear what causes the challenging behaviour and the team members were able to gradually work on the provocative behaviour of the patient. Most of the causes were related to traumatic experiences in the past. Small simple interventions led to a better quality of life for the patient and the team could discharge her to the nursing home with a clear treatment and supervision plan for the carers. The mental health care management organization came to the aforementioned case study with the question of whether the author wanted to deepen more on this subject and wanted to do research on challenging behaviour in older adults with severe mental illness and cognitive comorbidity. This subject is especially important because at the same time the government decided that the long-term beds must be decreased in psychiatry. Many elderly patients who may have lived most of their lives in the long-term psychiatric wards are being transferred to nursing homes, which lead to problems in the provision of care for these patients. The author claims an expertise centre could provide the solution. The expertise centre challenging behaviour aims to diagnose the possible causes of challenging behaviour and investigate what interventions can be effective. As a theoretical basis it uses the Neuman Systems Model. This nursing model can be used both as a theoretical framework, based on a systems thinking perspective, as well as on a methodical approach to explore nursing problems. Based on this case study an expertise centre for challenging behaviour will be developed in which a multidisciplinary team consisting of a psychiatrist, a nurse practitioner and a nurse will visit the nursing home team members and talk with the patient if possible and his or her family. This team will also focus on the interaction between the caregivers and the patient. The hypothesis of the author is that these efforts will ultimately lead to a better quality of life, fewer readmissions in a psychiatric hospital and a higher satisfaction with the family or directly involved healthcare professionals with the patient. In a next study the patient outcomes of the expertise centre will be investigated as well as the cost-benefits.

Contested Spaces: The Problem with Modern Psychiatric Interiors

ABSTRACTThis paper demonstrates how the interior design of many UK state psychiatric wards for adult acute patients arrived at the current status quo and why this needs to be readdressed. Acute wards within the National Health Service (NHS) are standard psychiatric inpatient wards for 18–65-year-old service-users. Drawing on historical determinants for the psychiatric ward, from both design and medical perspectives, this research shows how the interiors of these wards have often been rooted in, and reflective of, both design and psychiatric practices. Today, an investigation into the interiors of psychiatric wards is important, as we need to ascertain the extent to which the move towards service-user led care and socially responsive design is reflected in the wards themselves. These are not long-term wards like their nineteenth-century and pre-Second World War antecedents, but now in many ways are respite from the outside world: the “community,” in which patients struggle to cope. Their role is to help patients deal more ably with life as an outpatient–“community care.” That is the ideal scenario. Conversely, they can be used as an interim step to more specialist psychiatric services if required. As will be shown, what is apparent from the existing research among service-users on acute psychiatric wards, there is a strong preference for the familiar, the humane and deinstitutionalized environments. Furthermore, studies have shown environments that prioritize the familiar to be economically and medically effective. However, the importance of the “psychotherapeutic milieu” confronts the “rationality” underpinning the dominance of most medical discourse and much design practice and discourse. As a result we are too often left with stark and institutional settings. Indeed, with regards to hospital design generally, Waller and Fine wrote: “We have now reached a position where far too many hospitals succeed in making people feel worse than they did when they came through the main entrance” (2004: 5). Throughout this paper it will be demonstrated that a complex dialogue exists between the interests of the service-providers, both medical and design, who too frequently put functional efficiency before everything else, and the service-users' need for a therapeutic and healing environment. Accordingly, psychiatric wards are contested spaces–physically, academically, and methodologically.

Post stroke disposition from a Geriatric-Rehabilitative Stroke Care Area: an Italian experience

A large number of stroke patients cannot be discharged at home. Studies on post stroke disposition have low validity outside the country in which they are carried out because healthcare systems offer different rehabilitative and long-term facilities. Moreover absolute selection criteria for admission to rehabilitation are not available yet. Few studies on post-stroke disposition from Italian stroke units are available. Authors evaluated data of a 18-month period from a geriatric managed stroke care area where comprehensive multi-professional assessment and discharge planning are routinely carried out. Only patients discharged with diagnosis related to acute stroke were considered. Baseline characteristics, clinical, neurological and functional conditions according to the structured multidimensional assessment were prospectively collected in the stroke unit registry. Univariate and multinomial logistic regression were performed to identify independent variables associated with three discharge settings: home, rehabilitation and skilled long-term ward. Out of 188 patients evaluated, 56.4% were discharged home, 18.6% to rehabilitation and 25.0% to long-term ward. Data showed an efficient disposition to intermediate settings with a shorter length of stay compared to other international studies. Factors associated with post-stroke disposition were age, dysphagia, neurological impairment on admission (NIH-SS≥6), after stroke functional status (mRankin≥3), poor pre-stroke functional level (mRankin≥3) and hemorrhagic stroke. Dysphagia, severe neurological impairment and post-stroke disability were associated with discharge to rehabilitation and long term ward. These two settings differed in age and pre-stroke functional condition. Patients discharged to long-term wards were about 10 years older than those admitted to rehabilitative ward. Only 5% of patients discharged to rehabilitation had a pre-stroke mRankin score ‰¥3. Disposition to a skilled longterm ward of older patients with pre-stroke disability seemed positive on an economic ground but further studies are mandatory to understand the consequences in terms of functional recovery and social costs.

Evaluation of biological specimen acceptability in a complex clinical laboratory before and after implementing automated grading serum indices

ABSTRACTContinuous monitoring of specimen acceptability, collection and transport can result in the prompt identification and correction of problems, leading to improved patient care and a reduction in unnecessary redraws and delays in reporting results. This study aims to identify unacceptable blood specimens and to calculate the specimen rejection rate (SRR) before and after the implementation of automated checks of serum indices. This study was conducted between January 2009 and December 2010. The number of rejected specimens, location and reason for rejection were recorded. The Architect c8000 analyser (Abbott, Illinois, USA) was used to assess serum indices based on characteristic spectral patterns and mathematical manipulations of absorbance values measured at several wavelengths. The SRR was calculated, and the target cut-off value for the SRR was <0.5%, as established by the College of American Pathologists (CAP). The SRR values were 0.13% and 0.21% for the years 2009 and 2010, respectively. Haemolysis was the most significant reason for sample rejection, with cumulative rejection rates (CRR) of 49.3% and 61.4% for 2009 and 2010, respectively. Adult intensive care units (ICUs) had the most sample rejections (23.5%), followed by neonatal ICUs (13.8%), cardiac ICUs (13%), paediatric ICUs (10.8%) and long-term wards (10.5%), of which 60%, 79%, 84.9%, 36.6 % and 75%, respectively, of the rejected samples were haemolysed. The increase in rejected samples may be due to an improvement in staff awareness of sample rejection, aided by automatic sample integrity grading by automated chemistry analysis systems.

KPC-mediated resistance in Klebsiella pneumoniae in two hospitals in Padua, Italy, June 2009-December 2011: massive spreading of a KPC-3-encoding plasmid and involvement of non-intensive care units

BackgroundKlebsiella pneumoniae carbapenemases (KPCs) producing bacteria have emerged as a cause of multidrug-resistant nosocomial infections worldwide. KPCs are plasmid-encoded enzymes capable of hydrolysing a broad spectrum of beta-lactams, including carbapenems and monobactams, therefore worryingly limiting antimicrobial treatment options. Analysis of circulating bacterial strains and KPC alleles may help understanding the route of KPC dissemination and therefore help containing the infection.MethodsKPC-producing Klebsiella pneumoniae dissemination in two 1580- and 300- bed hospitals in Padua, Italy, from initial outbreak in 2009 to late 2011 was analysed. Molecular and clinical epidemiology, including bacterial strains, KPC-encoding plasmid sequences and associated resistance genes, involved hospital wards and relocation of patients were described. Routine antimicrobial susceptibility testing and MIC of carbapenems on clinical isolates were performed. Detection of resistance genes was obtained by PCR and sequencing. MLST, PFGE and ERIC were used for molecular genotyping. Plasmid analysis was obtained by digestion with restriction enzymes and deep sequencing.ResultsKPC-positive clinical samples were isolated from nearly 200 patients. In the initial outbreak intensive care units were almost exclusively involved, while medical, surgical and long-term wards were successively massively concerned. Analysis of KPC alleles, plasmids and bacterial sequence types (STs) indicated that during the initial outbreak KPC-3 in ST258 and KPC-2 in ST147 were each confined in one of the two surveilled hospitals. While KPC-2 dissemination was effectively contained, KPC-3 in ST258 cross-spreading was observed. The simultaneous presence of two carbapenemases, VIM-1 and KPC-2, in the same isolate was also observed in three patients. Total sequencing of plasmid content of two KPC-3 strains showed novel association of resistance plasmids.ConclusionsThe acquired molecular epidemiology demonstrated that 1) both acquisitions from outward sources and patient relocation within the hospitals were responsible for the observed spreading; 2) KPC-3-encoding Klebsiella pneumoniae ST258 prevailed over other strains. In addition, the described massive transfer of KPC-mediated resistance to non-intensive care units may anticipate spreading of resistance to the non-hospitalized population. Therefore, genotypic analysis alongside phenotypic identification of carbapenemase producers, also at the carriage state, is advisable to prevent and contain further carbapenemase resistance dissemination.

Reducing Antipsychotic Polypharmacy Among Psychogeriatric and Adult Patients with Chronic Schizophrenia

At the Institute of Mental Health/Woodbridge Hospital, 55% of the long-stay patients are on more than two antipsychotics for treatment of chronic schizophrenia. Our aim was to reduce antipsychotic polypharmacy (APP) among chronic schizophrenia inpatients at the long-term wards at the Institute of Mental Health, Singapore from 2006 to 2008. Using Clinical Practice Improvement Program (CPIP) methodology and using a Plan, Do, Study, Act approach, we surveyed patients, physicians, and nurses for responses regarding reducing the amount of APP for psychiatric patients. The first CPIP (CPIP1) was conducted from August 2006 to January 2007, and focused on psychogeriatric chronic schizophrenia inpatients. This methodology was spread to a second CPIP (CPIP2) from April 2008 to October 2008, which focused on adult chronic schizophrenia inpatients. Both CPIPs were successful in the reduction of APP within the geriatric and adult long-term patients. For CPIP1, eight patients had their antipsychotics reduced. There was a reduction of an average chlorpromazine-equivalent dose per day from 375 mg per patient to 170 mg. For CPIP2, the average number of antipsychotics was reduced from 2.9 to 2.27 from July 2008 to October 2008. There was a reduction of an average chlorpromazine-equivalent dose per day from 1523 mg per patient to 1246 mg. There was no documented relapse within six months of implementation of both the projects. APP in long-term patients suffering from chronic schizophrenia can be safely reduced with proper clinical titration, aided by guidelines and protocols.

The Persecuting God and the Crucified Self: The Case of Olav and the Transformation of His Pathological Self-Image

This case study describes the treatment of "Olav," a divorced lawyer in his mid-30's, who, at the time of treatment, had been continuously hospitalized in closed, short-term psychiatric wards for more than seven years with severe treatment-resistant depression, transient psychotic episodes, self-destructive behavior, and suicide attempts. He was about to be admitted to a long-term ward for chronic schizophrenics. A great deal of his psychopathology revolved around his feeling tortured from condemning inner voices of what he called "the Committee" that he believed were the sacred voices of God. The present case study describes Olav's treatment in our institution's "VITA" unit, a 12-week, group-based, residential day-treatment program that explicitly focuses on existential and religious issues. The VITA program includes diary-writing, affect consciousness, and regular group sessions consisting of such activities as mindfulness training; art therapy focusing on drawing or painting internal representations of self, father, mother and God; multiple group experiences; and reflection on existential issues. A standard assessment battery documents Olav's dramatic improvement over the course of treatment and at one-year follow-up.

SUPERVISION WITH ISABEL MENZIES LYTH

In this paper the author describes two separate experiences of working with Isabel Menzies Lyth, first between 1987–1988 and then from 2002–2005. She recollects Isabel's seminal role as staff group facilitator on a long-term rehabilitation ward at Littlemore Hospital, the McKnight Unit, where the author worked as a nursing assistant. She describes how Isabel's insights and interpretations in that group introduced the staff to a new way of thinking, and shed light on complex ethical and clinical dilemmas. She discusses the powerful, sometimes surprising, impact of Isabel's psychoanalytic understanding of psychosis, and of the anxieties that the staff team faced in this work. She then describes the experience of fortnightly supervision with Isabel, some 15 years later, when the author had qualified as a clinical psychologist and was working in a forensic unit with mentally ill offender patients. The paper is a personal recollection of Isabel's enduring insights and a description of her keen intellect, sensitivity and compassion in practice.

Characteristics of patients in a ward of Academic Internal Medicine: implications for medical care, training programmes and research

To describe the characteristics of "delayed discharge patients" and the factors associated with "delayed discharges", we performed a 12-month observational study on patients classified as "delayed discharge patients" admitted to an Academic Internal Medicine ward. We assessed the demographic variables, the number and severity of diseases using the Geriatric Index of Comorbidity (GIC), the cognitive, affective and functional status using, respectively, the Mini Mental Stare Examination, the Geriatric Depression Scale and the Barthel Index. We assessed the total length of stay (T-LHS), the total inappropriate length of stay (T-ILHS), the median length of stays (M-LHS), the median inappropriate length of stay (M-ILHS) and evaluated the factors associated with delayed discharge. "Delayed discharge patients" were 11.9% of all patients. The mean age was 81.9 years, 74.0% were in the IV class of GIC and 33.5% were at the some time totally dependent and affected by severe or non-assessable cognitive impairments. The patients had 2584 T-LHS, of which 1058 (40.9%) were T-ILHS. Their M-LHS was 15 days, and the M-ILHS was 5 days. In general, the greater the LHS, the greater is the ILHS (Spearman's rho + 0.68, P < 0.001). Using a multivariate analysis, only the absence of formal aids before hospitalisation is independently associated with delayed discharge (F = 4.39, P = 0.038). The majority of the delays (69%) resulted from the difficulty in finding beds in long-term hospital wards, but the longest M-ILHS (9 days) was found in patients waiting for the Geriatric Evaluation Unit. The profile of patients and the pattern of hospital utilisation suggest a need to reorient the health care system, and to develop appropriate resources for the academic functions of education, research and patient care.

A STUDY ON END OF LIFE IN THE INSTITUION FOR OLD PEOPLE FROM AN USE CHARACTERISTIC

This paper is focused on the environmental influence on the end of life in the institution for old people. The purpose of the study is to make clear that the institution support all aspects of older people's lives in the end of life such as sustain social and independent living escape from hospital model spaces and medical care. The study investigated the unit type nursing home and Long-term Ward which are thought as an end of life care place in Japan, grasped the process and the actual situation such as use forms of many space related to the life care. The result showed that each institution is considered of value as the end of life care place from the viewpoint of attaching weight to a private room, unit type, and care for life. The paper made clear that the old people could sustain the existing life by the staff and an improved environment in the end of life period because the staff and family supported them in view point of the dweller not the patient. In addition, it confirm that there is no need of common space such as a family room or mortuary by the filled up private room.

Weight increase in patients with dementia, and alteration in meal routines and meal environment after integrity promoting care

To follow weight changes in patients with moderate and severe dementia and analyse how these changes related to biological and psychological parameters after staff education and support in integrity promoting care. A further aim was to describe meal environment and routines relative to the intervention. Weight loss in patients with dementia and in particular Alzheimer's disease is common. The aetiology appears multifactorial with the meal environment and a decreased independence while eating among the factors. Over a three-month intervention period, an integrity-promoting care training programme was conducted with the staff of a long-term ward. Alzheimer's disease patients, 18 from an intervention ward and 15 from a control ward were included and possible effects were evaluated. Weighing was conducted at the start and after completion of the intervention. Weight changes were analysed in relation to psychological and biochemical parameters. In addition, the staff wrote diaries about, for example changes made in the environment and in their work. The most prominent difference observed was weight increases in 13 of 18 patients compared with two of 15 patients in the control ward. No weight changes were related to the type of dementia. The individual weight changes correlated significantly to changes in the intellectual functions. Relationships between weight change, increased motor function and increased appetite were non-significant. There was no significant relationship between weight changes and changes in biochemical parameters. According to the staff, increased contact with the patients and a more pleasant atmosphere resulted when the meal environment and routines were changed. Weight gain in patients with moderate and severe dementia was achieved by adjusting the meal environment to the individual's needs. Staff education was profitable, as increased competence seemed to promote individually adapted feeding situations. Ensuring good meal situations need to be given high priority.

Old and Given up for Dying? Palliative Care Units in Nursing Homes

The palliative unit at Bergen Red Cross Nursing Home opened in June 2000. In a prospective study, the authors investigated 196 patients admitted to the palliative care unit and 286 patients on the long-term wards. In Norway, 40% of the population dies in nursing homes. It is essential to develop good standards of palliative care for these patients. Palliative care units in nursing homes can provide excellent palliative care if they are given the competence and resources that are needed. Our patients on the long-term ward receive a high standard of palliative care, influenced by the competence and teaching programs of the palliative unit. This article aims to describe the challenges and tasks that should be focused on to ensure that old patients, no matter what their age or diagnosis, preserve their dignity and receive good palliative care during the final phase of their lives.

The High Cost of Care

Back to table of contents Previous article Next article LetterFull AccessThe High Cost of CareVicki Fox WieselthierVicki Fox WieselthierSearch for more papers by this authorPublished Online:1 May 2000https://doi.org/10.1176/appi.ps.51.5.676AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To the Editor: In the Economic Grand Rounds column of the December 1999 issue, Dr. Durrenberger and his coauthors (1) describe selecting four patients admitted to the long-term ward of a state hospital in Kentucky, using criteria that were not revealed, and then comparing the cost of their inpatient care to the cost of mental health care of 25 clients randomly selected from an outpatient program. The authors then used incomplete data on these inpatients to conclude that a system of involuntary outpatient commitment would save money for the state of Kentucky.In none of the cases were there sufficient data to be able to separate the cost of psychiatric care from other medical expenses. Since the monthly inpatient costs for 80-year-old Mr. A were four times greater then the cost of providing inpatient care to 41-year-old Ms. C, nonpsychiatric care costs must surely have been involved, but they were not detailed. Nonpsychiatric medical costs for the comparison group were not provided. No information was given about the kind or intensity of outpatient services that were made available to these individuals following discharge.Thanks to the Bellevue Outpatient Study (2), we now know that court orders alone do not improve treatment outcomes; the availability of comprehensive community-based services does. Two of the four people in this sample actually cost less to treat in the hospital than it would have cost to provide the most intensive outpatient treatment regimen the authors describe.The real issue here may be that a substantial portion of the cost of care for outpatients is shifted to the federal Medicaid and Medicare programs. This shift means that community treatment under involuntary outpatient commitment would cost the state of Kentucky less money, a compelling argument to bureaucrats concerned with state budgets. From a human rights and social justice perspective, relying on court orders to enforce treatment compliance rather than creating a comprehensive system of care that people embrace voluntarily is reprehensible.Ms. Wieselthier is executive director of Mad Nation in St. Louis, Missouri.

Is there a disproportional increase in health care costs for schizophrenic patients?

Empirical data on costs of care for chronically mentally ill patients in Germany are rare. There is a lack of cross-sectional studies as well as of any analysis of the long-term course of mental health care costs. This study combines data from two cost-studies on patients with schizophrenia, conducted in the same catchment area at an interval of 15 years, to draw conclusions about the long-term course of these costs. The direct costs of comprehensive community based mental health care had increased by 77.0% during 15 years, while the costs of a permanent stay in a long-term ward of a psychiatric hospital had increased by 78.5% in the same period. This increase was 27 and 28.5 per cent higher than the general rise in cost of living in Germany during the interval between the two studies. This higher-than-average increase in mental health care costs was accompanied by a much higher cost-effectiveness. Thus, this rise of costs must be seen as a consequence of the great deficits and the resulting basic improvement of care for chronically mentally ill patients in Germany, which was demanded by an expert-commission of the government in the mid-seventies.

The needs for care of the chronic mentally ill relocating from psychiatric hospital to the community: A pilot study

A pilot study is reported of non-hospital residential care for people with chronic mental illness. The Needs for Care Assessment (NFCA) was used to ascertain the clinical and social functioning of six patients who transferred from a long-term psychiatric ward to a high-support community hostel. Standardised interviews were conducted with patients and care-staff before re-location, during the settling-in period and one year later. Results indicate improvements in social and clinical functioning. Unmeetable needs in the hospital became meetable in the hostel. Residents expressed a preference for hostel accommodation.Staff and participants’ opinions regarding improvements in functioning appeared to differ. This study provided a first step to further explorative, but empirically-based analyses concerning hostel accommodation for people with chronic psychiatric disabilities.

The psychiatric patient's right to self‐determination: a preliminary investigation from the professional nurse's point of view

The aim of this preliminary empirical investigation was to explore the concept of self-determination and to discuss its applicability to psychiatric nursing. The data were collected with a questionnaire submitted to professional nurses (n = 127) working on the long-term wards in four Finnish hospitals. Data analysis combined the methods of content analysis and quantitative statistics. A tentative concept apparatus was created in order to provide nursing science with a broader understanding of the issue at hand. Nurses identified various factors that act to restrict and to support self-determination: the most common restrictive factor was the patient's illness or condition, and the most common supportive factor was nursing intervention. Views differed on the importance of self-determination in the case of psychiatric patients; over half of the nurses described the right to self-determination as very important. On the basis of the findings it is concluded that self-determination is a valid concept for the psychiatric patient. It was also thought to serve the needs of education as well as evaluation.