Use of case-mix reimbursement in psychiatric inpatients has been limited as a result of a lack of systems which effectively group patients according to required resource needs. In recognition of the fact that many patient factors, in addition to diagnosis influence delivery of care in psychiatry, new measures of patient need are emerging.
This study compared improvement realized by using a multidimensional measure of patient severity, the Computerized Severity Index (CSI), to predict length of stay (LOS) in psychiatric inpatients over that achieved by using patient variables routinely collected in the discharge abstract.
Through retrospective chart review, severity ratings were made on 355 psychiatric discharges with primary diagnoses of psychotic or major depressive disorders. Those ratings were combined with demographic and diagnostic data available in discharge abstracts and were then entered into multivariate regression analyses to model LOS.
CSI ratings significantly contributed to prediction models, which accounted for an additional 9% to 11% of variation in LOS over discharge abstract data. Among patients with psychotic disorders, maximum severity during hospitalization was the best predictor of LOS, whereas among patients with depressive disorders, it was an increase in severity following admission.
Severity ratings, based on chart review, improved prediction of LOS over discharge abstract variables for psychiatric inpatients in two diagnostic groups. Further research is needed to estimate the impact of incorporating severity ratings into a grouping system for all psychiatric inpatients. Estimation of predictive accuracy is important to determine the amount of risk passed on to providers in a payment system based on psychiatric case mix.
This study compares outpatients with intellectual disability (ID) receiving specialised services to outpatients with ID receiving general services in Ontario's tertiary mental healthcare system in terms of demographics, symptom profile, strengths and resources, and clinical service needs.
A secondary analysis of Colorado Client Assessment Record data collected from all tertiary psychiatric hospitals in the province was completed for a stratified random sample of 246 outpatients identified as having ID, from both specialised and general programmes.
Individuals with ID in specialised programmes differed from patients with ID in general programmes with regard to demographics, diagnostic profile, symptom presentation and recommended level of care.
Further research is required to determine why individuals access some services over others and to evaluate whether specialised services are more appropriate for certain subgroups with ID than others.
Over the years, the closure of institutions has meant that individuals with intellectual disabilities (IDs) must access mainstream (i.e. general) mental health services. However, concern that general services may not adequately meet the needs of patients with ID and mental illness has led to the development and implementation of more specialised programmes. This study compares patients with ID receiving specialised services to patients with ID receiving general services in Ontario's tertiary mental healthcare system in terms of demographics, symptom profile, strengths and resources and clinical service needs.
A secondary analysis of Colorado Client Assessment Record data collected from all tertiary psychiatric hospitals in the province was completed for all 371 inpatients with ID, from both specialised and general programmes.
Inpatients in specialised programmes were more likely to have a diagnosis of mood disorder and were less likely to have a substance abuse or psychotic disorder. Individuals receiving specialised services had higher ratings of challenging behaviour than those in more general programmes. The two groups did not differ significantly in terms of recommended level of care, although more inpatients from specialised programmes were rated as requiring Level 4 care than inpatients from general programmes.
In Ontario, inpatients in specialised and general programmes have similar overall levels of need but unique clinical profiles that should be taken into consideration when designing interventions for them.
Consumer preference surveys can provide valuable information on which to base the planning and development of housing for groups with special needs. The authors describe a survey that explored the housing histories, problems, needs, and preferences of a sample of 38 chronically homeless women contacted in metropolitan Toronto hostels and drop-in centers. Despite having multiple mental and physical health problems, the women showed a strong preference for a normal, independent living situation. However, they acknowledged the need for a range of supportive services to maintain themselves in such a situation. The women strongly opposed being housed in settings with mentally ill persons, with alcohol or drug abusers, and with those involved in criminal activities.
Department of Psychiatry, University of Toronto, Centre for Addiction and Mental Health, Health Systems Research and Consulting Unit, 250 College Street, 4th floor, Toronto, Ontario, Canada M5T 1R8. Janet_Durbin@camh.net
With the closure of a number of provincial psychiatric hospitals planned, the Ministry of Health of Ontario has commissioned a series of planning projects to identify alternative placements for current hospital patients. The goal is to match need to care in the least restrictive setting. A systematic, clinically driven planning process was implemented that involved three steps: development of a continuum of levels of care representing increasingly intensive and more restrictive supports, development of criteria and decision rules for placement, and comprehensive needs assessment of current patients using the Colorado Client Assessment Record. Results showed that only 10% of current inpatients need to remain in the hospital, and over 60% could live independently in the community with appropriate supports. Evidence supports concurrent validity of the planning model, but further work is needed to assess whether recommended levels of care effectively meet consumer needs in the least restrictive setting.
Tertiary care subpopulations are characterized by having more than one significant condition, each of which has been traditionally dealt with by different systems of care. They experience severe and persistent mental illness and one or more of the following: age-related physical or medical conditions, substance use disorders, developmental handicaps, and acquired brain injury. This paper provides estimates of prevalence for each of these subgroups and discusses best practices which have developed in response to their special needs.
Comment In: Can J Psychiatry. 2000 Aug;45(6):57010986576
There are some individuals with severe and persistent mental illnesses who cannot be managed by primary and secondary services and who require tertiary care. Such clients are characterized by aggressiveness, noncompliance with medication, and dangerousness. Tertiary care program elements include psychosocial rehabilitation, sophisticated medication management, and behavioural approaches. Tertiary care may be delivered through assertive community treatment and/or specialized outreach teams, community residential programs, or hospital-based services. Increasingly, organized systems have been developed to ensure that individuals meet criteria for tertiary care and receive the most appropriate level of care. Most importantly, the delivery of tertiary care must not be tied to particular settings or time frames, and level of care must be delinked from model or location of care in order to create flexible, efficient, effective mental health services.