As pressure mounts to reduce the number of costly acute care beds, governments and the literature propose top-down ratios. Is this reasonable and fair to the responsible medical officers who, as the key care providers, will need to admit patients and develop discharge plans in a reduced-beds environment?
Treating physicians of all acute care inpatients on a given day (n = 212) and all new acute care admissions over a 2-week period (n = 125) completed an adapted version of the Nottingham Acute Beds Use Survey (NABUS) Questionnaire.
On a given day, only 62 of 212 inpatients were unsuited for any alternative to acute care hospitalization. A floor ratio of 18 acute care beds per 100,000 inhabitants seems adequate for the catchment area in question, provided that alternatives to hospitalization are fully and efficiently available. Alternatives essentially involve an array of the following: supervised residential settings, day hospitals, and intensive home care (2 to 6 hours weekly). The ratio of intensive home care workers required would be 25 per 100,000 inhabitants.
Long-term institutionalization is no longer the preferred treatment for the severely mentally ill. Several models for outpatient treatment of the severely mentally ill have been developed, among them Assertive Community Treatment (ACT). The literature on this model is reviewed in a Cochrane review and in randomized trials comparing ACT with hospital admission. ACT is a clinically effective approach to managing the care of severely ill people in the community. ACT, if correctly targeted on high users of in-patient-care, can substantially reduce costs of hospital care whilst improving outcome and patient and relatives satisfaction. Setting up ACT teams should be supported by politicians, professionals and consumers.
Better Beginnings, Better Futures is a 25-year primary prevention policy research demonstration project. Its major purpose is to assess the extent to which community-based primary prevention programs can be effective in preventing emotional, behavioural, physical and cognitive problems in children from economically disadvantaged communities. The project grew out of a number of primary prevention initiatives introduced by the Ontario Ministry of Community and Social Services (MCSS) since the late 1970s. Eleven sites, four of them located on native reserves, received funding in January, 1991 to establish programs in their communities. From the beginning, a qualitative, naturalistic research approach has been utilized to document and understand the ways in which the programs have developed in the various Better Beginnings communities.
The management of mentally ill people committing minor criminal offences has been a social concern in Canada for more than thirty years. Processing of these individuals through the Justice system results in a well-known 'revolving door' syndrome. One approach to this problem is the diversion of these offenders from the Justice system to the network of health and social services that can address their overall well-being. A lack of empirical evidence on diversion programs has been identified as a main roadblock to their acceptance.
To describe outcomes and service utilization of clients using the Calgary Diversion Program, a community-based alternative to incarceration for persons with serious mental disorders who commit minor offences.
The study employed mixed quantitative and qualitative methods, and used a quasi-experimental design with the clients serving as their own controls. The Calgary Diversion Program was formed in 2002, with this study spanning client enrollment (n=179) from 2002-2003.
Before to after program enrolment comparisons found justice system complaints, charges and court appearances to have been reduced between 84% and 91% in those clients that participated successfully in the program, while at the same time found reductions of between 25% and 48% of acute services. Both quantitative and qualitative results indicated a high degree of satisfaction on the part of both providers and clients. Statistically significant improvement in the Brief Psychiatric Rating Scale values between baseline and three months after program entry were observed, while quality of life measurement showed statistically significant improvements in six of nine indicators. Acute health care and justice system costs were compared for the nine months prior to referral and the nine months following referral, with an average reduction in total costs of CAD 1,721 per client.
The findings presented in this paper are the first significant contribution to empirical research on diversion programs in Canada. The study suggests improved outcomes, support from clients and providers, and reduced overall costs. However, the nature of the study design limits firm conclusions to be made. Longer term follow-up is a key area for future research. IMPLICATION FOR HEALTH POLICIES: This results identified through the study, as well as the accompanying information on the Calgary program's implementation and functioning, are an important building block in moving towards a strategy to address a long-standing social concern. In an era of cost-consciousness, policy makers need to consider programs that not only have the opportunity to improve patient outcomes, but as well show promise in reducing health and other social service costs.
The paper is concerned with part of the results of an analysis of expenditures for the treatment of schizophrenic patients. The task of the present fragment was to delineate ways of optimizing the functioning of the psychiatric assistance services. Research methods including clinico-economic, statistic, mathematic and epidemiological approaches are described in detail. Based on an examination of the representative group of schizophrenic patients (n-386) of one of the psychoneurological dispensaries of Moscow, it has been established that the main "direct" (793.8 rubels per patient/year on the average) and "indirect" (3520.94 rubels per patient/year on the average) expenditures are connected with expensive inpatient treatment and disability allowance payments. It is suggested that redistribution of investments with a purpose of eliminating economic unbalance between different psychiatric services (hospital and ambulatory) will contribute to optimizing their functioning and enable the efficacy of their work to be enhanced.
In 1980-1981, two communal housing schemes for young psychiatric patients in the Municipality of Copenhagen were established. The object was to offer these persons a home for a limited period (maximum three years). The object of this investigation is to describe the patients who lived in these communal homes during the period 1.3.1980-28.2.1989, to investigate the duration of hospitalization in psychiatric departments two years before and two years after they stay in the communal home and, on the basis of the experience gained, to discuss the possibilities and limitations of this form of housing. The investigation is retrospective and based on hospital case records. It includes 56 persons: 37 men and 19 women. The average age was 28.7 years. 92% of the residents had a chronic psychiatric disease. They had received psychiatric treatment early and had long histories with prolonged periods of hospitalization. The average duration of hospitalization was 17 months. At the conclusion of the investigation, 33 residents had moved out two or more years ago. The average duration of hospitalization for this group was reduced to approximately 1/3 of the duration of hospitalization prior to the stay in the communal home. The structure outlined here may be employed for a number of the chronic psychiatric patients but a communal psychiatric offer should include a greater spectrum of possibilities for chronic patients to cover their requirements. Establishing an offer of this type demands multidisciplinary cooperation.
The financial costs of community-based treatment, stressing home treatment, were compared with the cost of hospital-based treatment during one year. Of 155 patients destined to receive inpatient treatment, 76 were randomly assigned to home treatment, 79 to hospital treatment; the two groups were similar as to important social, demographic, and clinical characteristics. The principal differences between the two treatments concerned the focus of treatment, the locale of treatment, the degree to which continuity of treatment was maintained, and the roles of the respective treatment staffs. Manpower and operating costs, measured in dollars, were estimated in two ways. Either way, hospital-based treatment was more expensive during the year: 64.1% more expensive (+3,250 vs. +1,980 per patient) in the first instance, 108.9% more expensive (+6,750 vs. +3,230 per patient) in the second. With two exceptions during the first month of treatment, the proportions of patients and families receiving either treatment who incurred other costs of treatment were low, and the differences between groups were not significantly different. A higher proportion of patients and families receiving home-based treatment defrayed the cost of the patient's psychotropic drugs; second, a higher proportion of families of patients receiving hospital-based treatment defrayed transportation costs. The proportions of patients and families incurring costs of the consequences of illness were low, and the differences between treatment groups were not significant. We compared this study with similar studies, discussed the generalizability of the results of this study and similar studies, and identified issues for future research.
Although the association between continuity of care and health outcomes among persons with severe mental illness is beginning to be elucidated, the association between continuity and costs has remained virtually unexplored. The purpose of this study was to examine the relationship of continuity of care and health care costs in a sample of 437 adults with severe mental illness in three health regions of Alberta, Canada.
Service use events and costs were tracked through self-reported and administrative data. Associations between continuity and costs were examined by using analysis of variance and regression analysis.
Mean+/-SD total, hospital, and community cost over the 17-month study period were $24,070+/-$25,643, $12,505+/-$20,991, and $2,848+/-$4,420, respectively. The difference in means across levels of observer-rated continuity was not statistically significant for total cost, but improved continuity was associated with both lower hospital cost and higher community cost. Total cost was significantly lower for patients with a higher self-rated quality of life as indicated on the EQ-5D visual analogue scale, although associations did not hold up in the regression analysis. Patients with higher functioning as rated by the Multnomah Community Abilities Scale had significantly lower total and community costs.
The study showed a relationship between continuity of care and both hospital and community costs. The data also indicate that a relationship exists between cost and level of patient functioning. It will be necessary to conduct further studies using experimental designs to examine the impact of shifting resources from hospitals to the community, particularly for high-need patients, on continuity of care and subsequent outcomes.
Comment On: Psychiatr Serv. 2005 Sep;56(9):1061-916148318