Home treatment for acute psychiatric illness.

OBJECTIVE--To determine the factors influencing the successful outcome of community treatment for severe acute psychiatric illnesses that are traditionally treated in hospital. DESIGN--All patients from a single electoral ward who were either admitted to hospital or treated at home over a two year period (1 October 1987 to 30 September 1989) were included in the study and their case notes audited. The second year of the study is reported. SETTING--Electoral ward of Sparkbrook, Birmingham. SUBJECTS--99 Patients aged 16-65 with severe acute psychiatric illness. RESULTS--65 Patients were managed by home treatment alone; 34 required admission to hospital. The location of treatment was significantly (all p less than 0.05) influenced by social characteristics of the patients (marital state, age (in men), ethnicity, and living alone) and by characteristics of the referral (occurring out of hours; assessment taking place at hospital or police station). DSM-III-R diagnosis was more weakly associated with outcome. Violence during the episode was significantly related to admission, although deliberate self harm was not. CONCLUSIONS--Home treatment is feasible for most patients with acute psychiatric illness. A 24 hour on call assessment service increases the likelihood of success because admission is determined more strongly by social characteristics of the patient and the referral than by illness factors. Admission will still be required for some patients. A locally based mental health resource centre, a 24 hour on call service, an open referral system, and an active follow up policy increase the effectiveness of a home treatment service.     

Home based care and standard hospital care for patients with severe mental illness: a randomised controlled trial.

OBJECTIVE--To compare the efficacy of home based care with standard hospital care in treating serious mental illness. DESIGN--Randomised controlled trial. SETTING--South Southwark, London. PATIENTS--189 patients aged 18-64 living in catchment area. 92 were randomised to home based care (daily living programme) and 97 to standard hospital care. At three months'' follow up 68 home care and 60 hospital patients were evaluated. MAIN OUTCOME MEASURES--Use of hospital beds, psychiatric diagnosis, social functioning, patients'' and relatives'' satisfaction, and activity of daily living programme staff. RESULTS--Home care reduced hospital stay by 80% (median stay six days in home care group, 53 days in hospital group) and did not increase the number of admissions compared with hospital care. On clinical and social outcome there was a non-significant trend in favour of home care, but both groups showed big improvements. On the global adjustment scale home care patients improved by 26.8 points and the hospital group by 21.6 points (difference 5.2; 95% confidence interval -1.5 to 12). Other rating scales showed similar trends. Home care patients required a wide range of support in areas such as housing, finance, and work. Only three patients dropped out from the programme. CONCLUSIONS--Home based care may offer some slight advantages over hospital based care for patients with serious mental illness and their relatives. The care is intensive, but the low drop out rate suggests appreciation. Changes to traditional training for mental health workers are required.     

Cost effectiveness of day and inpatient psychiatric treatment: results of a randomised controlled trial.

OBJECTIVE: To compare direct and indirect costs of day and inpatient treatment of acute psychiatric illness. DESIGN: Randomised controlled trial with outcome and costs assessed over 12 months after the date of admission. SETTING: Teaching hospital in an inner city area. SUBJECTS: 179 patients with acute psychiatric illness referred for admission who were suitable for random allocation to day hospital or inpatient treatment. 77 (43%) patients had schizophrenia. INTERVENTIONS: Routine inpatient or day hospital treatment. MAIN OUTCOME MEASURES: Direct and indirect costs over 12 months, clinical symptoms, social functioning, and burden on relatives over the follow up period. RESULTS: Clinical and social outcomes were similar at 12 months, except that inpatients improved significantly faster than day patients and burden on relatives was significantly less in the day hospital group at one year. Median direct costs to the hospital were 1923 pounds (95% confidence interval 750 pounds to 3174 pounds) per patient less for day hospital treatment than inpatient treatment. Indirect costs were greater for day patients; when these were included, overall day hospital treatment was 2165 pounds cheaper than inpatient treatment (95% confidence interval of median difference 737 pounds to 3593 pounds). Including costs to informants when appropriate meant that day hospital treatment was 1994 pounds per patient cheaper (95% confidence interval 600 pounds to 3543 pounds). CONCLUSIONS: Day patient treatment is cheaper for the 30-40% of potential admissions that can be treated in this way. Carers of day hospital patients may bear additional costs. Carers of all patients with acute psychiatric illness are often themselves severely distressed at the time of admission, but day hospital treatment leads to less burden on carers in the long term.     

Cost analysis of early discharge after hip fracture.

OBJECTIVE--To ascertain the economic impact of an early discharge scheme for hip fracture patients. DESIGN--Population based study comparing costs of care for patients who had "hospital at home" as an option for rehabilitation and those who had no early discharge service available in their area of residence. SETTING--District hospital orthopaedic and rehabilitation wards and community hospital at home scheme. PATIENTS--1104 consecutively admitted patients with fractured neck of femur. 24 patients from outside the district were excluded. MAIN OUTCOME MEASURES--Cost per patient episode and number of bed days spent in hospital. RESULTS--Patients with the hospital at home option spent significantly less time as inpatients (mean of 32.5 v 41.7 days; p < 0.001). Those patients who were discharged early spent a mean of 11.5 days under hospital at home care. The total direct cost to the health service was significantly less for those patients with access to early discharge than those with no early discharge option (4884 pounds v 5606 pounds; p = 0.048). CONCLUSIONS--About 40% of patients with fractured neck of femur are suitable for early discharge to a scheme such as hospital at home. The availability of such a scheme leads to lower direct costs of rehabilitative care despite higher readmission costs. These savings accrue largely from shorter stays in orthopaedic and geriatric wards.     

Cost of illness for severe and non-severe diarrhea borne by households in a low-income urban community of Bangladesh: A cross-sectional study

The illness cost borne by households, known as out-of-pocket expenditure, was 74% of the total health expenditure in Bangladesh in 2017. Calculating economic burden of diarrhea of low-income urban community is important to identify potential cost savings strategies and prioritize policy decision to improve the quality of life of this population. This study aimed to estimate cost of illness and monthly percent expenditure borne by households due diarrhea in a low-income urban settlement of Dhaka, Bangladesh. We conducted this study in East Arichpur area of Tongi township in Dhaka, Bangladesh from September 17, 2015 to July 26, 2016. We used the World Health Organization (WHO) definition of three or more loose stool in 24 hours to enroll patients and enrolled 106 severe patients and 158 non-severe patients from Tongi General Hospital, local pharmacy and study community. The team enrolled patients between the first to third day of the illness (≤ 72 hours) and continued daily follow-up by phone until recovery. We considered direct and indirect costs to calculate cost-per-episode. We applied the published incidence rate to estimate the annual cost of diarrhea. The estimated average cost of illness for patient with severe diarrhea was US$ 27.39 [95% CI: 24.55, 30.23] (2,147 BDT), 17% of the average monthly income of the households. The average cost of illness for patient with non-severe diarrhea was US$ 6.36 [95% CI: 5.19, 7.55] (499 BDT), 4% of the average monthly income of households. A single diarrheal episode substantially affects financial condition of low-income urban community residents: a severe episode can cost almost equivalent to 4.35 days (17%) and a non-severe episode can cost almost equivalent to 1 day (4%) of household’s income. Preventing diarrhea preserves health and supports financial livelihoods.     

Randomised controlled trial of day patient versus inpatient psychiatric treatment.

OBJECTIVE--To assess the proportion of acutely ill psychiatric patients who can be treated in a day hospital and compare the outcome of day patient and inpatient treatment. DESIGN--Prospective randomised controlled trial of day patient versus inpatient treatment after exclusion of patients precluded by severity of illness or other factors from being treated as day patients. All three groups assessed at three and 12 months. SETTING--Teaching hospital serving small socially deprived inner city area. Day hospital designed to take acute admissions because of few beds. PATIENTS--175 Patients were considered, of whom 73 could not be allocated. Of the remaining 102 patients, 51 were allocated to each treatment setting but only 89 became established in treatment--namely, 41 day patients and 48 inpatients. 73 Of these 89 patients were reassessed at three months and 70 at one year. INTERVENTIONS--Standard day patient and inpatient treatment. MAIN OUTCOME MEASURES--Discharge from hospital and return to previous level of social functioning; reduction of psychiatric symptoms, abnormal behaviour, and burden on relatives. RESULTS--33 Of 48 inpatients were discharged at three months compared with 17 of 41 day patients. But at one year 9 of 48 inpatients and three of 41 day patients were in hospital. 18 Of 35 day patients and 16 of 39 inpatients were at their previous level of social functioning at one year. The only significant difference at three months was a greater improvement in social role performance in the inpatients. At one year there was no significant difference between day patients and inpatients in present state examination summary scores and social role performance, burden, or behaviour. CONCLUSIONS--Roughly 40% of all acutely ill patients presenting for admission to a psychiatric unit may be treated satisfactorily in a well staffed day hospital. The outcome of treatment is similar to that of inpatient care but might possibly reduce readmissions. The hospital costs seem to be similar but further research is required to assess the costs in terms of extra demands on relatives, general practitioners, and other community resources.     

Effectiveness of paramedic practitioners in attending 999 calls from elderly people in the community: cluster randomised controlled trial

Objective To evaluate the benefits of paramedic practitioners assessing and, when possible, treating older people in the community after minor injury or illness. Paramedic practitioners have been trained with extended skills to assess, treat, and discharge older patients with minor acute conditions in the community.Design Cluster randomised controlled trial involving 56 clusters. Weeks were randomised to the paramedic practitioner service being active (intervention) or inactive (control) when the standard 999 service was available.Setting A large urban area in England.Participants 3018 patients aged over 60 who called the emergency services (n=1549 intervention, n=1469 control).Main outcome measures Emergency department attendance or hospital admission between 0 and 28 days; interval from time of call to time of discharge; patients'' satisfaction with the service received.Results Overall, patients in the intervention group were less likely to attend an emergency department (relative risk 0.72, 95% confidence interval 0.68 to 0.75) or require hospital admission within 28 days (0.87, 0.81 to 0.94) and experienced a shorter total episode time (235 v 278 minutes, 95% confidence interval for difference −60 minutes to −25 minutes). Patients in the intervention group were more likely to report being highly satisfied with their healthcare episode (relative risk 1.16, 1.09 to 1.23). There was no significant difference in 28 day mortality (0.87, 0.63 to 1.21).Conclusions Paramedics with extended skills can provide a clinically effective alternative to standard ambulance transfer and treatment in an emergency department for elderly patients with acute minor conditions.Trial registration ISRCTN27796329.     

Relation between bed use,social deprivation,and overall bed availability in acute adult psychiatric units,and alternative residential options: a cross sectional survey,one day census data,and staff interviews.

OBJECTIVES: To examine the relation between bed use, social deprivation, and overall bed availability in acute adult psychiatric units and to explore the range of alternative residential options. DESIGN: Cross sectional survey, combined with one day census data; ratings by and interviews with staff; examination of routine data sources. SETTINGS: Nationally representative sample of acute psychiatric units. SUBJECTS: 2236 patients who were inpatients on census day. MAIN OUTCOME MEASURES: Bed occupancy levels, judged need for continuing inpatient care, reasons preventing discharge, scores on the Health of the Nation outcome scales. RESULTS: Bed occupancy was related to social deprivation and total availability of acute beds (r = 0.66, 95% confidence interval 0.19 to 0.88, F = 8.72, df = 2.23; P = 0.002). However, 27% (603/2215) of current inpatients (61% (90/148) of those with stays of > 6 months) were judged not to need continuing admission. The major reasons preventing discharge were lack of suitable accommodation (37% (176/482) of patients in hospital < 6 months v 36% (31/86) of those in hospital > 6 months); inadequate domiciliary based community support (23% (113) v 9% (8)); and lack of long term rehabilitation places (21% (100) v 47% (40)). Scores on the Health of the Nation outcome scale were generally consistent with these staff judgments. CONCLUSIONS: The shortage of beds in acute psychiatric units is related to both social deprivation and the overall availability of acute beds. Patients currently inappropriately placed on acute admission wards should be relocated into more suitable accommodation, either in hospital or in the community. A range of provisions is required; simply providing more acute beds is not the answer.     

The community hospital: a three-year study.

In a three-year period a community hospital of 40 beds discharged 2086 patients, their mean length of stay being 14.8 days. Some 68% of the patients treated were over 65, and 8.9% died in hospital. While the most common diagnosis on admission was disease of the respiratory tract, this does not indicate the actual cause of admission. For 142 patients from one practice this was acute illness in 44% of the cases, assessment in 20%, and a need for nursing care in 36%. If the community hospital had not been available about half these patients would have been admitted to the general hospital.     

Integrated hospital and community psychiatric services and use of inpatient beds.

The impact of introducing a divisional psychiatric service based in the community in Nottingham in 1981 on adult psychiatric admissions (patients aged 15-65) was examined with data from the Nottingham case register. During 1980-5 the number of psychiatric admissions fell significantly (4.5% a year) compared with the national figures (0.46% a year). Admissions were reduced most for the diagnoses of affective psychosis and neurotic and personality disorders. The average duration of admission fell by 3.6% a year, and use of inpatient beds fell by 37.5%. Integrating hospital and community psychiatric services by creating sectors is a viable and economically feasible way of improving psychiatric services.     

Schizophrenia and family

Family represents an important supportive social network for most patients with schizophrenia. In order to provide safe and low-stress environment, necessary for the successful long-term treatment of schizophrenia the family must be helped. Family members suffer both emotionally and financially. Their burden is high and quality of life is low. Relatives change their life values and preferences when a severe mental illness occurs in the family and are ready to cooperate. Family interventions constitute an integral part of complex schizophrenia treatment. To be successful interventions must take into account relatives beliefs, perspectives and issues of concern. The goal of this paper is to 1) overview studies on family burden, 2) provide theoretical background for family interventions, 3) describe a family psychoeducational approach as an optimal treatment modification.     

Needs for care from a demand led community psychiatric service: a study of patients with major mental illness.

OBJECTIVE--To measure needs for care of patients aged 18-65 years with major mental illness. DESIGN. Identification of everyone in one area seen by a health professional within the previous five years because of a psychotic disorder. Interview of a one in three sample of patients and their main carers with the cardinal needs schedule. SETTING--Hamilton, a socially deprived district of Scotland. SUBJECTS--71 subjects were interviewed from the original sample of 263 patients. MAIN OUTCOME MEASURES--"Cardinal problems" in seven clinical and eight social areas of functioning; these are defined as problems requiring action. "Needs"-cardinal problems for which suitable interventions exist but have not been tried recently. RESULTS--High levels of morbidity were found. 30 interviewed patients (42%; 95% confidence interval 31% to 54%) had one or more clinical needs. 35 (49%; 38% to 61%) had one or more social needs. Skills to deal with all but seven needs in the sample were available at the time of investigation. Patients not being seen by the community mental health team were similar in severity and levels of need to those who were on the community team''s caseload. Care was unequivocally and severely inadequate for four patients. Shortcomings in service delivery usually arose from failure to monitor some patients at home. Problems were not due to shortage of acute psychiatric beds nor the absence of an elaborate assertive community care team. CONCLUSIONS--Systematic assessment of needs with research instruments can give valuable insights into the successes and failures of community care of people with major mental illness. Most needs could be dealt with in these patients but in our area (and probably most other parts of the United Kingdom) this would entail diversion of resources from people with less severe disorders.     

Community care for patients with schizophrenia one year after hospital discharge.

OBJECTIVES--To document the circumstances and care of patients with schizophrenia who had recently been discharged from local psychiatric inpatient services, and to establish the extent to which misgivings about community care might be justified. DESIGN--Cross sectional surveys with review of case notes. Follow up interviews with questionnaires administered one year after discharge. SETTING--Two inner London districts (West Lambeth and Lewisham) with high levels of social deprivation and at different stages of developing community services. PATIENTS--90 and 50 patients in the two services respectively, aged 18 to 65, who satisfied the Research Diagnostic Criteria for schizophrenia and who were discharged from inpatient services. MAIN OUTCOME MEASURES--Diagnosis elicited by present state examination, global social disability rating, use of services during the three months before interview. RESULTS--89 of the 140 patients (64%) had been ill for five or more years, yet few were former long stay inpatients. 55% (50/91; 95% confidence interval 45% to 65%) of those interviewed had current psychotic mental states and 22% (27/124; 16% to 31%) were functioning socially at very poor or severely maladjusted levels. 86% (107/124) were unemployed. The majority of patients had seen a mental health or social service professional, yet only 16% (20/124) were in specialised accomodation (excluding hospitals) and only 23% (17/73) of those eligible had used day care. Small numbers of people had experienced homelessness (two) or imprisonment (four over six months). CONCLUSIONS--Many schizophrenic patients leaving local psychiatric inpatient care have active symptomatology and profound social disabilities. Community care was characterised by high rates of contact with service professionals but little supported accommodation or day activity. This group of clients may require dedicated provision, which would actively encourage them to use services protected from the demands of those with less severe illness.     

Costs and benefits of a community special care baby service

Between January 1981 and December 1986 3829 low birthweight (<2500 g) infants and 1980 other high risk infants were cared for at home after they were discharged from hospital by a specialist neonatal nursing service. Of the infants who were referred to this service, 720 (12%) weighed under 2000 g and 1919 (33%) under 2250 g at the time of discharge home. The infants were visited by the community neonatal sisters on an average of 11 occasions, but the number of visits varied from six to over 100 depending on the needs of the child and parents. There was close liaison with other community and hospital staff. Two hundred and thirty (4%) referred infants were readmitted to hospital while under the care of the specialist nursing service. In 1985 the cost of the service was £127 000, or £123 for each infant referred. Providing this specialist support at home allowed much earlier discharge of low birthweight infants from hospital. When compared with the cost of providing continuing inpatient neonatal care earlier discharge was estimated to have saved roughly £250 000 in 1985.Low birthweight infants have an increased risk of serious illness or death that extends beyond the neonatal period. Many are born to young and socially disadvantaged parents who can benefit from expert guidance and support at home. A community neonatal nursing service has advantages for high risk infants and their parents, is cost effective, and allows more efficient use of limited hospital resources.     

Barriers and errors in the implementation of community psychiatry in Slovenia

Background Slovenian psychiatry is predominantly hospital based. A programme for the development of general community psychiatric services was proposed to improve access to and quality and comprehensiveness of psychiatric care according to the modern standards of delivery of psychiatric services.Aim The aim of the paper is to present the programme for developing community services that was proposed to the Slovenian government, and to describe the barriers to its implementation that were encountered, as well as the errors made by the programme authors, that contributed to the rejection of the programme last year.Conclusions There are historical, political, professional and service organisation characteristics that impede the development of community psychiatry in Slovenia. These are to be addressed through coordinated action involving primary care professionals, non-government organisations with service users and carers, the Health Insurance Agency and politicians involved in the planning of health services.     

The Development and Organization of a Children's Psychiatric Hospital

Thistletown Hospital is a children''s psychiatric hospital which was established by the Department of Health of the Province of Ontario. Special legislation permitting control of the admissions procedures was enacted. The administrative organization consists of a series of committees made up of the heads of hospital departments. An advisory board of distinguished psychiatrists and psychologists advises the Minister of Health directly on major policy changes or innovations envisaged for the hospital. Clinical organization is related to four functions: (1) service (treatment and assessment), (2) research, (3) training of staff, and (4) community education.The basic units of the hospital are related to the treatment or research design necessary in special diagnostic categories. A children''s psychiatric hospital should not be restricted to in-patient facilities but should consist of a totally community-oriented service.     

A Novel Approach for Measuring the Burden of Uncomplicated Plasmodium falciparum Malaria: Application to Data from Zambia

Measurement of malaria burden is fraught with complexity, due to the natural history of the disease, delays in seeking treatment or failure of case management. Attempts to establish an appropriate case definition for a malaria episode has often resulted in ambiguities and challenges because of poor information about treatment seeking, patterns of infection, recurrence of fever and asymptomatic infection. While the primary reason for treating malaria is to reduce disease burden, the effects of treatment are generally ignored in estimates of the burden of malaria morbidity, which are usually presented in terms of numbers of clinical cases or episodes, with the main data sources being reports from health facilities and parasite prevalence surveys. The use of burden estimates that do not consider effects of treatment, leads to under-estimation of the impact of improvements in case management. Official estimates of burden very likely massively underestimate the impact of the roll-out of ACT as first-line therapy across Africa. This paper proposes a novel approach for estimating burden of disease based on the point prevalence of malaria attributable disease, or equivalently, the days with malaria fever in unit time. The technique makes use of data available from standard community surveys, analyses of fever patterns in malaria therapy patients, and data on recall bias. Application of this approach to data from Zambia for 2009–2010 gave an estimate of 2.6 (95% credible interval: 1.5–3.7) malaria attributable fever days per child-year. The estimates of recall bias, and of the numbers of days with illness contributing to single illness recalls, could be applied more generally. To obtain valid estimates of the overall malaria burden using these methods, there remains a need for surveys to include the whole range of ages of hosts in the population and for data on seasonality patterns in confirmed case series.     

Reduction in hospital readmission stay of elderly patients by a community based hospital discharge scheme: a randomised controlled trial.

STUDY OBJECTIVE--To compare a community support scheme using care attendants with standard aftercare for their effects on independence and morale of elderly patients discharged from hospital and on their use of health and social services. DESIGN--Randomised controlled study of cohort of patients over 75 discharged to their own homes. SETTING--District general hospital and community. PATIENTS--Total of 903 patients (mean age 82, 25% over 85). INTERVENTIONS--Total of 464 patients received support from care attendants on first day at home and for up to 12 hours a week for two weeks. Support comprised practical care, help with rehabilitation, and organising social help. The remaining 439 patients received standard aftercare. END POINT--Difference between two groups of 7% in hospital readmission rates or one point on activities of daily living scale (power 80%, significance level 5%). MEASUREMENTS AND MAIN RESULTS--Three months after the initial discharge 763 patients were interviewed (84%). There were no significant differences between the two groups in physical independence (activities of daily living scale), in measures of morale (Philadelphia scale), or in death rates. Hospital readmission rates within 18 months of discharge, however, were significantly higher in the control group and they spent more days in hospital (mean; control group 30.6 days, support group 17.1 days; p = 0.014). Of the patients living alone who were followed up for 18 months 21 (15%) receiving standard aftercare were readmitted more than twice compared with 6 (5%) supported by care attendants (p less than 0.01). CONCLUSIONS--If the findings are confirmed, and the policy extended to all patients over the age of 75 living alone, an average health district might expect either to save about 23 hospital beds at a net annual saving of about pounds 220,000 in the short term or to increase available beds by this number.     

“Chronicity,” “Nervios,” and community care: A case study of Puerto Rican psychiatric patients in New York City

The role of ethnicity, community structure, and folk concepts of mental illness in facilitating the adaptation of long term psychiatric patients to community living has received little attention. This article examines the cultural concepts of mental illness and the community involvement of 30 Puerto Rican psychiatric patients participating in a New York City treatment program. It is shown that many of the attributes usually associated with chronic mental illness do not apply to this population. It is argued that the folk concept of nervios helps to foster the integration of these patients in a wide range of community networks. The impact of gentrification on these patients' community integration is also discussed.