Assertive Community Treatment for People with Severe Mental Illness

Department of Health Policy and Management and Center for Research on Services for Severe Mental Illness, Johns Hopkins University, Baltimore, MD 21205, USA.
Health Services Research (Impact Factor: 2.78). 07/1999; 34(2):577-601.
Source: PubMed


To determine the effect of the Program for Assertive Community Treatment (PACT) model on psychiatric inpatient service use in a population of non-emergency psychiatric patients with severe chronic mental illness, and to test for variations in this effect with program staffing levels and patient characteristics such as race and age.
Data are taken from a randomized trial of PACT in Charleston, South Carolina for 144 patients recruited from August 1989 through July 1991.
Subjects were randomly assigned either to one of two PACT programs or to usual care at a local mental health center. Effects on hospital use were measured over an 18-month follow-up period via multiple regression analysis.
Data were obtained from Medicaid claims, chart reviews, subject, case manager, and family interviews; searches of the computerized patient and financial databases of the South Carolina Department of Mental Health and relevant hospitals; and searches of the hard copy and computerized financial databases of the two major local hospitals providing inpatient psychiatric care.
PACT participants were about 40 percent less likely to be hospitalized during the follow-up period. The effect was stronger for older patients. Lower PACT client/staff ratios also reduced the risk of hospitalization. No evidence of differential race effects was found. Given some hospital use, PACT did not influence the number of days of use.
Controlling for other covariates, PACT significantly reduces hospitalizations but the size of this effect varies with patient and program characteristics. This study shows that previous results on PACT can be applied to non-emergency patients even when the control condition is an up-to-date CMHC office-based case management program.

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    • "Psychiatric hospitalization in this sample occurred in both private and state hospitals. Treatment patterns typically differ markedly between these two types of hospitals, and national data show that costs per day in private hospitals are higher while inpatient length of stay is much shorter relative to state hospitals (Salkever et al. 1999). To capture these differences in settings, the model for hospital-based mental health costs (conditional on inpatient service use) included a control for the fraction of mental health hospitalizations in a private hospital. "
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    ABSTRACT: To determine the effects of housing and neighborhood features on residential instability and the costs of mental health services for individuals with chronic mental illness (CMI). Medicaid and service provider data on the mental health service utilization of 670 individuals with CMI between 1988 and 1993 were combined with primary data on housing attributes and costs, as well as census data on neighborhood characteristics. Study participants were living in independent housing units developed under the Robert Wood Johnson Foundation Program on Chronic Mental Illness in four of nine demonstration cities between 1988 and 1993. Participants were assigned on a first-come, first-served basis to housing units as they became available for occupancy after renovation by the housing providers. Multivariate statistical models are used to examine the relationship between features of the residential environment and three outcomes that were measured during the participant's occupancy in a study property: residential instability, community-based service costs, and hospital-based service costs. To assess cost-effectiveness, the mental health care cost savings associated with some residential features are compared with the cost of providing housing with these features. Health service utilization data were obtained from Medicaid and from state and local departments of mental health. Non-mental-health services, substance abuse services, and pharmaceuticals were screened out. Study participants living in newer and properly maintained buildings had lower mental health care costs and residential instability. Buildings with a richer set of amenity features, neighborhoods with no outward signs of physical deterioration, and neighborhoods with newer housing stock were also associated with reduced mental health care costs. Study participants were more residentially stable in buildings with fewer units and where a greater proportion of tenants were other individuals with CMI. Mental health care costs and residential instability tend to be reduced in neighborhoods with many nonresidential land uses and a higher proportion of renters. Mixed-race neighborhoods are associated with reduced probability of mental health hospitalization, but they also are associated with much higher hospitalization costs if hospitalized. The degree of income mixing in the neighborhood has no effect. Several of the key findings are consistent with theoretical expectations that higher-quality housing and neighborhoods lead to better mental health outcomes among individuals with CMI. The mental health care cost savings associated with these favorable features far outweigh the costs of developing and operating properties with them. Support for the hypothesis that "diverse-disorganized" neighborhoods are more accepting of individuals with CMI and, hence, associated with better mental health outcomes, is mixed.
    Health Services Research 11/2004; 39(5):1341-60. DOI:10.1111/j.1475-6773.2004.00293.x · 2.78 Impact Factor
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    ABSTRACT: Associations between individual, social, and service factors, recovery expectations and recovery strategies for individuals with mental illness
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