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An analysis of process and outcomes for new long-stay patients in a ward-in-a-house
Abstract
Detailed progress and outcome data for a small group of new long-stay patients living in a ward-ina-house (hospital hostel) were examined. There was no evidence of pre-existing differences related to final outcome. Those residents who were eventually resettled showed more evidence of improvement over the length of their stay, and had significantly better overall functioning in the period immediately prior to their resettlement. The group who were eventually transferred out of the unit showed less evidence of improvement and more evidence of deterioration, albeit commonly following some initial improvement. They also showed an increase in violent and aggressive behaviour in the weeks immediately prior to their move. The ongoing group of current residents appeared to be specifically characterised by significant fluctuations in their functioning over their length of stay. The implications of these findings for the long-term rehabilitation and care of these patients are discussed.
... This shift involved implementation of a range of community treatment approaches including community clinics, assertive outreach teams and supported accommodation. During this transition, the concept developed of a 'ward-in-a-house', which aimed to provide individualised, person-centered clinical care within a home like setting to people with complex and enduring mental illness [2]. The ward in the community approach was to enhance participation in usual domestic activities and to promote access to community facilities and public transport [2,3]. ...
... During this transition, the concept developed of a 'ward-in-a-house', which aimed to provide individualised, person-centered clinical care within a home like setting to people with complex and enduring mental illness [2]. The ward in the community approach was to enhance participation in usual domestic activities and to promote access to community facilities and public transport [2,3]. The Department of Health, Victoria, Australia chose a similar model, developing community care units (CCUs) which were implemented in 1996 [1,4]. ...
Background: Community Care Units (CCUs) are purpose built residential accommodation for adults with severe and enduring mental illness. The CCUs are staffed by clinical mental health staff 24 hours per day and there are consistent guidelines as to the process these programs utilise to prioritise who would most benefit from them. A CCU based in the Inner East of Melbourne, Australia, has utilised one bed as a ‘review program’ to assess patients’ functional livings skills and potential for engagement with the long-term rehabilitation program as part of a general more person-centered healthcare approach.
Aims: The purpose was to evaluate: (1) patient perception of the program and if this benefits their rehabilitation, (2) the perception of clinicians who refer to the program and (3) the perception of clinicians of the CCU multidisciplinary team (MDT).
Method: A purposive sample of patients and clinicians was employed. Semi-structured interviews were conducted with 7 patients who had participated in the review program between January 2010 - April 2012 and an online survey was conducted with responses from 5 case managers who had referred patients and 9 clinicians in the CCU MDT team who had participated in conducting the review.
Results: Our results indicated that patients found the process somewhat overwhelming and an adjustment to their daily routine; they were generally unclear as to the rationale for referral to the program. Clinicians found the program to be a useful process in assisting a more in-depth understanding of their patients’ needs.
Conclusion: Results suggest that review and modification to program delivery could enhance patient benefits and enhance more person-centered approaches to care.
... Positive outcomes for residents include increased autonomy and self esteem (Norman and Parker, 1990), and improvements in quality of life, social functioning and clinical state (Kaye and Khoosal, 1994).The issue that has occupied most research however has related to how hospital hostels contribute to resident rehabilitation and success seems to have been associated with levels of discharge into accommodation with lower levels of support. The findings indicate that high proportions of residents are indeed discharged (Garety et al., 1988; King et al., 2000; Reid and Garety, 1996; Shepherd et al., 1994a) but that a minority of residents are unlikely to be resettled (King et al., 2000; Shepherd et al., 1994a) which raises questions about the appropriateness of some placements in hospital hostels for those who seem unlikely to ever leave. Emerson (1998) evaluated four hospital hostels and found that effective outcomes were associated with levels of restrictiveness appropriate to levels of disablement suggesting that the hospital hostel model is not homogenous but is capable of dealing with varying levels of mental illness to produce outcomes appropriate to the individual. ...
... Positive outcomes for residents include increased autonomy and self esteem (Norman and Parker, 1990), and improvements in quality of life, social functioning and clinical state (Kaye and Khoosal, 1994).The issue that has occupied most research however has related to how hospital hostels contribute to resident rehabilitation and success seems to have been associated with levels of discharge into accommodation with lower levels of support. The findings indicate that high proportions of residents are indeed discharged (Garety et al., 1988; King et al., 2000; Reid and Garety, 1996; Shepherd et al., 1994a) but that a minority of residents are unlikely to be resettled (King et al., 2000; Shepherd et al., 1994a) which raises questions about the appropriateness of some placements in hospital hostels for those who seem unlikely to ever leave. Emerson (1998) evaluated four hospital hostels and found that effective outcomes were associated with levels of restrictiveness appropriate to levels of disablement suggesting that the hospital hostel model is not homogenous but is capable of dealing with varying levels of mental illness to produce outcomes appropriate to the individual. ...
This paper will explore the evidence relating to models of good practice regarding accommodation and related services for people with mental health problems in the UK. In the context of new "Supporting People" initiatives it is timely to consider the evidence base pertaining to different models of accommodation, ranging from those with relatively low levels of support to those with high levels of support. The literature reveals that there has tended to be an assumption that patients will progress from high(er) to low(er) levels of supported accommodation over time thereby marginalising the needs of a core of patients with particularly challenging behaviour who require long term, permanent accommodation with high levels of support. Over time these patients have been defined as "difficult to place" and it is argued here that this is not because their behaviour is necessarily difficult to manage but rather that existing models of supported accommodation have failed to take account of their needs, based as it is on an assumption that patients will inevitably progress and require fewer services over time. The paper concludes by examining the implications of the literature review for "Supporting People" and raises questions regarding the extent to which current proposals meet the challenges identified.
... In un piccolo ma accurato studio condotto da King et al. (2000) su un campione di 20 ospiti di SR, è emerso che nessuna delle molte variabili esaminate all'ingresso dei pazienti era in grado di predire l'esito (in termini di dimissione dalla SR e di altre variabili di esito) al follow-up a 2 anni. L'importante conclusione degli autori è che, data la difficoltà di prevedere il decorso del quadro clinico e psicosociale di ciascun paziente, l'inserimento in una SR dovrebbe essere attuato in una prospettiva molto 'aperta', ossia sapendo che potrebbero essere molti (e diversi) gli scenari che verranno a configurarsi. ...
Se le SR devono rappresentare, almeno per una parte dei pazienti che esse ospitano, un setting destinato al trattamento intensivo a lungo termine, l'analisi del processo assistenziale (ossia di ciò che concretamente si fa nelle SR, delle regole che caratterizzano lo svolgersi della vita comunitaria, delle attività condotte dagli operatori) appare una dimensione di fondamentale importanza da comprendere. Nell'ambito del progetto PROGRES, tale dimensione è stata oggetto di una valutazione approfondita, che viene descritta in questa sezione della monografia.
La Scheda Struttura conteneva molti item che esploravano varie caratteristiche e dimensioni del processo assistenziale. L'analisi dei dati ha preso in esame la descrizione dei parametri rilevanti per la comprensione di specifici aspetti del processo assistenziale in atto all'interno delle SR. Si sono anche esplorate eventuali associazioni fra caratteristiche delle SR e dei pazienti ospitati.
È stata inoltre condotta una analisi dei cluster al fine di individuare, sulla base dei dati disponibili, dei raggruppamenti omogenei di SR che consentano di cominciare a delineare una tassonomia di queste strutture e delle loro funzioni. In generale, l'analisi dei cluster classifica i casi in categorie o gruppi relativamente omogenei, basandosi sulla loro somiglianza o dissimiglianza rispetto alle variabili selezionate. Al fine di effettuare l'analisi dei cluster cercando di utilizzare il massimo numero di informazioni disponibili, sono stati messi a punto 4 punteggi sintetici: ciascuno di essi ha il compito di riassumere la presenza o assenza di varie caratteristiche o dimensioni inerenti al processo assistenziale.
... Other follow-up studies have consistently shown good community tenure in most patients resettled in residential facilities, although clinical improvements were often of limited magnitude [28][29][30][31][32][33]. ...
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This paper discusses the findings of a scoping study that aimed to explore evidence relating to models of good practice with regard to accommodation and related services for people with mental health problems in the UK. The literature reveals that there has tended to be an assumption that patients will progress from high(er) to low(er) levels of supported accommodation over time, thereby marginalising the needs of a core group of people with particularly challenging behaviour who require long-term, permanent accommodation with high levels of support. The paper concludes by examining the implications of the scoping study for current UK policies towards those with mental health problems.
Population and service characteristics were compared for youth (age 0-18 years) with and without schizophrenia-spectrum disorders, who received public mental health services in Hawaii's comprehensive system of care between July 1, 2000 and June 30, 2001.
Electronic records of youth with a diagnosis in the schizophrenia-spectrum (n=71) were compared to all other youth (n=13,904) who received services with respect to age, gender, ethnicity, comorbidity, type of service, and service cost.
The schizophrenia-spectrum group had higher Asian representation, greater comorbidity, and was more likely to receive restrictive services for a higher average annual expense. When restrictive services were provided, they were of similar duration and intensity across groups. Almost all youth received less intensive services, but the schizophrenia-spectrum group received a higher frequency or longer duration of such services.
Although youth with schizophrenia-spectrum disorders were uncommon, collectively they represented a distinct population with above average service consumption. Future monitoring of interventions and outcomes may help develop systematic and effective treatment strategies for youth with schizophrenia-spectrum disorders.
On 21 September 1977, the first British ‘hostel ward’ was opened. In this paper we review the thinking behind such a concept and evaluate its successes and failures. This is not simply of value as an introspective exercise since it is also crucial that service planners and providers who are moving towards the closure of mental hospitals should consider the value for their district of such a service.
Activity and outcome data for two ‘ward-in-a-house’ projects for new long-stay in-patients are described. The results confirm that up to a third may be successfully resettled providing that good quality sheltered housing is available. However, a similar proportion appear to find such environments too demanding and may be transferred after an acute exacerbation of symptoms or a violent incident. The remainder need high quality, ongoing care.
We describe different models of community care for persons with severe mental illness and review the research literature on case management, including the results of 75 studies. Most research has been conducted on the assertive community treatment (ACT) or intensive case management (ICM) models. Controlled research on ACT and ICM indicates that these models reduce time in the hospital and improve housing stability, especially among patients who are high service users. ACT and ICM appear to have moderate effects on improving symptomatology and quality of life. Most studies suggest little effect of ACT and ICM on social functioning, arrests and time spent in jail, or vocational functioning. Studies on reducing or withdrawing ACT or ICM services suggest some deterioration in gains. Research on other models of community care is inconclusive. We discuss the implications of the findings in terms of the need for specialization of ACT or ICM teams to address social and vocational functioning and substance abuse. We suggest directions for future research on models of community care, including evaluating implementation fidelity, exploring patient predictors of improvement, and evaluating the role of the helping alliance in mediating outcome.
A controlled modified cost-benefit evaluation of a hostel ward caring for new long-stay patients is described and results are presented for the first two years. In some respects the residents of the hostel ward had fewer psychotic impairments than those remaining on the wards of the district general hospital, mainly because the latter seem to continue to acquire such defects, while the former have remained relatively unchanged. The hostel ward residents also develop superior domestic skills, use more facilities in the community, and are more likely to be engaged in constructive activities than controls. These advantages were not purchased at a price, since the cost of providing this form of care for these patients has cost less than care provided by the district general hospital.
The present study evaluates the progress and outcomes of the first hostel-ward established in this country, sixteen years after its original opening. In this period seventy percent of residents have been discharged, the majority into supported hostel accommodation in the community. Although characteristics of residents admitted to the hostel have remained unchanged over the sixteen year period, the duration of stay of residents before discharge has reduced by almost fifty percent. In terms of long-term outcomes, the second cohort admitted has proved to be more successful than the first. A number of variables were associated with better outcome following discharge. These were: planned discharges to supported hostel accommodation, a diagnosis other than schizophrenia and fewer behavioural problems and higher levels of functioning at discharge. Compared to community-based hostels, fewer patients have been transferred to alternative hospital settings. This hostel-ward has, therefore, been able successfully to manage a group of very disabled individuals who have been excluded from community facilities. It is concluded that the "hostel-ward" model of provision should continue to form an important aspect in the spectrum of services for the severely mentally ill.
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This paper argues for the development of specialist, hospital-based rehabilitation services for a small number of very severely disabled people who need long term hospitalisation at some stage in their illness career and who can not be helped in-community settings. In general, appropriate services should be located in a DGH psychiatric unit and be in addition to acute services. Some could be on mental hospital sites and provide supra-district services to neighbouring districts. These in-patient services should: be as domestic as possible; be staffed by a multi-disciplinary team; provide realistic and individually tailored care programmes based on a goal-planning approach and a combination of biological, psychological and social interventions; provide opportunities for personal strengths and latent abilities to thrive; be functionally integrated with community-based rehabilitation services.
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Synopsis
Four hundred ‘new’ long-stay patients were studied and assessments of their needs for treatment and accommodation were made. About one third appeared to need further care in hospital. A further third could possibly be discharged if suitable accommodation in the community were available: most of this group were more handicapped than present residents in hostels. The remaining third had diverse needs; many were multiply handicapped – for example, by physical disability or mental retardation in addition to psychiatric disorder. At the moment the psychiatric hospital is virtually the only agency to accept the care of such people.
Of 24 residents of a ten-bed, community-based hostel ward suffering chronic psychiatric illness, nine have been resettled in the community, with four more expected to follow them. Five residents have made Douglas House their home but another six have manifested behavioural disturbance necessitating return to hospital wards. We found community discharge to be associated with illnesses having good prognostic features, while organic illness militated against such placement. Indicators of a prior history of behavioural disturbance seem to predict difficulties in managing a patient in this environment.
Using the Community Placement Questionnaire, the long-stay populations of five hospitals were surveyed. The results suggest that there is little need for large hospitals if adequate community provision is made. However, a small number of patients continue to accumulate for whom community placement is hard to envisage. Investigating the characteristics of the 'new long-stay' patients suggests that the usual definition should be extended to include those over 65 years old with no diagnosis of dementia and those in hospital for 1-10 years. About 20% of 'new long-stay' patients have organic diagnoses and the needs of this group require assessment.
A survey was undertaken at the end of 1984 of all patients occupying psychiatric beds for more than six months in an inner-London health district. Excluding those with senile dementia, 30 patients were identified. Two years later, a follow-up survey traced the original cohort and the accumulation of additional patients on the wards. The finding that the rate of discharge from the original group matches the accumulation of new patients into the survey suggests a need for new types of community provision within the district.
Patients aged 18-64 years, in hospital more than one but less than six years, were followed up five years after identification: 22% had died, 50% remained in-patients, and 28% had been discharged; only 10% of first admissions with organic brain disease had left hospital. Of those discharged, 37% had no contact with after-care services. Of those remaining in hospital, 39% did not require in-patient care. Patients' level of functioning had improved over the five years.
creative and innovative programs that may well be the envy of those who seek new and liberating solutions to the care of the chronic mentally ill. At the same time we have some systems of care whose gates are so rigidly kept that the most severely mentally ill individuals receive no services whatever. Many of them are homeless persons who seem unable to gain the social margin that they need in order to enter, or stay in, the service system. Services in Western Europe by contrast appear to gravitate toward the center. There seem to be fewer extravagant or strikingly dramatic programs; however, at the same time, relatively few persons within the population at risk seem to be entirely excluded from the system of care. It appears that most people get something, though it may not qualify as state-of-theart intervention according to standards set in American “model” programs (1).
Statistical analysis of single-case time-series data has received considerable attention. Many of the techniques discussed in the literature require long series of data or sophisticated statistical techniques. The present paper describes a number of 'quick and dirty' non-parametric tests which can be applied to relatively short time series. These tests require minimal calculations and can be carried out by inspecting graphical plots of the data. Each test is illustrated and tables for significance testing have been worked out. The importance of these tests lies in their potential to facilitate the accurate description of time series data. They are recommended as techniques for exploratory data analysis, the philosophy of which parallels Sidman's (1960) 'data led' approach to experimentation.
The paper describes the need for long-term inpatient care in an English health district whose psychiatric services were based on a unit in a District General Hospital. Patients who became long-stay were placed in a new hospital-hostel in a city centre. Three quarters of those eligible could be managed in the hostel, with those rejected posing more control problems. Patients in the hostel became less withdrawn and increased their activity and use of community facilities.
We observed 15 'new' long-stay patients in wards in a District General Hospital Unit and a mental hospital, and again when they had lived for a year in a new hospital-hostel. There were significant changes in time spent in the community, social interaction, activity and abnormal behaviour. Residents believed they had more freedom and none wanted to return to wards. Six patients remained on wards. They showed no comparable changes and all wanted to live elsewhere.
The renewed interest in the care and treatment of chronic psychiatric patients has led to an awareness of the need for improved assessment methods for this group. This article describes the development of REHAB, a behavior rating scale for use with people with chronic psychiatric disability, which has been carefully designed with respect to content, format, and ease of use. The article also draws together the various factor-analytic, reliability, validity, and sensitivity-to-change studies that provide the basic psychometric evidence for the scale's value. REHAB is presented as an integrated package of materials with special attention paid to training of raters and simplicity of interpretation. It has been used for a variety of different assessment purposes, in both research and clinical settings.
As a result of deinstitutionalization, acute care beds in state hospitals have become blocked by patients who lack access to appropriate community placements but who have derived maximum benefit from hospital care. To help plan community services for these patients, this study identified and described patients at an Oregon state hospital who were hospitalized longer than therapeutically necessary because no community facility could treat them. A total of 146 patients were identified during a three-month period, and 81 were described; 65 percent were men, 70 percent were schizophrenic, and 90 percent presented a risk to themselves or others. The patients exhibited few strengths, and one-third had a substance abuse problem, at least one counter-therapeutic attitude, or a need for medical monitoring. The authors describe how new community residential facilities can meet the needs of these difficult patients.
A new type of hostel ward is described in which domestic activities take the place of attendance at a day centre or industrial workshop. Residents no longer depend on the institution for meals, cleaning, or social activities. The programme is resident-orientated, and individual treatment plans are designed and effected using a points system. The emphasis of group activities is on communication and living skills. The hostel ward is able to care for our most disabled patients who are thought to need 24-hour nursing care.
Synopsis
The present study describes and evaluates aspects of care in a new residential unit for chronic patients. The findings suggest that the unit is relatively resident-orientated in its management practices and that the staff are similarly orientated in their attitudes. Staff also hold generally optimistic attitudes to residents' potential accomplishments and consider themselves highly involved in decision-making. They also show high levels of positive interactions with the residents. Various aspects of staff attitudes and behaviour are positively correlated with seniority or length of time on the unit. The results are discussed in terms of the unit's organizational structure and its possible impact on residents' functioning.
Shortly after the 1963 passage of the Community Mental Health Centers Act, New York State launched the construction of four new psychiatric centers, including the Richard H. Hutchings Psychiatric Center in Syracuse. The Hutchings acute care crisis stabilization model was intended to significantly diminish the phenomenon of chronic psychiatric disability. After a decade of operation, however, the Hutchings Center must deal with a caseload of young and chronically disabled individuals who are contributing to the build-up both in the hospital and in the community of the new long-stay patient. The idiosyncratic needs of this chronic group must be defined so that prescriptive programs can be built to meet their needs. The Hutchings Center's original goal of returning patients to and serving them in the community remains the same, but the process of treatment, rehabilitation, and long-term community support must change.
This paper is concerned with the care of the most difficult and severely disabled new patients presenting to mental health services in the U.K. Questions of definition will be examined and the clinical and social characteristics of the population discussed. Since the defining characteristics (and prevalence) of this group are strongly affected by the overall service context, the range of community provisions within one health district (Cambridge) will be described. Examples of a new kind of institutional solution-the 'ward-in-a-house'-will then be presented, together with the underlying principles of management and care. The benefits and limitations of the model will be discussed.
This second report of a national audit of new long-stay (NLS) psychiatric patients describes the services caring for the patients and the reasons why patients were still in hospital.
Data analyses addressed the prevalence of NLS patients, the residential resources available to services, the distributions of patients within services, clinicians' views as to the appropriateness of current placement and the reasons for any inappropriate placements.
The average point prevalence was 6.1 per 100,000 population; it was significantly lower in England and Wales (5.6, s.d. = 3.2) than in Scotland and Northern Ireland (10.7, s.d. = 6.4, ANOVA F ratio = 10.9, P < 0.01). The estimated rate of accumulation was 1.3 per 100,000 population per year. Many English services had very few non-acute psychiatric beds and 31% of English NLS patients, despite their protracted lengths of stay, were housed on acute wards. Assessors thought that 61% of patients would be better placed in a non-hospital setting; 47% were thought to require a community-based residential setting, and of these over one-half were still in hospital because no suitable community placement was available.
Many NLS patients remain in hospital because their residential needs are not met by existing community provision.
This first report of a national audit of new long-stay (NLS) psychiatric patients conducted in 1992 describes the survey method and characteristics of the cohort.
Psychiatrists from 59 UK mental health services returned data on 905 patients, aged 18-64 on admission, who had been in hospital for between six months and three years.
Two particular sub-groups were observed. Younger NLS patients (aged 18-34) were predominantly single men with schizophrenia; 43% of these had a history of serious violence, dangerous behaviour or admission to a Special Hospital and over one-third were formally detained. Older NLS patients (aged 55-67) were predominantly married or previously married women, more often with a diagnosis of affective disorder or dementia and with poor personal and social functioning; over half were at moderate or severe risk of non-deliberate self-harm.
Despite the continued policy of bed closures and focus on care in the community, some patients admitted recently to psychiatric units in the UK still have protracted hospital stays.
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.
Cross sectional survey, combined with one day census data; ratings by and interviews with staff; examination of routine data sources.
Nationally representative sample of acute psychiatric units.
2236 patients who were inpatients on census day.
Bed occupancy levels, judged need for continuing inpatient care, reasons preventing discharge, scores on the Health of the Nation outcome scales.
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.
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.
Certain independent inquiries, the failure to implement the care programme approach, the new mental health strategy, the recent National Service Framework for Mental Health (Department of Health (DoH), 1999), and the Fallon Inquiry into the Personality Disorder Unit at Ashworth Special Hospital have all raised many questions about psychiatric care which remain unanswered. The issue of organizing and developing forensic services can be regarded as a key element if safer services are to be a reality. This article offers a model for forensic mental health services which is derived from policy statements, the published strategy, research, and discussion papers.
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