Special Section on the GAF: Continuity of Care and Clinical Outcomes in a National Health System

Department of Psychiatry, Yale University, New Haven, Connecticut, United States
Psychiatric Services (Impact Factor: 2.41). 05/2005; 56(4):427-33. DOI: 10.1176/
Source: PubMed


Continuity of care is widely viewed as a key quality indicator for outpatient mental health care. However, few studies have been conducted of the relationship between continuity of care and client outcomes. This study examined the relationship between measures of three aspects of continuity of care (regularity of care, continuity of treatment across organizational boundaries, and intensity of treatment) and the Global Assessment of Functioning (GAF), a single-item mental health status measure, in a national health care system.
Three analytic samples were derived from a nationwide Department of Veterans Affairs administrative data set: patients with at least one inpatient GAF rating and a later outpatient GAF rating (N=8,334) and two groups who had at least two outpatient GAF ratings, one group that was beginning a new episode of treatment (N=49,946) and a second group in ongoing treatment (N=123,371). Hierarchical linear modeling was used to control for potential site-level autocorrelation and to adjust for differences in diagnostic status, sociodemographic characteristics, baseline GAF score, and the length of time between GAF ratings.
Several positive and significant relationships were found for discharged inpatients and new outpatients. However, only a few of these relationships could be confidently said to be clinically meaningful. Specifically, among discharged inpatients, for every additional month in which an outpatient visit occurred over a six-month period, there was a .69 increase in the GAF change score for a total increase of 4.1 points. Among new outpatients the equivalent values were smaller, at .3 and 1.8. In contrast with the findings for discharged inpatients and new outpatients, high intensity of care was negatively associated with GAF change scores for continuing outpatients.
In contrast with several earlier studies, this study showed positive and statistically significant associations between several continuity-of-care measures and client outcomes. These relationships were observed only in transitional treatment situations, that is, after hospital discharge and at the beginning an episode of outpatient care, situations in which continuity of care may be especially important. However, although positive and statistically significant, the magnitude of these effects may not have been clinically meaningful.

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Available from: Greg Greenberg, Nov 05, 2015
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    • "It has been viewed as a process measure and an outcome as well as a benchmark of overall quality of care (Christakis, 2003). COC is also an important link to patient clinical and resource utilization outcomes (Van Walraven et al., 2010), including health (Adair et al., 2005), mental health (Greenberg and Rosenheck, 2005), and homelessness (Fortney et al., 2003). A qualitative meta-synthesis on patients' perceptions of COC (Waibel et al., 2012) indicates that there are relatively few studies that use COC ratings made directly by service recipients with SMI, and the association between selfrated continuity and service recipient outcomes during significant service changes has rarely been examined. "
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    ABSTRACT: We investigated the impact of critical time intervention (CTI) on self-reported indicators of quality of continuity of care (COC) after discharge from inpatient psychiatric treatment with data from a randomized controlled trial that assessed the effectiveness of the intervention in reducing recurrent homelessness. Postdischarge COC outcome measures among previously homeless persons with severe mental illness randomly assigned to receive usual services only (n = 73) or 9 months of CTI in addition to usual services (n = 77) were compared. Those assigned to CTI had greater perceived access to care than the usual services group did, with this impact extending beyond the point at which the intervention ended. A time-limited care coordination intervention provided immediately after hospital discharge may improve COC, but further studies are needed to substantiate an effect of CTI on long-term continuity outcomes.
    Full-text · Article · Jan 2015 · Journal of Nervous & Mental Disease
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    • "Continuity of care for severely ill patients has been an important topic in mental health services research [38,39]. Several studies have found a positive relationship between high levels of continuity of care and important outcomes such as improved quality of life, improved community functioning, lower severity of symptoms, and greater service satisfaction [40,41]. We believe one possible explanation for the importance of service-system on the rate of involuntary admission may be that the proximity and local control of psychiatric beds and the integration of services lower the threshold for inpatient admission and thereby allow patients to be readily admitted before the condition becomes too grave [32,42-44]. "
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    ABSTRACT: Studies on the effect of organizational factors on the involuntary admission of psychiatric patients have been few and yielded inconclusive results. The objective was to examine the importance of type of service-system, level of care, length of inpatient stay, gender, age, and diagnosis on rates of involuntary admission, by comparing one deinstitutionalized and one locally institutionalized service-system, in a naturalistic experiment. 5538 admissions to two specialist psychiatric service-areas in North Norway were studied, covering a four-year period (2003-2006). The importance of various predictors on involuntary admission were analyzed in a logistic regression models RESULTS: Involuntary admission to the services was associated with the diagnosis of psychosis, male sex, being referred to inpatient treatment, as well as type of service-system. Patients from the deinstitutionalized system were more likely to be involuntarily admitted. Several factors predicted involuntary status, including male sex, the diagnosis of psychosis, and type of service-system. The results suggests that having psychiatric beds available locally may be more favourable than a traditional deinstitutionalized service system with local outpatient clinics and central mental hospitals, with respect to the use of involuntary admission.
    Full-text · Article · Feb 2014 · BMC Health Services Research
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    • "Studies show that continuity of care has psychological and social effects in terms of the user's quality of life, ability to function within the community and satisfaction with the care services [14], and also effects on the system, for example, through lower hospital costs and higher community costs [15]. Continuity of care may be considered as both a process and an outcome [16], but in terms of individual patient outcome, the results tend to be more variable [14,17,18. "
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    ABSTRACT: Users of mental health services often move between different primary and specialised health and care services, depending on their current condition, and this often leads to fragmentation of care. The aim of this study was to map care pathways in the case of young adult mental health service users and to identify key obstacles to continuity of care. Quarterly semi-structured interviews were performed with nine young adults with mental health difficulties, following their pathways in and out of different services in the course of a year. Key obstacles to continuity of care included the mental health system's lack of access to treatment, lack of integration between different specialist services, lack of progress in care and inadequate coordination tools such as 'Individual Plan' and case conferences that did not prevent fragmented care pathways. Continuity of care should be more explicitly linked to aspirations for development and progress in the users' care pathways, and how service providers can cooperate with users to actually develop and make progress. Coordination tools such as case conferences and 'individual plans' should be upgraded to this end and utilised to the utmost. This may be the most effective way to counteract the system obstacles.
    Full-text · Article · Aug 2013 · International journal of integrated care
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