Janet Durbin

Continuity of Care: Validation of a New Self-report Measure for Individuals Using Mental Health Services

Continuity of care is a concern for individuals with persistent mental illness who need diverse services over time in response to multiple and changing needs. Efforts to study continuity have been hampered by lack of appropriate instruments. The Alberta Continuity of Services Scale — Mental Health is a newly developed, self-report scale that assesses continuity of care across settings and providers. This study examined the structure, reliability, and validity of the measure among users of community mental health programs. Findings were positive. Scores captured both positive and negative perceptions of care. Factor analyses elucidated 3 components of continuity—system access, interpersonal aspects, and care team function. Associations between the continuity scores and selected client and service use measures supported its validity. The tool holds promise for system monitoring, but would need refinements to create a shorter, conceptually clearer version. Also, performance among individuals with mild and very severe levels of mental illness needs to be evaluated.

Needs-based planning: Evaluation of a level-of-care planning model

With the closure of a number of provincial psychiatric hospitals planned, the Ministry of Health of Ontario has commissioned a series of planning projects to identify alternative placements for current hospital patients. The goal is to match need to care in the least restrictive setting. A systematic, clinically driven planning process was implemented that involved three steps: development of a continuum of levels of care representing increasingly intensive and more restrictive supports, development of criteria and decision rules for placement, and comprehensive needs assessment of current patients using the Colorado Client Assessment Record. Results showed that only 10% of current inpatients need to remain in the hospital, and over 60% could live independently in the community with appropriate supports. Evidence supports concurrent validity of the planning model, but further work is needed to assess whether recommended levels of care effectively meet consumer needs in the least restrictive setting.

Does Systems Integration Affect Continuity of Mental Health Care

Continuity of care is a concern for mental health clients in the post deinstitutionalization era of community care. A proposed solution is systems integration. This paper reviewed research on systems integration, focusing on continuity of care outcomes. A positive association between systems integration and client continuity of care was consistently demonstrated. Better results were obtained in systems characterized by stronger management arrangements, fewer service sectors, and system wide implementation of intensive case management and centralized access to services. Future research should evaluate a wider range of systems integrating mechanisms, using client-based measures that more directly represent continuity of care experiences.

Social networks of residents in supportive housing.

One goal of supportive housing is to enlarge and improve the functioning of the social support networks of residents. The networks of a convenience sample of 42 residents were assessed using scales developed by Barrera. The size of the networks (11.5) was no larger than that reported for similar clients living in other types of community settings but the composition differed. Staff and co-residents appear to partially replace rather than add to family and friends. This is of concern because friends are uniquely important determinants of satisfaction. An association between perceived need for support and network size was also found. These findings suggest some positive influences but also raise questions about unintended negative consequences of living in artificially constructed social environments.

Quality of Communication Between Primary Health Care and Mental Health Care: An Examination of Referral and Discharge Letters

In managing treatment for persons with mental illness, the primary care physician (PCP) needs to communicate with mental health (MH) professionals in various settings over time to provide appropriate management and continuity of care. However, effective communication between PCPs and MH specialists is often poor. The present study reviewed evidence on the quality of information transfer between PCPs and specialist MH providers for referral requests and after inpatient discharge. Twenty-three audit studies were identified that assessed the quality of content and nine that assessed strategies to improve quality. Results indicated that rates of item reporting were variable. Within the limited evidence on interventions to improve quality, use of structured forms showed positive results. Follow-up work can identify a minimum set of items to include in information transfers, along with item definitions and structures for holding this information. Then, methodologies for measuring data quality, including electronically generated performance metrics, can be developed.

The clinical profile and service needs of psychiatric inpatients with intellectual disabilities and forensic involvement

Abstract There is increasing recognition around the world that individuals with intellectual disabilities (ID) and mental health issues with forensic involvement are a particularly complex patient group whose needs are not well met. However, few studies have examined how these individuals may differ from other service users within a psychiatric hospital setting. Inpatients with ID and forensic involvement were compared to non-forensic inpatients with ID and to forensic inpatients without ID in terms of psychiatric diagnoses and clinical issues. Inpatients with ID and forensic involvement were younger, more often male, had greater lengths of stay, were more likely to have a personality disorder diagnosis and less likely to have a mood disorder diagnosis than their counterparts with ID. They were also similar to their forensic counterparts without ID with regards to demographics, but were less likely to have a substance abuse or psychotic disorder diagnosis. Furthermore, patients with ID and forensic involvement exhibit more severe symptoms, have fewer resources, and a higher recommended level of care than other forensic patients. Patients with ID and forensic involvement present with unique demographic and clinical profiles. The characteristics that set these individuals apart from other services users should be taken into account in order to better meet the needs of this complex group.

A Comparison of Patients with Intellectual Disability Receiving Specialised and General Services in Ontario's Psychiatric Hospitals.

BACKGROUND Over the years, the closure of institutions has meant that individuals with intellectual disabilities (IDs) must access mainstream (i.e. general) mental health services. However, concern that general services may not adequately meet the needs of patients with ID and mental illness has led to the development and implementation of more specialised programmes. This study compares patients with ID receiving specialised services to patients with ID receiving general services in Ontarios tertiary mental healthcare system in terms of demographics, symptom profile, strengths and resources and clinical service needs. METHOD A secondary analysis of Colorado Client Assessment Record data collected from all tertiary psychiatric hospitals in the province was completed for all 371 inpatients with ID, from both specialised and general programmes. RESULTS Inpatients in specialised programmes were more likely to have a diagnosis of mood disorder and were less likely to have a substance abuse or psychotic disorder. Individuals receiving specialised services had higher ratings of challenging behaviour than those in more general programmes. The two groups did not differ significantly in terms of recommended level of care, although more inpatients from specialised programmes were rated as requiring Level 4 care than inpatients from general programmes. CONCLUSIONS In Ontario, inpatients in specialised and general programmes have similar overall levels of need but unique clinical profiles that should be taken into consideration when designing interventions for them.

Educating the Public About Mental Illness and Homelessness: A Cautionary Note

Objective: To determine whether the viewing of a video depicting the successful struggles of homeless persons with mental illness in finding and maintaining housing can have a positive impact on attitudes toward homeless persons with mental illness. Method: Five hundred and seventy-five high school students attending a brief educational session on mental illness participated in 1 of 3 comparison versions of the 2-hour program (control, video, video plus discussion). All completed an “Attitudes toward Homelessness and Mental Illness Questionnaire.” Demographic and prior exposure variables were entered as covariates in between-group analyses of variance. Results: Females and subjects who had more prior encounters with homeless persons were found to have the most positive attitudes. After controlling for these effects, the video alone had a negative impact on attitudes relative to the other groups, while the video followed by a discussion with one of the people featured in it had a largely positive impact. Conclusions: The apparent immediacy and the evocative power of video presentations cannot substitute for direct contact for the purpose of promoting positive attitude change. The findings are consistent with prior research emphasizing the importance of direct interaction with members of stigmatized groups to reduce negative attitudes. Education programs trying to destigmatize mental illness and homelessness using videos should proceed with caution.

Classifying psychiatric inpatients: Seeking better measures

BACKGROUND Use of case-mix reimbursement in psychiatric inpatients has been limited as a result of a lack of systems which effectively group patients according to required resource needs. In recognition of the fact that many patient factors, in addition to diagnosis influence delivery of care in psychiatry, new measures of patient need are emerging. OBJECTIVE This study compared improvement realized by using a multidimensional measure of patient severity, the Computerized Severity Index (CSI), to predict length of stay (LOS) in psychiatric inpatients over that achieved by using patient variables routinely collected in the discharge abstract. METHOD Through retrospective chart review, severity ratings were made on 355 psychiatric discharges with primary diagnoses of psychotic or major depressive disorders. Those ratings were combined with demographic and diagnostic data available in discharge abstracts and were then entered into multivariate regression analyses to model LOS. RESULT CSI ratings significantly contributed to prediction models, which accounted for an additional 9% to 11% of variation in LOS over discharge abstract data. Among patients with psychotic disorders, maximum severity during hospitalization was the best predictor of LOS, whereas among patients with depressive disorders, it was an increase in severity following admission. CONCLUSION Severity ratings, based on chart review, improved prediction of LOS over discharge abstract variables for psychiatric inpatients in two diagnostic groups. Further research is needed to estimate the impact of incorporating severity ratings into a grouping system for all psychiatric inpatients. Estimation of predictive accuracy is important to determine the amount of risk passed on to providers in a payment system based on psychiatric case mix.

Tertiary mental health services : I. Key concepts

There are some individuals with severe and persistent mental illnesses who cannot be managed by primary and secondary services and who require tertiary care. Such clients are characterized by aggressiveness, noncompliance with medication, and dangerousness. Tertiary care program elements include psychosocial rehabilitation, sophisticated medication management, and behavioural approaches. Tertiary care may be delivered through assertive community treatment and/or specialized outreach teams, community residential programs, or hospital-based services. Increasingly, organized systems have been developed to ensure that individuals meet criteria for tertiary care and receive the most appropriate level of care. Most importantly, the delivery of tertiary care must not be tied to particular settings or timeframes, and level of care must be delinked from model or location of care in order to create flexible, efficient, effective mental health services.