151
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Segal SP, Riley S. Caring for Persons with Serious Mental Illness: Policy and Practice Suggestions. SOCIAL WORK IN MENTAL HEALTH 2003; 1:1-17. [PMID: 33564276 PMCID: PMC7869837 DOI: 10.1300/j200v01n03_01] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
This article places evidenced-based knowledge of practice within the social context of care and proposes five policy objectives and specific policy and program changes to address care needs of people with serious mental illness. In spite of demonstration programs that provide the basis for proposed policy initiatives throughout the United States, treatment provision for this population remains inadequate and their safety and well-being continues to be at risk. The authors suggest that treatment initiatives need to be tied to stable policies protecting the mentally ill from adverse social context changes. The authors conclude that policies are needed that will enhance housing assistance, independent social functioning, personal empowerment, and treatment engagement. In addition, efforts are needed to make better use of inpatient hospital care, to better understand the role of assisted treatment, and to better develop consistent long-term fiscal support for the seriously mentally ill. They offer specific policy recommendations for changes in HUD programs, Medicaid and Medicare funding, and treatment programming that address these needs.
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Affiliation(s)
- Steven P Segal
- Mental Health and Social Welfare Research Group, University of California, Berkeley, School of Social Welfare, 120 Haviland Hall, Berkeley, CA 94720
| | - Sharon Riley
- Mental Health and Social Welfare Research Group, University of California, Berkeley, School of Social Welfare, 120 Haviland Hall, Berkeley, CA 94720
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152
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Abstract
BACKGROUND Case management in its various forms represents a major innovation in mental health care. Its efficacy remains controversial. AIMS To update after a decade a previous review article (Holloway, 1991). METHODS Descriptive literature and controlled trials of case management and its derivative Assertive Community Treatment (ACT) was accessed through four comprehensive and systematic reviews of the literature, repeated Medline and Embase searches and personal contacts. RESULTS AND CONCLUSIONS The concept of case management has continued to evolve over the past decade. No controlled trial has been published exploring the model of the case manager as a service broker without responsibility for the provision of care. Basic case management principles have frequently been incorporated within routine clinical practice. Published controlled trials of ACT, which were almost exclusively carried out in North America, have shown markedly positive results. However caution is required in extrapolating these findings to routine clinical practice within different systems of health and social care. Case management is not in itself an effective treatment for severe mental illness.
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153
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Thornicroft G, Susser E. Evidence-based psychotherapeutic interventions in the community care of schizophrenia. Br J Psychiatry 2001; 178:2-4. [PMID: 11136201 DOI: 10.1192/bjp.178.1.2] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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154
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McQuistion HL, Goisman RM, Tennison CR. Psychosocial rehabilitation: issues and answers for psychiatry. Community Ment Health J 2000; 36:605-16. [PMID: 11079188 DOI: 10.1023/a:1001990320197] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
The American Association of Community Psychiatrists has composed a set of principles to guide psychiatry's relationship with psychosocial rehabilitation. They consist of five basic precepts offering the profession an orientation to rehabilitation, accompanied by seven issues that discuss aspects of how psychiatry must finally adopt psychosocial rehabilitation as a model of practice with people who have severe psychiatric disorders. The authors advance the argument that a confluence of developments, both within and beyond psychiatry, has now created an opportunity for psychiatry to build a mutually productive relationship with rehabilitation.
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155
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Morrell-Bellai T, Goering PN, Boydell KM. Becoming and remaining homeless: a qualitative investigation. Issues Ment Health Nurs 2000; 21:581-604. [PMID: 11271135 DOI: 10.1080/01612840050110290] [Citation(s) in RCA: 70] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
This article reports the qualitative findings of a multimethod study of the homeless population in Toronto, Canada. The qualitative component sought to identify how people become homeless and why some individuals remain homeless for an extended period of time or cycle in and out of homelessness (the chronically homeless). In-depth, semistructured interviews were conducted with 29 homeless adults. The findings suggest that people both become and remain homeless due to a combination of macro level factors (poverty, lack of employment, low welfare wages, lack of affordable housing) and personal vulnerability (childhood abuse or neglect, mental health symptoms, impoverished support networks, substance abuse). Chronically homeless individuals often reported experiences of severe childhood trauma and tended to attribute their continued homelessness to a substance abuse problem. It is concluded that both macro and individual level factors must be considered in planning programs and services to address the issue of homelessness in Canada.
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Affiliation(s)
- T Morrell-Bellai
- Health Systems Research Unit, Centre for Addiction and Mental Health, Clarke Division, Toronto, Ontario, Canada
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156
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Susser E, Finnerty M, Mojtabai R, Yale S, Conover S, Goetz R, Amador X. Reliability of the life chart schedule for assessment of the long-term course of schizophrenia. Schizophr Res 2000; 42:67-77. [PMID: 10706987 DOI: 10.1016/s0920-9964(99)00088-2] [Citation(s) in RCA: 68] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
We report on the inter-rater reliability of the Life Chart Schedule (LCS). The LCS is designed to assess the long-term course of schizophrenia in four key domains (symptoms, treatment, residence, and work) over two time periods (past two years, entire period of illness). The subjects were 27 consecutive admissions to a schizophrenia research unit. The LCS was filled out by pairs of raters, blinded to each others' ratings, using the same data (interview with subject and chart). Reliability was examined for 45 LCS ratings selected from all four domains and both time periods. Selected ratings pertained to the duration of specified experiences, the quality of these experiences, and the long-term time trend. The kappa statistic and the intra-class correlation coefficient (ICC) were used to determine inter-rater reliability for continuous and categorical ratings, respectively. LCS ratings proved reliable in all four key domains and both time periods. The reliability was fair to excellent for ratings of duration of experience (ICC ranged from 0.53 to 0.99), quality of experience (kappa ranged from 0.46 to 0. 92) and long-term time trends (kappa ranged from 0.66 to 0.94). The LCS can be used to obtain reliable ratings of the long-term course of schizophrenia in multiple domains.
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Affiliation(s)
- E Susser
- Columbia University, Department of Psychiatry, New York, NY 10032,
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157
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Herman D, Opler L, Felix A, Valencia E, Wyatt RJ, Susser E. A critical time intervention with mentally ill homeless men: impact on psychiatric symptoms. J Nerv Ment Dis 2000; 188:135-40. [PMID: 10749277 DOI: 10.1097/00005053-200003000-00002] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
We describe the impact of a psychosocial intervention, critical time intervention (CTI), on the cardinal symptom dimensions of schizophrenia, namely negative, positive, and general psychopathology. Ninety-six men with schizophrenia and other psychotic disorders who were discharged from a homeless shelter were randomly assigned to receive either CTI or usual services only. CTI is a time-limited intervention designed to enhance continuity of care during the transition from institution to community. Symptom severity at baseline and at 6 months was assessed using the Positive and Negative Syndrome Scale. Using data on 76 subjects for whom we have complete symptom data, we assessed the impact of CTI on change in symptoms. The results suggest that CTI was associated with a statistically significant decrease in negative symptoms at the 6-month follow-up, reflecting modest clinical improvement. There was no significant effect on positive or general psychopathology symptoms.
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Affiliation(s)
- D Herman
- New York State Psychiatric Institute, Department of Psychiatry, Columbia University College of Physicians and Surgeons, New York 10032, USA
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158
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Preston NJ, Fazio S. Establishing the efficacy and cost effectiveness of community intensive case management of long-term mentally ill: a matched control group study. Aust N Z J Psychiatry 2000; 34:114-21. [PMID: 11185923 DOI: 10.1046/j.1440-1614.2000.00696.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The study attempted to identify whether chronic mentally ill persons after receiving intensive case management (ICM) could demonstrate improved inpatient service utilisation compared with a matched control group cohort. Costings were measured to observe whether the increase in providing intensive outpatient contacts would be offset by savings in reduced inpatient service utilisation. METHOD Eighty ICM patients were matched on ICD-9 diagnosis, age, gender, length of illness, age at first inpatient and outpatient contact, marital status, educational level, employment status, country of birth, year of arrival to Australia and religion. Inpatient bed-days and outpatient contacts were recorded and compared 12 months prior to ICM treatment, 12 and 24 months after ICM using within/between group repeated measures analysis of variance. RESULTS The ICM group demonstrate significant reductions in inpatient service utilisation both within the 12- and 24-month period after receiving ICM treatment. The cost differential by 24 months of treatment was $801,475 in favour of the ICM model. The increase in costs of outpatient contacts were offset by a significant reduction in inpatient service utilisation. CONCLUSION When outpatient contacts averaged one contact a week for the duration of the study period no significant reductions in inpatient service utilisation was recorded, as demonstrated by comparison with the matched control group. By increasing outpatient contacts by 3-4 contacts a week, inpatient contacts reduced by 36.8%. ICM is an efficacious and cost effective way to implement community-based services to the chronically long-term mentally ill.
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Affiliation(s)
- N J Preston
- Fremantle Hospital and Health Service, Western Australia, Australia.
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159
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Abstract
BACKGROUND Assertive Community Treatment (ACT) was developed in the early 1970s as a response to the closing down of psychiatric hospitals. ACT is a team-based approach aiming at keeping ill people in contact with services, reducing hospital admissions and improving outcome, especially social functioning and quality of life. OBJECTIVES To determine the effectiveness of Assertive Community Treatment (ACT) as an alternative to i. standard community care, ii. traditional hospital-based rehabilitation, and iii. case management. For each of the three comparisons the main outcome indices were i. remaining in contact with the psychiatric services, ii. extent of psychiatric hospital admissions, iii. clinical and social outcome and iv. costs. SEARCH STRATEGY Electronic searches of CINAHL (1982-1997), the Cochrane Schizophrenia Group's Register of trials (1997), EMBASE (1980-1997), MEDLINE (1966-1997), PsycLIT (1974-1997) and SCISEARCH (1997) were undertaken. References of all identified studies were searched for further trial citations. SELECTION CRITERIA The inclusion criteria were that studies should i. be randomised controlled trials, ii. have compared ACT to standard community care, hospital-based rehabilitation, or case management and iii. have been carried out on people with severe mental disorder the majority of whom were aged from 18 to 65. Studies of ACT were defined as those in which the investigators described the intervention as "Assertive Community Treatment" or one of its synonyms. Studies of ACT as an alternative to hospital admission, hospital diversion programmes, for those in crisis, were excluded. The reliability of the inclusion criteria were evaluated. DATA COLLECTION AND ANALYSIS Three types of outcome data were available: i. categorical data, ii. numerical data based on counts of real life events (count data) and iii. numerical data collected by standardised instruments (scale data). Categorical data were extracted twice and then cross-checked. Peto Odds Ratios and the number needed to treat (NNT) were calculated. Numerical count data were extracted twice and cross-checked. Count data could not be combined across studies for technical reasons (the data were skewed) but all relevant observations based on count data were reported in the review. Numerical scale data were subject to a quality assessment. The validity of the quality assessment was itself assessed. Numerical scale data of suitable quality were combined using the standardised mean difference statistic where possible, otherwise the data were reported in the text or 'Other data tables' of the review. MAIN RESULTS ACT versus standard community care Those receiving ACT were more likely to remain in contact with services than people receiving standard community care (OR 0.51, 99%CI 0.37-0.70). People allocated to ACT were less likely to be admitted to hospital than those receiving standard community care (OR 0.59, 99%CI 0.41-0.85) and spent less time in hospital. In terms of clinical and social outcome, significant and robust differences between ACT and standard community care were found on i. accommodation status, ii. employment and iii. patient satisfaction. There were no differences between ACT and control treatments on mental state or social functioning. ACT invariably reduced the cost of hospital care, but did not have a clear cut advantage over standard care when other costs were taken into account. ACT versus hospital-based rehabilitation services Those receiving ACT were no more likely to remain in contact with services than those receiving hospital-based rehabilitation, but confidence intervals for the odds ratio were wide. People getting ACT were significantly less likely to be admitted to hospital than those receiving hospital-based rehabilitation (OR 0.2, 99%CI 0.09-0.46) and spent less time in hospital. Those allocated to ACT were significantly more likely to be living independently (OR (for not living independently) 0.19, 99%CI 0.06-0. (A
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Affiliation(s)
- M Marshall
- Department of Community Psychiatry, University of Manchester, Academic Unit, Royal Preston Hospital, Sharoe Green Lane, Fulwood, Preston, Lancashire, UK, PR2 4HT.
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160
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Representative Payee for Individuals with Severe Mental Illness at Community Counseling Centers of Chicago. ALCOHOLISM TREATMENT QUARTERLY 1999. [DOI: 10.1300/j020v17n01_10] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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161
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Wadhwa S, Lavizzo-Mourey R. Tools, methods, and strategies. Do innovative models of health care delivery improve quality of care for selected vulnerable populations? A systematic review. THE JOINT COMMISSION JOURNAL ON QUALITY IMPROVEMENT 1999; 25:408-33. [PMID: 10434191 DOI: 10.1016/s1070-3241(16)30455-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND A criticism of conventional office or clinic-based models of care is that they focus on patients' urgent problems and do not provide the comprehensive assessments, education, and psychosocial support that vulnerable patients also need. Innovative models have emerged to address these needs. A systematic review of prospective studies involving searches of computerized databases, reviews of reference lists, and contacts with authors, was conducted to determine whether multidisciplinary teams, outreach or home care, and case management improve the quality of the care in two vulnerable populations-the terminally ill and the mentally ill. RESULTS Literature searches identified 730 citations. 52 original articles met screening standards, and 24 studies fulfilled all criteria. Patient and caregiver satisfaction was consistently higher with innovative models. In no study was satisfaction lower. Functional, clinical, or psychological improvements were not consistently demonstrated. For mentally ill patients, multidisciplinary outreach strategies were effective in reducing inpatient hospitalizations. Costs were inadequately assessed in the studies to draw a summary conclusion. DISCUSSION Like other interventions, health care delivery models can be assessed from an evidence-based perspective. More needs to be learned about the costs and health improvements of innovative models before we can determine whether the increased patient and caregiver satisfaction found justifies widespread use of these models. Development of a uniform set of quality outcome measures and encouragement to evaluate efforts and disseminate results will help accomplish this goal.
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Affiliation(s)
- S Wadhwa
- Division of Geriatrics Medicine, University of Pennsylvania Health System, Philadelphia, USA.
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162
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Shinn M, Weitzman BC, Stojanovic D, Knickman JR, Jiménez L, Duchon L, James S, Krantz DH. Predictors of homelessness among families in New York City: from shelter request to housing stability. Am J Public Health 1998; 88:1651-7. [PMID: 9807531 PMCID: PMC1508577 DOI: 10.2105/ajph.88.11.1651] [Citation(s) in RCA: 95] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES This study examined predictors of entry into shelter and subsequent housing stability for a cohort of families receiving public assistance in New York City. METHODS Interviews were conducted with 266 families as they requested shelter and with a comparison sample of 298 families selected at random from the welfare caseload. Respondents were reinterviewed 5 years later. Families with prior history of shelter use were excluded from the follow-up study. RESULTS Demographic characteristics and housing conditions were the most important risk factors for shelter entry; enduring poverty and disruptive social experiences also contributed. Five years later, four fifths of sheltered families had their own apartment. Receipt of subsidized housing was the primary predictor of housing stability among formerly homeless families (odds ratio [OR] = 20.6, 95% confidence interval [CI] = 9.9, 42.9). CONCLUSIONS Housing subsidies are critical to ending homelessness among families.
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Affiliation(s)
- M Shinn
- Department of Psychology, Wagner Graduate School of Public Service, New York University, NY 10003, USA
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163
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Crews C, Batal H, Elasy T, Casper E, Mehler PS. Primary care for those with severe and persistent mental illness. West J Med 1998; 169:245-50. [PMID: 9795595 PMCID: PMC1305304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
Historically, the medical care of persons with severe and persistent mental illness (SPMI) has been suboptimal. In many communities, large gaps exist in the continuum of services necessary to meet the medical needs of those patients, and existing services are not well coordinated. The effect of the managed mental health care on patients with SPMI remains to be seen, but it does not bode well for patients who are already at risk for being undertreated. We initiated primary care clinics exclusively for patients with SPMI because of our belief that integrating primary care and mental health services offers the best hope of improving health care for those patients. Our experience to date is instructive for other health care systems.
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Affiliation(s)
- C Crews
- University of Colorado Health Sciences Center, Denver, USA
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164
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Becker T, Müller U. Relevance of brain imaging studies for social psychiatry. EPIDEMIOLOGIA E PSICHIATRIA SOCIALE 1998; 7:89-93. [PMID: 9763758 DOI: 10.1017/s1121189x00007211] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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165
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Evans MF. Strategy to prevent recurrent homelessness among the mentally ill. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 1998; 44:512-3. [PMID: 9559190 PMCID: PMC2277684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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166
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Abstract
Compares conceptualizations of homelessness as a temporary state through which people pass or a permanent trait that emanates from individual characteristics. Evidence from a longitudinal study of 564 homeless families in New York City and additional secondary sources supports the view that for families, homelessness is a temporary state that is resolved by the provision of subsidized housing. Even for single individuals with severe mental disturbances, housing is a key factor in ending homelessness, although here there is more evidence that social services also contribute. Policy implications are that governments should take a more active role in reducing homelessness by providing access to subsidized housing.
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Affiliation(s)
- M Shinn
- Department of Psychology, New York University, New York 10003, USA
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167
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Breakey WR. It's time for the public health community to declare war on homelessness. Am J Public Health 1997; 87:153-5. [PMID: 9103087 PMCID: PMC1380782 DOI: 10.2105/ajph.87.2.153] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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168
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Affiliation(s)
- A G Shaper
- Department of Primary Care and Population Sciences, Royal Free Hospital School of Medicine, London, UK
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169
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Thornicroft G. Annotation: the importance of transitional care in reducing homelessness. Am J Public Health 1997; 87:158-9. [PMID: 9103090 PMCID: PMC1380785 DOI: 10.2105/ajph.87.2.158] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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170
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Conover S, Berkman A, Gheith A, Jahiel R, Stanley D, Geller PA, Valencia E, Susser E. Methods for successful follow-up of elusive urban populations: an ethnographic approach with homeless men. BULLETIN OF THE NEW YORK ACADEMY OF MEDICINE 1997; 74:90-108. [PMID: 9211004 PMCID: PMC2359247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Public health is paying increasing attention to elusive urban populations such as the homeless, street drug users, and illegal immigrants. Yet, valid data on the health of these populations remain scarce; longitudinal research, in particular, has been hampered by poor follow-up rates. This paper reports on the follow-up methods used in two randomized clinical trials among one such population, namely, homeless men with mental illness. Each of the two trials achieved virtually complete follow-up over 18 months. The authors describe the ethnographic approach to follow-up used in these trials and elaborate its application to four components of the follow-up: training interviewers, tracking participants, administering the research office, and conducting assessments. The ethnographic follow-up method is adaptable to other studies and other settings, and may provide a replicable model for achieving high follow-up rates in urban epidemiologic studies.
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Affiliation(s)
- S Conover
- HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute, New York, USA
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