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Tucker K, Zikos D, Vick DJ. Association of Hospital Readmission Rates With Discharge Disposition for Patients With Psychotic Disorders. J Healthc Manag 2023; 68:198-214. [PMID: 37159018 DOI: 10.1097/jhm-d-22-00115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
GOAL We explored how readmissions may result from patients' lack of access to aftercare services, failure to adhere to psychotropic medication plans, and inability to understand and follow hospital discharge recommendations. We also investigated whether insurance status, demographics, and socioeconomic status are associated with hospital readmissions. This study is important because readmissions contribute to increased personal and hospital expenses and decreased community tenure (the ability to maintain stability between hospital admissions). Addressing hospital readmissions will promote optimal discharge practices beginning on day one of hospital admission. METHODS The study examined the differences in hospital readmission rates for patients with a primary psychotic disorder diagnosis. Discharge data were drawn in 2017 from the Nationwide Readmissions Database. Inclusion criteria included patients aged 0-89 years who were readmitted to a hospital between less than 24 hr and up to 30 days from discharge. Exclusion criteria were principal medical diagnoses, unplanned 30-day readmissions, and discharges against medical advice. The sampling frame included 269,906 weighted number of patients diagnosed with a psychotic disorder treated at one of 2,355 U.S. community hospitals. The sample size was 148,529 unweighted numbers of patients discharged. PRINCIPAL FINDINGS In a logistic regression model, weighted variables were calculated and used to determine an association between the discharge dispositions and readmissions. After controlling for hospital characteristics and patient demographics, we found that the odds for readmission for routine and short-term hospital discharge dispositions decreased for home health care discharges, which indicated that home health care can prevent readmissions. The finding was statistically significant when controlling for payer type and patient age and gender. PRACTICAL APPLICATIONS The findings support home health care as an effective option for patients with severe psychosis. Home health care reduces readmissions and is recommended, when appropriate, as an aftercare service following inpatient hospitalization and may enhance the quality of patient care. Improving healthcare quality involves optimizing, streamlining, and promoting standardized processes in discharge planning and direct transitions to aftercare services.
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Affiliation(s)
- Kariba Tucker
- School of Health Sciences, Central Michigan University, Mount Pleasant, Michigan
| | - Dimitrios Zikos
- School of Health Sciences and Herbert H. & Grace A. Dow College of Health Professions, Central Michigan University
| | - Dan J Vick
- School of Health Sciences and Herbert H. & Grace A. Dow College of Health Professions, Central Michigan University
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Effectiveness of More Personalized, Case-Managed, and Multicomponent Treatment for Patients with Severe Schizophrenia Compared to the Standard Treatment: A Ten-Year Follow-Up. J Pers Med 2022; 12:jpm12071101. [PMID: 35887598 PMCID: PMC9323927 DOI: 10.3390/jpm12071101] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 06/22/2022] [Accepted: 06/29/2022] [Indexed: 11/25/2022] Open
Abstract
Case management is a model of personalized intervention in people with severe mental illness. To explore the treatment adherence and effectiveness of patients with severe schizophrenia (Clinical Global Impression Severity, CGI-S ≥ 5) undergoing treatment in a community-based, case-managed program (CMP) with an integrated pharmacological and psychosocial approach compared with the standard treatment, an observational, ten-year follow-up study was conducted on patients treated in mental health units (MHUs) or a CMP (n = 688). Treatment discontinuation, hospitalizations, suicide attempts, and antipsychotic (AP) medications were recorded. Clinical severity was assessed with the CGI-S. Adherence to the CMP was higher than adherence to standard treatment (p < 0.001). There were fewer hospitalizations and suicide attempts in the CMP (p < 0.001). The clinical severity decreased more in the CMP (p < 0.005). Long-acting injectable (LAI) antipsychotic medication was more closely related to these outcomes than oral antipsychotics (APs) were (p < 0.001). Patients with severe schizophrenia in an integrated CMP recorded higher treatment compliance and better outcomes compared with standard care. Treatment with LAI APs was linked to these outcomes. A personalized combination of case management and LAI AP medication was more effective in these patients than standard treatment and oral APs.
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Heo J, Yoon NH, Shin S, Yu SY, Lee M. Effects of the Mental Health and Welfare Law revision on schizophrenia patients in Korea: an interrupted time series analysis. Int J Ment Health Syst 2021; 15:76. [PMID: 34649587 PMCID: PMC8515641 DOI: 10.1186/s13033-021-00499-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 09/07/2021] [Indexed: 11/17/2022] Open
Abstract
Background High rates of involuntary hospitalization and long lengths of stay have been problematic in Korea. To address these problems, the Mental Health and Welfare Law was revised in 2016, mainly to protect patient rights by managing involuntary admissions. The aim of this study was to evaluate the impact of the revised Mental Health and Welfare Law on deinstitutionalization by using routinely collected data from hospital admissions and continuity of mental health service use after hospital discharge as proxy measures of deinstitutionalization. Methods We used monthly-aggregated claims-based data with a principal or secondary diagnosis of schizophrenia from 2012 to 2019, collected by the National Health Insurance Service. Outcome variables included rates of first admission; discharges; re-admissions within 7, 30, and 90 days; outpatient visits after discharge within 7 and 30 days; and continuity of visits, at least once a month for 6 months after discharge. Using interrupted time series analysis, we estimated the change in levels and trends of the rates after revision, controlling for baseline level and trend. Results There was no significant change in first admission and discharge rates after the revision. Immediately after the revision, however, the rates of re-admission within 7 and 30 days dropped significantly, by 2.24% and 1.99%, respectively. The slopes of the re-admission rate decreased significantly, by 0.10% and 0.14%, respectively. The slopes of the re-admission rate within 90 days decreased (0.001%). The rates of outpatient visits within 7 and 30 days increased by 1.98% and 2.72%, respectively. The rate of continuous care showed an immediate 4.0% increase. Conclusions The revision had slight but significant effects on deinstitutionalization, especially decreasing short-term re-admission and increasing immediate outpatient service utilization.
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Affiliation(s)
- Jongho Heo
- National Assembly Futures Institute, National Assembly Member's Hall, 1, Uisadang-daero, Yeongdeungpo-gu, Seoul, 07233, Republic of Korea
| | - Nan-He Yoon
- Division of Social Welfare and Health Administration, Wonkwang University, 460 Iksandae-ro, Iksan, 54538, Republic of Korea
| | - Soyoun Shin
- Seoul National University College of Nursing Seoul, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Soo-Young Yu
- Department of Nursing Science, Jeonju University, 303, Cheonjam-ro, Wansan-gu, Jeonju, Jeollabuk-do, 55069, Republic of Korea
| | - Manwoo Lee
- National Assembly Research Service, 1, Uisadang-daero, Yeongdeungpo-gu, Seoul, 07233, Republic of Korea.
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Witt KG, Hetrick SE, Rajaram G, Hazell P, Taylor Salisbury TL, Townsend E, Hawton K. Psychosocial interventions for self-harm in adults. Cochrane Database Syst Rev 2021; 4:CD013668. [PMID: 33884617 PMCID: PMC8094743 DOI: 10.1002/14651858.cd013668.pub2] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Self-harm (SH; intentional self-poisoning or self-injury regardless of degree of suicidal intent or other types of motivation) is a growing problem in most counties, often repeated, and associated with suicide. There has been a substantial increase in both the number of trials and therapeutic approaches of psychosocial interventions for SH in adults. This review therefore updates a previous Cochrane Review (last published in 2016) on the role of psychosocial interventions in the treatment of SH in adults. OBJECTIVES To assess the effects of psychosocial interventions for self-harm (SH) compared to comparison types of care (e.g. treatment-as-usual, routine psychiatric care, enhanced usual care, active comparator) for adults (aged 18 years or older) who engage in SH. SEARCH METHODS We searched the Cochrane Common Mental Disorders Specialised Register, the Cochrane Library (Central Register of Controlled Trials [CENTRAL] and Cochrane Database of Systematic reviews [CDSR]), together with MEDLINE, Ovid Embase, and PsycINFO (to 4 July 2020). SELECTION CRITERIA We included all randomised controlled trials (RCTs) comparing interventions of specific psychosocial treatments versus treatment-as-usual (TAU), routine psychiatric care, enhanced usual care (EUC), active comparator, or a combination of these, in the treatment of adults with a recent (within six months of trial entry) episode of SH resulting in presentation to hospital or clinical services. The primary outcome was the occurrence of a repeated episode of SH over a maximum follow-up period of two years. Secondary outcomes included treatment adherence, depression, hopelessness, general functioning, social functioning, suicidal ideation, and suicide. DATA COLLECTION AND ANALYSIS We independently selected trials, extracted data, and appraised trial quality. For binary outcomes, we calculated odds ratio (ORs) and their 95% confidence intervals (CIs). For continuous outcomes, we calculated mean differences (MDs) or standardised mean differences (SMDs) and 95% CIs. The overall quality of evidence for the primary outcome (i.e. repetition of SH at post-intervention) was appraised for each intervention using the GRADE approach. MAIN RESULTS We included data from 76 trials with a total of 21,414 participants. Participants in these trials were predominately female (61.9%) with a mean age of 31.8 years (standard deviation [SD] 11.7 years). On the basis of data from four trials, individual cognitive behavioural therapy (CBT)-based psychotherapy may reduce repetition of SH as compared to TAU or another comparator by the end of the intervention (OR 0.35, 95% CI 0.12 to 1.02; N = 238; k = 4; GRADE: low certainty evidence), although there was imprecision in the effect estimate. At longer follow-up time points (e.g., 6- and 12-months) there was some evidence that individual CBT-based psychotherapy may reduce SH repetition. Whilst there may be a slightly lower rate of SH repetition for dialectical behaviour therapy (DBT) (66.0%) as compared to TAU or alternative psychotherapy (68.2%), the evidence remains uncertain as to whether DBT reduces absolute repetition of SH by the post-intervention assessment. On the basis of data from a single trial, mentalisation-based therapy (MBT) reduces repetition of SH and frequency of SH by the post-intervention assessment (OR 0.35, 95% CI 0.17 to 0.73; N = 134; k = 1; GRADE: high-certainty evidence). A group-based emotion-regulation psychotherapy may also reduce repetition of SH by the post-intervention assessment based on evidence from two trials by the same author group (OR 0.34, 95% CI 0.13 to 0.88; N = 83; k = 2; moderate-certainty evidence). There is probably little to no effect for different variants of DBT on absolute repetition of SH, including DBT group-based skills training, DBT individual skills training, or an experimental form of DBT in which participants were given significantly longer cognitive exposure to stressful events. The evidence remains uncertain as to whether provision of information and support, based on the Suicide Trends in At-Risk Territories (START) and the SUicide-PREvention Multisite Intervention Study on Suicidal behaviors (SUPRE-MISS) models, have any effect on repetition of SH by the post-intervention assessment. There was no evidence of a difference for psychodynamic psychotherapy, case management, general practitioner (GP) management, remote contact interventions, and other multimodal interventions, or a variety of brief emergency department-based interventions. AUTHORS' CONCLUSIONS Overall, there were significant methodological limitations across the trials included in this review. Given the moderate or very low quality of the available evidence, there is only uncertain evidence regarding a number of psychosocial interventions for adults who engage in SH. Psychosocial therapy based on CBT approaches may result in fewer individuals repeating SH at longer follow-up time points, although no such effect was found at the post-intervention assessment and the quality of evidence, according to the GRADE criteria, was low. Given findings in single trials, or trials by the same author group, both MBT and group-based emotion regulation therapy should be further developed and evaluated in adults. DBT may also lead to a reduction in frequency of SH. Other interventions were mostly evaluated in single trials of moderate to very low quality such that the evidence relating to the use of these interventions is inconclusive at present.
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Affiliation(s)
- Katrina G Witt
- Orygen, Parkville, Melbourne, Australia
- Centre for Youth Mental Health, The University of Melbourne, Melbourne, Australia
| | - Sarah E Hetrick
- Department of Psychological Medicine, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Gowri Rajaram
- Orygen, Parkville, Melbourne, Australia
- Centre for Youth Mental Health, The University of Melbourne, Melbourne, Australia
| | - Philip Hazell
- Speciality of Psychiatry, University of Sydney School of Medicine, Sydney, Australia
| | - Tatiana L Taylor Salisbury
- Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Ellen Townsend
- Self-Harm Research Group, School of Psychology, University of Nottingham, Nottingham, UK
| | - Keith Hawton
- Centre for Suicide Research, Department of Psychiatry, University of Oxford, Oxford, UK
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Witt KG, Hawton K, Hetrick SE, Taylor Salisbury TL, Townsend E, Hazell P. Psychosocial interventions for self-harm in adults. Hippokratia 2020. [DOI: 10.1002/14651858.cd013668] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Katrina G Witt
- Orygen; Parkville, Melbourne Australia
- Centre for Youth Mental Health; The University of Melbourne; Melbourne Australia
| | - Keith Hawton
- Centre for Suicide Research, Department of Psychiatry; University of Oxford; Oxford UK
| | - Sarah E Hetrick
- Department of Psychological Medicine; University of Auckland; Auckland New Zealand
| | - Tatiana L Taylor Salisbury
- Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience; King's College London; London UK
| | - Ellen Townsend
- Self-Harm Research Group, School of Psychology; University of Nottingham; Nottingham UK
| | - Philip Hazell
- Discipline of Psychiatry; The University of Sydney School of Medicine; Sydney Australia
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Abstract
During the last decades services to people with severe mental health problems have gone through important changes. Terms as de-, trans-, reinstitutionalisation and dehospitalisation has been used. The objective of the study was to collected data about the changes in a welfare society about the new institutional landscape after the mental hospital area. Data about interventions from social welfare agencies, psychiatric care, and prisons were collected from local and national register as well as data about cause of death and socio-economic status for 1355 persons treated with a diagnosis of psychosis in a Stockholm area 2004-2008. Psychiatric in-patient care and prisons are marginalized. Different interventions in open care touched a very large number of persons. Social welfare agencies play an increasing role in this context. The total institutions have been replaced by a network of micro-institutions sometimes offering help but also control.
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Smith-Merry J, Gillespie J, Hancock N, Yen I. Doing mental health care integration: a qualitative study of a new work role. Int J Ment Health Syst 2015; 9:32. [PMID: 26300963 PMCID: PMC4546146 DOI: 10.1186/s13033-015-0025-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Accepted: 08/12/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Mental health care in Australia is fragmented and inaccessible for people experiencing severe and complex mental ill-health. Partners in Recovery is a Federal Government funded scheme that was designed to improve coordination of care and needs for this group. Support Facilitators are the core service delivery component of this scheme and have been employed to work with clients to coordinate their care needs and, through doing so, bring the system closer together. OBJECTIVE To understand how Partners in Recovery Support Facilitators establish themselves as a new role in the mental health system, their experiences of the role, the challenges that they face and what has enabled their work. METHODS In-depth qualitative interviews were carried out with 15 Support Facilitators and team leaders working in Partners in Recovery in two regions in Western Sydney (representing approximately 35 % of those working in these roles in the regions). Analysis of the interview data focused on the work that the Support Facilitators do, how they conceptualise their role and enablers and barriers to their work. RESULTS The support facilitator role is dominated by efforts to seek out, establish and maintain connections of use in addressing their clients' needs. In doing this Support Facilitators use existing interagency forums and develop their own ad hoc groupings through which they can share knowledge and help each other. Support Facilitators also use these groups to educate the sector about Partners in Recovery, its utility and their own role. The diversity of support facilitator backgrounds are seen as both and asset and a barrier and they describe a process of striving to establish an internally collective identity as well as external role clarity and acceptance. At this early stage of PIR establishment, poor communication was identified as the key barrier to Support Facilitators' work. CONCLUSIONS We find that the Support Facilitators are building the role from within and using trial and error to develop their practice in coordination. We argue that a strong organisational hierarchy is necessary for support facilitation to be effective and to allow the role to develop effectively. We find that their progress is limited by overall program instability caused by changing government policy priorities.
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Affiliation(s)
- Jennifer Smith-Merry
- />Faculty of Health Sciences and Menzies Centre for Health Policy, University of Sydney, PO Box 170, Lidcombe, NSW 1825 Australia
| | - Jim Gillespie
- />School of Public Health and Menzies Centre for Health Policy, Edward Ford Building A27, The University of Sydney, Sydney, NSW 2006 Australia
| | - Nicola Hancock
- />Faculty of Health Sciences, University of Sydney, PO Box 170, Lidcombe, NSW 1825 Australia
| | - Ivy Yen
- />Faculty of Health Sciences and Menzies Centre for Health Policy, University of Sydney, PO Box 170, Lidcombe, NSW 1825 Australia
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Malakouti SK, Mirabzadeh A, Nojomi M, Ahmadi Tonkaboni A, Nadarkhani F, Mirzaie M, Chimeh N. Clinical outcomes and cost effectiveness of two aftercare models provided by general physicians and nurses to patients with severe mental illness. Med J Islam Repub Iran 2015; 29:196. [PMID: 26157714 PMCID: PMC4476229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2014] [Accepted: 12/07/2014] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Implementing community-based psychiatric services is one of the priorities of the WHO/EMRO mental health programs. This study presents an aftercare service, as a community based-service, for patients with severe mental illness (SMIs). METHODS In this randomized controlled clinical trial design, 176 patients, who attended selective hospitals with SMI, were allocated into three groups: clinical case managers provided by general practitioners, nurses and the control group (usual treatment). The clients and their caregivers received monthly home visits (education and treatment supervision). The effectiveness of the intervention was measured by indicators of psychopathology such as scores of YOUNG, caregivers' knowledge and satisfaction with the services. Health-related quality of life (SF-36) was considered as the primary outcome variable. Data were collected at baseline and at 12 months follow-up. Direct and indirect medical costs were obtained through a periodic completion of questionnaires and interviews by caregivers. Cost effectiveness ratio was estimated as cost per QALY gained in each group. SPSS 16.0 was used in this survey and statistical methods were chi-square, ANOVA, Scheffe as post-Hoc test and paired sample t-test with 95% confidence interval and 0.05 significance level. RESULTS The results of our study revealed that the score of YOUNG, caregivers' knowledge and satisfaction with service were improved in both intervention groups after 12 months. Improvement in health-related quality of life was observed in the general practitioner and nurse group. The incremental cost effectiveness ratio was 5740807 IRR and 5048459 IRR per QALYs gained in the general practitioner and nurse groups, respectively. CONCLUSION The model of aftercare services provided by trained nurses is the most cost- effective and feasible model for Iran's socio-economic conditions with low resource allocations.
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Affiliation(s)
- Seyed Kazem Malakouti
- MD, Associate Professor of Psychiatry, Mental Health Research Centre, Tehran Psychiatric Institute, Faculty of Behavioral Sciences and Mental Health, Iran University of Medical Sciences, Tehran, Iran.
| | - Arash Mirabzadeh
- Associate Professor of Psychiatry, Department of Psychiatry, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran.
| | - Marzieh Nojomi
- MD, MPH, Professor of Community Medicine, Department of Community Medicine; Mental Health Research Centre, Iran University of Medical Sciences, Tehran, Iran.
| | - Ali Ahmadi Tonkaboni
- Researcher, Mental Health Research Centre, Tehran Psychiatric Institute; Faculty of Behavioral Sciences and Mental Health, Iran University of Medical Sciences, Tehran, Iran.
| | - Faranak Nadarkhani
- MS, Researcher, Mental Health Research Centre, Tehran Psychiatric Institute, Faculty of Behavioral Sciences and Mental Health, Iran University of Medical Sciences; Tehran, Iran.
| | - Mosleh Mirzaie
- MS, Psychologist, Researcher, Mental Health Research Centre, Tehran Psychiatric Institute, Faculty of Behavioral Sciences and Mental Health, Iran University of Medical Sciences, Tehran, Iran.
| | - Narges Chimeh
- Assistant Professor of Psychiatry, Family Research Institute, Shahid Beheshti University, Tehran, Iran.
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Kerkemeyer L, Mostardt S, Biermann J, Wasem J, Neumann A, Walendzik A, Jahn R, Bartels C, Falkai P, Brannath W, Breunig-Lyriti V, Mester B, Timm J, Wobrock T. Evaluation of an integrated care program for schizophrenia: concept and study design. Eur Arch Psychiatry Clin Neurosci 2015; 265:155-62. [PMID: 24906973 DOI: 10.1007/s00406-014-0508-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2013] [Accepted: 05/24/2014] [Indexed: 10/25/2022]
Abstract
Concept and design of an independent scientific evaluation of different pathways of care for schizophrenia patients in Germany with respect to effectiveness and efficiency are presented. In this prospective, observational study, schizophrenia patients receiving an integrated care treatment, the intervention group (IG), are compared with patients under routine care conditions treated by the same physician (first control group, CG 1). A second control group (CG 2) of patients treated by office-based psychiatrists not participating in the integrated care program will be recruited and their data compared with the two other groups. The total amount of psychiatric hospital days after 12 months is defined as primary outcome parameter. Secondary outcome parameters comprise the frequency of psychiatric inpatient readmissions, severity of schizophrenia symptoms, remission rates and quality of life. Patients undergo assessments at baseline, month 6 and 12 using standardized and experimental questionnaires. Routine data of a regional German social health insurance fund complement information on included patients. Additionally, a cost-effectiveness and cost-utility analysis will be performed. Until now, 137 psychiatrists included 980 patients in the integrated care project in Lower Saxony, Germany, and 47 psychiatrists (IG and both CGs) are willing to participate in the independent evaluation. For the first time, a prospective observational controlled evaluation study of a countrywide integrated care project planning to recruit 500 schizophrenia patients has started using comprehensive assessments as well as routine data of a social health insurance fund.
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Affiliation(s)
- L Kerkemeyer
- Institute for Health Care Management and Research, University of Duisburg-Essen, Schützenbahn 70, 45127, Essen, Germany,
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Reilly S, Miranda‐Castillo C, Malouf R, Hoe J, Toot S, Challis D, Orrell M. Case management approaches to home support for people with dementia. Cochrane Database Syst Rev 2015; 1:CD008345. [PMID: 25560977 PMCID: PMC6823260 DOI: 10.1002/14651858.cd008345.pub2] [Citation(s) in RCA: 100] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Over 35 million people are estimated to be living with dementia in the world and the societal costs are very high. Case management is a widely used and strongly promoted complex intervention for organising and co-ordinating care at the level of the individual, with the aim of providing long-term care for people with dementia in the community as an alternative to early admission to a care home or hospital. OBJECTIVES To evaluate the effectiveness of case management approaches to home support for people with dementia, from the perspective of the different people involved (patients, carers, and staff) compared with other forms of treatment, including 'treatment as usual', standard community treatment and other non-case management interventions. SEARCH METHODS We searched the following databases up to 31 December 2013: ALOIS, the Specialised Register of the Cochrane Dementia and Cognitive Improvement Group,The Cochrane Library, MEDLINE, EMBASE, PsycINFO, CINAHL, LILACS, Web of Science (including Science Citation Index Expanded (SCI-EXPANDED) and Social Science Citation Index), Campbell Collaboration/SORO database and the Specialised Register of the Cochrane Effective Practice and Organisation of Care Group. We updated this search in March 2014 but results have not yet been incorporated. SELECTION CRITERIA We include randomised controlled trials (RCTs) of case management interventions for people with dementia living in the community and their carers. We screened interventions to ensure that they focused on planning and co-ordination of care. DATA COLLECTION AND ANALYSIS We used standard methodological procedures as required by The Cochrane Collaboration. Two review authors independently extracted data and made 'Risk of bias' assessments using Cochrane criteria. For continuous outcomes, we used the mean difference (MD) or standardised mean difference (SMD) between groups along with its confidence interval (95% CI). We applied a fixed- or random-effects model as appropriate. For binary or dichotomous data, we generated the corresponding odds ratio (OR) with 95% CI. We assessed heterogeneity by the I² statistic. MAIN RESULTS We include 13 RCTs involving 9615 participants with dementia in the review. Case management interventions in studies varied. We found low to moderate overall risk of bias; 69% of studies were at high risk for performance bias.The case management group were significantly less likely to be institutionalised (admissions to residential or nursing homes) at six months (OR 0.82, 95% CI 0.69 to 0.98, n = 5741, 6 RCTs, I² = 0%, P = 0.02) and at 18 months (OR 0.25, 95% CI 0.10 to 0.61, n = 363, 4 RCTs, I² = 0%, P = 0.003). However, the effects at 10 - 12 months (OR 0.95, 95% CI 0.83 to 1.08, n = 5990, 9 RCTs, I² = 48%, P = 0.39) and 24 months (OR 1.03, 95% CI 0.52 to 2.03, n = 201, 2 RCTs, I² = 0%, P = 0.94) were uncertain. There was evidence from one trial of a reduction in the number of days per month in a residential home or hospital unit in the case management group at six months (MD -5.80, 95% CI -7.93 to -3.67, n = 88, 1 RCT, P < 0.0001) and at 12 months (MD -7.70, 95% CI -9.38 to -6.02, n = 88, 1 RCT, P < 0.0001). One trial reported the length of time until participants were institutionalised at 12 months and the effects were uncertain (hazard ratio (HR): 0.66, 95% CI 0.38 to 1.14, P = 0.14). There was no difference in the number of people admitted to hospital at six (4 RCTs, 439 participants), 12 (5 RCTs, 585 participants) and 18 months (5 RCTs, 613 participants). For mortality at 4 - 6, 12, 18 - 24 and 36 months, and for participants' or carers' quality of life at 4, 6, 12 and 18 months, there were no significant effects. There was some evidence of benefits in carer burden at six months (SMD -0.07, 95% CI -0.12 to -0.01, n = 4601, 4 RCTs, I² = 26%, P = 0.03) but the effects at 12 or 18 months were uncertain. Additionally, some evidence indicated case management was more effective at reducing behaviour disturbance at 18 months (SMD -0.35, 95% CI -0.63 to -0.07, n = 206, 2 RCTs I² = 0%, P = 0.01) but effects were uncertain at four (2 RCTs), six (4 RCTs) or 12 months (5 RCTs).The case management group showed a small significant improvement in carer depression at 18 months (SMD -0.08, 95% CI -0.16 to -0.01, n = 2888, 3 RCTs, I² = 0%, P = 0.03). Conversely, the case management group showed greater improvement in carer well-being in a single study at six months (MD -2.20 CI CI -4.14 to -0.26, n = 65, 1 RCT, P = 0.03) but the effects were uncertain at 12 or 18 months. There was some evidence that case management reduced the total cost of services at 12 months (SMD -0.07, 95% CI -0.12 to -0.02, n = 5276, 2 RCTs, P = 0.01) and incurred lower dollar expenditure for the total three years (MD= -705.00, 95% CI -1170.31 to -239.69, n = 5170, 1 RCT, P = 0.003). Data on a number of outcomes consistently indicated that the intervention group received significantly more community services. AUTHORS' CONCLUSIONS There is some evidence that case management is beneficial at improving some outcomes at certain time points, both in the person with dementia and in their carer. However, there was considerable heterogeneity between the interventions, outcomes measured and time points across the 13 included RCTs. There was some evidence from good-quality studies to suggest that admissions to care homes and overall healthcare costs are reduced in the medium term; however, the results at longer points of follow-up were uncertain. There was not enough evidence to clearly assess whether case management could delay institutionalisation in care homes. There were uncertain results in patient depression, functional abilities and cognition. Further work should be undertaken to investigate what components of case management are associated with improvement in outcomes. Increased consistency in measures of outcome would support future meta-analysis.
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Affiliation(s)
- Siobhan Reilly
- Faculty of Health and Medicine, Lancaster UniversityDivision of Health ResearchC07 Furness BuildingLancasterUKLA1 4YG
| | - Claudia Miranda‐Castillo
- Universidad de ValparaísoEscuela de Psicología, Facultad de MedicinaAv Brasil 2140ValparaísoChile
| | - Reem Malouf
- University of OxfordNational Perinatal Epidemiology Unit (NPEU)Old Road CampusOxfordUKOX3 7LF
| | - Juanita Hoe
- University College LondonMental Health Sciences UnitCharles Bell House67‐73 Riding House StreetLondonUKW1W 7EJ
| | - Sandeep Toot
- North East London NHS Foundation Trust, Goodmayes HospitalResearch and Development DepartmentBarley Lane, GoodmayesEssexLondonUKIG3 8XJ
| | - David Challis
- University of ManchesterPersonal Social Services Research UnitDover Street BuildingOxford RoadManchesterUKM13 9PL
| | - Martin Orrell
- University College LondonMental Health Sciences UnitCharles Bell House67‐73 Riding House StreetLondonUKW1W 7EJ
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Meijboom B, Van den Bosch L, Schalk R. Refining case management for dementia using insights from operations management. QUALITY IN AGEING AND OLDER ADULTS 2014. [DOI: 10.1108/qaoa-04-2014-0005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Purpose– Providers of healthcare services face increasing performance demands in terms of cost-efficiency as well as client centeredness. Dementia care is an illustrative example in this respect. Due to the aging society, the number of dementia clients is expected to grow significantly, which implies increasing costs. At the same time, demands in terms of coherent and high-quality care for dementia clients are increasing, putting a stronger emphasis on demand driven, responsive care and service processes. Literature shows that case management in dementia care is beneficial for persons with dementia and caregivers, but costly. Using insights from operations management (OM), the purpose of this paper is to develop a new model for case management in dementia care.Design/methodology/approach– To address both cost containment and customer orientation, insights from OM, in particular front/back office (FO/BO) configuration and modularity theory, are used to develop an innovative conceptual model for case management in dementia care.Findings– This framework offers a new way of conceptualizing care provision throughout the different phases of a chronic disease process. Linking FO/BO configurations and modular organizing with case management makes it possible to create a cost-effective and client-centered system of healthcare management.Originality/value– A new model is developed to address both cost containment and customer orientation based on insights from OM, in particular FO/BO configuration and modularity theory.
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Babalola O, Gormez V, Alwan NA, Johnstone P, Sampson S. Length of hospitalisation for people with severe mental illness. Cochrane Database Syst Rev 2014:CD000384. [PMID: 24477710 PMCID: PMC10105316 DOI: 10.1002/14651858.cd000384.pub3] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND In high-income countries, over the last three decades, the length of hospital stays for people with serious mental illness has reduced drastically although considerable variation remains. In lower-income countries this variation may be greater. Some argue that reduction in hospital stay leads to 'revolving door admissions' and worsening mental health outcomes despite apparent cost savings, whilst others suggest longer stays may be more harmful by institutionalising people to hospital care. OBJECTIVES To evaluate the effect of short stay/brief admission hospital care with long stay/standard in-patient care in people with serious mental illness. SEARCH METHODS We searched the Cochrane Schizophrenia Group's register of trials, July 2007 and updated this search in May 2012. SELECTION CRITERIA We included all randomised controlled trials comparing planned short/brief with long/standard hospital stays for people with serious mental illnesses. DATA COLLECTION AND ANALYSIS We extracted data independently. For dichotomous data we calculated risk ratios (RR) and their 95% confidence intervals (CI) on an intention-to-treat basis based using a fixed-effect model. For continuous data, had we identified such data, we planned to calculate fixed-effect mean differences (MD). We assessed risk of bias for included studies and rated quality of evidence using GRADE. MAIN RESULTS We included six relevant trials undertaken between 1969 and 1980. We found no significant difference in death (n = 175, 1 RCT, RR in the longer term 0.42, CI 0.10 to 1.83, very low quality evidence). In the long term, there was no difference in improvement of mental state (n = 61, 1 RCT, RR 3.39, CI 0.76 to 15.02, very low quality evidence). There was no difference in readmission to hospital (n = 651, 4 RCTs, RR by the long term 1.26, CI 1.00 to 1.57, low quality evidence). Data for leaving the study prematurely by the longer term showed no difference (n = 229, 2 RCTs, (RR 0.77, CI 0.34 to 1.77, low quality evidence). There was a significant difference favouring short stay (P = 0.01) in numbers of participants with delayed discharge from hospital exceeding the time planned in study (n = 404, 3 RCTs, RR in the longer term 0.54, CI 0.33 to 0.88, low quality evidence). There was no difference in numbers of participants lost to follow-up (n = 404, 3 RCTs, RR by the longer term 1.07, CI 0.70 to 1.62, low quality evidence). Finally, there was a significant difference favouring short-stay hospitalisation for social functioning, including unemployment, unable to housekeep, or unknown employment status (n = 330, 2 RCTs, RR by longer term 0.61, CI 0.50 to 0.76, very low quality evidence). AUTHORS' CONCLUSIONS The effects of hospital care and the length of stay is important for mental health policy. We found limited low and very low quality data which were all over 30 years old. Outcomes from these studies do suggest that a planned short-stay policy does not encourage a 'revolving door' pattern of admission and disjointed care for people with serious mental illness. More large, well-designed and reported trials are justified especially where a short-stay policy is not routine care.
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Effectiveness of a low-intensity home-based aftercare for patients with severe mental disorders: a 12-month randomized controlled study. Community Ment Health J 2012; 48:766-70. [PMID: 22772746 DOI: 10.1007/s10597-012-9516-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2011] [Accepted: 06/27/2012] [Indexed: 10/28/2022]
Abstract
To examine the effectiveness of a low-intensity home-based aftercare service, 130 patients with schizophrenia, schizoaffective disorder or bipolar disorder were randomized to receive either home aftercare or treatment-as-usual. In home aftercare, a general practitioner and a social worker made home visits once in a month after discharge from the hospital wherein they provided education and treatment. In a 1-year follow-up, home aftercare led to greater reduction in rehospitalization rate, more improvement in psychotic symptoms and global illness severity, as well as greater service satisfaction. The implementation of this low-intensity aftercare is recommended, especially in less resourceful settings.
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Möller HJ. How close is evidence to truth in evidence-based treatment of mental disorders? Eur Arch Psychiatry Clin Neurosci 2012; 262:277-89. [PMID: 22105603 DOI: 10.1007/s00406-011-0273-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2011] [Accepted: 10/28/2011] [Indexed: 11/27/2022]
Abstract
Given the importance of the term 'evidence' in evidence-based medicine (EBM), the meaning of this term is evaluated, going back to the philosophical tradition and current meaning of the terms 'evidence' and 'truth'. Based on this, current problems in the definition of evidence and in the grading of evidence in EBM are described, taking examples from the field of psychiatry and especially pharmacopsychiatry. These problems underline that the use of the term evidence in EBM is inconsistent and inconclusive. This should be fairly stated in all EBM-related publications, especially in EBM-based guidelines, to avoid severe misunderstandings in and outside the field of psychiatry. Although EBM might have increased empirically driven rational decision-making in psychiatry/medicine, the current limitations should be carefully considered.
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Affiliation(s)
- Hans-Jürgen Möller
- Department of Psychiatry, Ludwig-Maximilian University Munich, Munich, Germany.
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Weinmann S, Gaebel W. [Care requirements for severe mental disorders. Scientific evidence for integration of clinical psychiatry and community psychiatry]. DER NERVENARZT 2005; 76:809-10, 812-6, 819-21. [PMID: 15580465 DOI: 10.1007/s00115-004-1851-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
In Germany it is not clear which forms of community mental health care should be encouraged to meet the needs particularly of the severely mentally ill. We performed a literature review of systematic meta-analyses and controlled trials and show that a set of well-evaluated and effective psychiatric care systems is available, of which only a few are being implemented in Germany. It becomes obvious that in Germany organizational requirements for an integration of psychiatric services are not being adequately met, particularly in the case of schizophrenia. Team-based assertive community treatment, crisis intervention teams, community mental health teams, and modern job rehabilitation programs, which have been established primarily in English-speaking countries, could not be effectively adapted for German psychiatric care. At the same time many psychiatric care models have been poorly evaluated. Given the available scientific evidence we comment on future requisites and further developments in German psychiatry to meet the growing need of care for people with severe mental illnesses.
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Affiliation(s)
- S Weinmann
- Rheinische Kliniken Düsseldorf, Klinik und Poliklinik für Psychiatrie und Psychotherapie der Heinrich-Heine-Universität Düsseldorf.
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Ravelli DP, Buwalda VJA, Slooff CJAJ, Schrijvers AJP, van Engeland H. Do integrated mental healthcare organisations facilitate process quality in the treatment of people with schizophrenia and related psychoses? Int J Integr Care 2003; 3:e17. [PMID: 16896377 PMCID: PMC1483946 DOI: 10.5334/ijic.74] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2002] [Revised: 01/05/2003] [Accepted: 01/30/2003] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE The objective of this study is to investigate the influence of mergers of ambulatory and mental healthcare organisations on the process quality of care for persons suffering from schizophrenia or related psychoses. THEORY On the basis of the theory of Donabedian we assume the relationships between three types of quality in healthcare: structure quality, process quality and outcome quality. This study focuses on the influences of structure quality, i.e. years since merger and catchment area size upon process quality. METHODS Criteria according to Tugwell for evaluating healthcare were used to describe the process quality of schizophrenia care, resulting in a process quality questionnaire with 6 subscales and 21 items. Leading psychiatrists of 31 Dutch mental healthcare organisations, covering 89% of the country, answered the questionnaire. Both programmes and documents from the responding institutions and schizophrenia projects were analysed. Correlations of two determinants, age of the merged organisation and catchment area size, were made with total scale scores and the sub scores of the questionnaire. RESULTS The response rate was 97% (31/32). Twenty-two organisations (71%) had a score of more than 50% on the used scale, 8 (29%) scored less. Two evidence-based interventions were implemented in more than 50% of the organisations, three in less than 50%. A low degree of implementation occurs in establishing care for people with schizophrenia from ethnic minorities, standardising diagnostic procedures and continuity of care. No significant relationship between the age of the merged organisation ('age') and the total process quality of schizophrenia care was found, however, the relationships between age and the subscales availability of interventions and integrated treatment were significant. No association was found between the size of the MHO's catchment area and any of the used subscales. CONCLUSIONS The age of integration of residential and ambulatory mental health institutions correlates significantly with two subscales of process quality of schizophrenia care, i.e. availability of interventions and treatment. Catchment area size is not significantly associated with process quality or any of the subscales. Despite the mentioned positive effects, the overall picture of schizophrenia care is not very positive. Additional forces other than merely integration of ambulatory and residential services are needed for the further implementation of evidence-based interventions, diagnostic standards and continuity of care. The development of a national 'schizophrenia standard' (like in other countries) in relation with implementation plans and strategies to evaluate care on a regional level is recommended as well as further research on patient outcomes in relation to mergers of mental healthcare organisations.
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Affiliation(s)
- D P Ravelli
- General Psychiatric Hospital Robert Fleury, Leidschendam, The Netherlands.
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Dekker J, Wijdenes W, Koning YA, Gardien R, Hermandes-Willenborg L, Nusselder H. Assertive community treatment in Amsterdam. Community Ment Health J 2002; 38:425-34. [PMID: 12236412 DOI: 10.1023/a:1019816613834] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
In Amsterdam in the Netherlands, in 1993, an intensive case management project was initiated. This article describes this well-known Dutch project as it was tested in a randomised clinical trial using regular outpatient and inpatient care as the control conditions. All the patients in this project are very ill and most of them suffer from schizophrenia. The new form of care has the same effect on everyday problems as regular care. The basis of this data is too narrow for the drawing of conclusions about the risk of suicide. Longer follow-up would be advisable in order to improve our understanding of this problem. There has been no drop in compulsory admissions. On the other hand, there has been a spectacular decrease in the number of bed days (a reduction of 66% in the second year of the ACT programme).
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Affiliation(s)
- J Dekker
- Mentrum, Mental Health Organisation Amsterdam
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