The closing of Central State Hospital: long-term outcomes for persons with severe mental illness

An Innovative Approach to the Dismantlement of a Forensic Psychiatric Hospital in Italy: A Ten-year Impact Evaluation

Aims

This study aimed to evaluate the impacts of a pilot project concerning the closure of a Forensic Psychiatric Hospital (FPH) inspired by Human Development Theory and the Capability Approach.

Background

The dismantlement of the FPH of Barcellona Pozzo di Gotto (Sicily Region in Italy) began in 2010 with the pilot project Luce é Libertà and ended in 2017. With the closure of six FPHs, Italy officially became the first country worldwide to close such institutions. After the closure of FPHs, some critical issues emerged, and the debate shifted to developing small-scale facilities and residences for the execution of security measures (RESM). However, few studies have provided results on the cohort of patients discharged from FPHs.

Objective

Following are the objectives of this study: a) Assessing the effectiveness of the pilot project in terms of better functioning accordingly to the Classification of Functioning of Disability and Health (ICF) framework, social and labour insertion, health conditions, level of dangerousness to other, rate of readmission in forensic services, b) cost analysis, and c) describing how the CA has been applied and translated into methodological and administrative devices and concrete intervention strategies.

Methods

A pre-post evaluation design was performed with a comparison between the intervention and the control group for the healthcare cost analysis. Data were collected from 2010 to 2019 at three points: T0) as a baseline, T1 and T2) for the follow-up. The instruments are a structured questionnaire, the Scale HoNOS Secure, 4 sub-scales of ICF (Activity and participation dimensions: sociality, culture, and knowledge, daily life, income, and work) (Cronbach's Alpha from 0.76 to 0.94), and n.20 interviews with key stakeholders and beneficiaries.

Results

Main results include a) the discharge of 55 patients through the use of a person-centered approach and the Personal Capability Budget (PCB), b) the expansion of substantial freedom of choice and the improvement of ICF score (t-test Sig. <, 02), c) the reduction of the risk for others and themselves (Mean Diff. -2,15 Sig. .000), d) at T2 42% of beneficiaries achieved a job placement and 36% were living in one's own home, e) at T2 the need of security measures has reduced from the initial 70% to 6.8%, and f) reduction of the healthcare costs from the fourth year onwards.

Conclusion

Indications emerge to support processes of deinstitutionalisation and capabilities expansion through innovative models, a person-centered approach supported by PCBs, social finance, and social impact investments.

Core services of intensive case management for people with mental illness: A network analysis

BACKGROUND

In intensive case management (ICM), users receive a wide variety of services of varying content, which makes it difficult to understand the global features of ICM programs.

AIMS

The aim of this study was to examine the features of ICM programs using network analysis.

METHODS

A total of 233 ICM users in two Japanese medical institutions were recruited to participate. All received services were recorded for 2 months. In the network analysis, nodes represented types of ICM services and edges between two nodes depicted when over 5% of participants received both types of services.

RESULTS

We found high centrality values for 'H5. Hospital-based counseling', 'O13. Outreach support for mental health medications', 'H13. Hospital-based support for mental health medication', 'T5. Counseling via telecommunication', 'H3. Hospital-based coordination of services in the medical institution' and 'T2. Coordination of services with other institutions via telecommunication'. These results indicated that these services were associated with various other types of services. Social functioning was related to 'O13. Outreach support for mental health medication', whereas need for ICM was related to 'H13. Hospital-based support for mental health medications', 'T5. Counseling via telecommunication' and 'T2. Coordination of services with other institutions via telecommunication'.

CONCLUSION

Based on these findings, we speculated that there are at least five types of core services in ICM: regular face-to-face contact, outreach services, hospital-based services, easy contacts and coordination. These findings clarified the features of ICM programs, which may help improve the understanding of case managers' practice.

Long-term hospitalizations for schizophrenia in the Czech Republic 1998-2012

Deinstitutionalization has not been pursued in the post-communist Europe until recently. The population of psychiatric patients institutionalized in the regional mental hospitals is, however, largely understudied. The aim of this study is to assess discharges of long-term inpatients with schizophrenia from Czech psychiatric hospitals and to analyse re-hospitalizations within this group. The nationwide register of all-cause inpatient hospitalizations was merged with the nationwide register of all-cause deaths on an individual level basis. Descriptive statistics, survival analysis and logistic regression were performed. 3601 patients with schizophrenia previously hospitalized for more than a year were discharged from Czech mental hospitals between 1998 and 2012. This included 260 patients hospitalized for >20years. Nearly one fifth (n=707) of the long-term patients died during the hospitalization; and discharges of 19.36% (n=697) were only administrative in their nature. Out of 2197 truly discharged patients, 14.88% (n=327) were re-hospitalized within 2weeks after the discharge. The highest odds of rehospitalization were associated with being discharged against medical advice (OR 5.27, CI: 3.77-7.35, p<0.001). These data are important for the ongoing mental health care reforms in the Czech Republic and other countries in the Central and Eastern Europe.

Deinstitutionalised patients, homelessness and imprisonment: systematic review

BACKGROUND

Reports linking the deinstitutionalisation of psychiatric care with homelessness and imprisonment have been published widely.

AIMS

To identify cohort studies that followed up or traced back long-term psychiatric hospital residents who had been discharged as a consequence of deinstitutionalisation.

METHOD

A broad search strategy was used and 9435 titles and abstracts were screened, 416 full articles reviewed and 171 articles from cohort studies of deinstitutionalised patients were examined in detail.

RESULTS

Twenty-three studies of unique populations assessed homelessness and imprisonment among patients discharged from long-term care. Homelessness and imprisonment occurred sporadically; in the majority of studies no single case of homelessness or imprisonment was reported.

CONCLUSIONS

Our results contradict the findings of ecological studies which indicated a strong correlation between the decreasing number of psychiatric beds and an increasing number of people with mental health problems who were homeless or in prison.

Redevelopment of tertiary psychiatric services in British Columbia: a prospective study of clinical, social, and residential outcomes of former long-stay inpatients

OBJECTIVE

The objective of this study is to assess the clinical and social outcomes for a cohort of patients who were part of the redevelopment of psychiatric services in British Columbia.

METHOD

This study used a naturalistic, quasi-experimental design, to examine the outcomes of a cohort of 189 long-stay patients at Riverview Hospital (RVH), some of whom moved into Tertiary Psychiatric Residential Facilities (TPRFs), some into the community in less structured facilities, and some remained at RVH. Data was collected from clinical files at RVH and at each participating site, semi-structured interviews and self-report measures were completed with patients. In addition, semi-structured interviews were also conducted with staff members.

RESULTS

There was very minimal evidence of transinstitutionalization to prisons or homelessness; one participant resided in a correctional facility, one resided in a forensic facility, and one participant spent some time homeless. In addition, the majority of participants remained in residences that provided 24h care. Eighty percent of our population was diagnosed with a schizophrenia spectrum disorder. Psychiatric symptoms remained fairly stable; some embarrassing social behaviors increased; however, aggressive behaviors showed no increase; neuropsychological deficits did not deteriorate, there were even some improvements. Participants demonstrated increases in several independent living skills including: money management, food preparation and storage, job skills, and transportation skills. In addition, participants experienced a significant increase in their perceived quality of life.

CONCLUSIONS

This study builds on existing research demonstrating that well-planned and appropriately resourced hospital closures can lead to positive psycho-social outcomes for participants and can successfully avoid negative outcomes such as transinstitutionalization to the judiciary system and homelessness.

Does transinstitutionalization explain the overrepresentation of people with serious mental illnesses in the criminal justice system?

Although there is broad consensus that people with serious mental illnesses (SMI) are overrepresented in correctional settings, there is less agreement about the policy trends that may have created this situation. Some researchers and policymakers posit a direct link between deinstitutionalization and increased rates of SMI in jails and prisons, a phenomenon described as transinstitutionalization. Others offer evidence that challenges this hypothesis and suggest that it may be a reductionist explanation. This paper reviews claims from both sides of the debate, and concludes that merely increasing access to state psychiatric hospital beds would likely not reduce the number of people with SMI in jails and prisons. A more nuanced approach is recommended for explaining why people with SMI become involved in the criminal justice system and why developing effective strategies to divert them out of jails and prisons and into community-based treatment is needed to improve both their mental health and criminal justice outcomes.

Does deinstitutionalization increase suicide?

OBJECTIVES

(1) To test whether public psychiatric bed reduction may increase suicide rates; (2) to investigate whether the supply of private hospital psychiatric beds-separately for not-for-profit and for-profit-can substitute for public bed reduction without increasing suicides; and (3) to examine whether the level of community mental health resources moderates the relationship between public bed reduction and suicide rates.

METHODS

We examined state-level variation in suicide rates in relation to psychiatric beds and community mental health spending in the United States for the years 1982-1998. We categorize psychiatric beds separately for public, not-for-profit, and for-profit hospitals.

PRINCIPAL FINDINGS

Reduced public psychiatric bed supply was found to increase suicide rates. We found no evidence that not-for-profit or for-profit bed supply compensates for public bed reductions. However, greater community mental health spending buffers the adverse effect of public bed reductions on suicide. We estimate that in 2008, an additional decline in public psychiatric hospital beds would raise suicide rates for almost all states.

CONCLUSIONS

Downsizing of public inpatient mental health services may increase suicide rates. Nevertheless, an increase in community mental health funding may be promising.

Impact of a rehabilitation legislation on the survival in the community of long-term patients discharged from psychiatric hospitals in Israel

BACKGROUND

The aim of the present study was to examine the impact of the Rehabilitation Law 2000 in Israel (which provides a basket of rehabilitation services for every mentally disabled patient) on the survival in the community of a population of long-stay psychiatric patients released from psychiatric hospitals.

METHODS

A naturalistic follow-up study was performed on long-stay patients discharged ("key discharge") from two Israel psychiatric hospitals closed before (in 1997) and after (in 2000) introduction of the Rehabilitation Law 2000. The data source was the National Psychiatric Hospitalization Registry.

RESULTS

The study population consisted of 611 patients. The percentage of patients who, at closure of hospital, were discharged directly into the community was eightfold higher following the Rehabilitation Law 2000 than before. There was also a trend for a lower readmission rate for those patients who were discharged into the community in the post-law period, both for those whose key discharge was directly to the community and for those who were later discharged after being transferred to another hospital at key discharge. Concerning the mean duration of inpatient stay, there was no difference between the two cohorts, whether hospitalizations followed transfer to another hospital from key discharge or rehospitalization from the community. Interestingly, the Rehabilitation Law did not have a significant effect on patients' mortality after key discharge.

CONCLUSION

The Rehabilitation Law 2000 has a beneficial effect on the opportunities of long-stay psychiatric patients to resettle in the community without increasing risk of death.

A comparison of agency-based and self-report methods of measuring services across an urban environment by a drug-abusing homeless population

The purpose of this paper is to advance the methodology for studying service assessment by comparing self-report and agency-generated methods. This study compares 30-day self-reported service use for homeless individuals (N = 229) randomly recruited from a single urban environment (St Louis, Missouri) with similar data collected from a broad array of service agencies providing homeless, substance abuse and outpatient mental health services across the same environment. Comparisons were made between self-report and agency-based data on shelter use, outpatient mental health service use (case management, psychiatric treatment, group therapy), outpatient substance abuse service use (case management, counselling, group therapy) and drop-in/day treatment use. Consistently low levels of kappa scores (all under 0.4) and correlation coefficients (only shelter use demonstrated significant agreement) were found. Findings demonstrated that the two methods of collecting service data are generally not concordant at the individual level. Certain demographic characteristics (increased age, being male, non-white ethnicity) and diagnoses (cocaine abuse/dependence, mania, schizophrenia) were associated with decreased reliability between the two methods of data collection. The two methods of assessment appeared to capture overlapping but not identical information. Each method of assessment has different utility to researchers and providers wishing to assess service use.

Sexual networks and HIV risk of people with severe mental illness in institutional and community-based care

This study examines the sexual networks and HIV risk of clients with severe mental illness in treatment in institutional and community care settings. Data were gathered through structured interviews with 401 clients at three community mental health centers and two state psychiatric hospitals. Results indicate that community clients are more likely than hospital patients to be currently sexually active and to engage in high-risk sexual behavior whereas hospitalized patients tend to have more transient sexual relationships with partners who also have a mental illness. These findings suggest that mental health treatment settings may be shaping the HIV epidemic among psychiatric patients because of the impact they have on the structure of clients' sexual networks.

Closing of a state hospital: an overview and framework for a case study

This article introduces the trends in deinstitutionalization, the limitations of previous research, and the design and research questions of the Central State Hospital (CSH) closing studies. Previously, the central engine of deinstitutionalization has been the downsizing, and not the closing, of facilities to decrease available beds. Only 14 state hospitals closed between 1970 and 1990. However, since 1990, 40 hospitals have closed. Moreover, beginning in 1993, for the first time since deinstitutionalization began, funding for state psychiatric facilities was less than for community-based services. Previous research on both the downsizing and closing of hospitals has focused predominantly on relatively short-term clinical and social outcomes of patients. The current study is a multidisciplinary, longitudinal, multiple-stakeholder study of the closing of a state-run, long-term care facility in Indiana. The articles that follow focus on the clinical, psychological, social, and attitudinal outcomes for patients, workers, families, and the public following the closing of CSH.

The family experience of deinstitutionalization: insights from the closing of Central State Hospital

Since the early 1970s, policy makers and researchers have expressed concern about the potential negative consequences of deinstitutionalization on families. This article summarizes results of a survey of family and lay caregivers of patients discharged from Central State Hospital, which closed in June 1994. The survey was designed to assess the impact of the closing on family members, including their attitudes, caregiving responsibilities, and involvement in the treatment of the patients. Results indicate that family members have mixed feelings about the closure. Family caregivers also reported that they have not been asked to take on significant amounts of the caregiving responsibilities since the clients were moved from the hospital. Family members described a significant reduction in the frequency of contact they had with their loved ones and with professional caregivers since the closure. Implications for behavioral health policy makers considering or planning closing or downsizing long-term care facilities are discussed.

"Stakeholder" attitudes over time toward the closing of a state hospital

For four groups--patients (N = 80), their families or lay caregivers (N = 120), hospital workers (N = 124), and the public (N = 108)--attitudes toward the decision to close the only long-term, urban state hospital are traced over time. Initially, patients were most supportive of the closing decision (65.4%), followed by family members (39.8%), the general public (27.8%), and workers (10.4%). A majority of all groups favored fixing the hospital. Almost half of the clients and more than half of other stakeholders expressed concerns about homelessness. Most attitudes were consistent despite respondents' sociodemographic characteristics. The overall profile of group attitudes remained remarkably stable, although there was a good deal of change in individuals' positions. Public support for fixing the hospital decreased significantly, and differences among stakeholders regarding homelessness disappeared. These findings reinforce the importance of ascertaining different constituencies' positions and recognizing the slowly changing response of stakeholders even under massive and successful policy change.

Fiscal outcomes of the closing of Central State Hospital: an analysis of the costs to state government

This study reports estimates of the preclosure and postclosure costs of mental health services for patients directly affected by the closing of Central State Hospital. The data come from state budget documents and from the billing records of the community mental health centers serving the discharged clients. On average, it cost Indiana approximately $68,347 (in 1995 dollars) to provide 12 months of state hospital care for this client cohort in fiscal year 1993. In contrast, during the first year following the closure, the average per patient cost to the state was $55,417. When clients were served exclusively in community care settings, the average annual per patient cost was $40,618. The analyses suggest that the closing reduced the costs of caring for this cohort of patients by approximately 18.9%. A significant portion of the cost savings to the state mental health budget was achieved by shifting some of the direct patient care costs to Medicaid/Medicare.