In-patient rehabilitation: clinical outcomes and cost implications

Three-year-cohort-study: clinical and cost effectiveness of an inpatient psychiatric rehabilitation

Introduction

There has been a resurgence of interest in psychiatric rehabilitation to cater to patients with chronic and complex mental illnesses.

Aims

This study is aimed at examining patients' characteristics and the prevalence of psychiatric and non-psychiatric comorbidity in a local inpatient rehabilitation service, as well as to investigate the impact of the whole-system approach to rehabilitation on future utilization of mental health services and to analyze the cost-effectiveness and quality of this service.

Method

Patients managed over 3 years in a psychiatric rehabilitation inpatient unit were self-controlled; they were retrospectively (pre-rehabilitation) and prospectively (post-rehabilitation) examined for readmission rate, length of stay (LOS), and emergency room (ER) visits. Relevant information was retrieved from Discharge Abstract Database (DAD), Patient Registration System (STAR), and Emergency Department Information System (EDIS). The quality of care in the rehabilitation unit was examined using the Quality Indicator for Rehabilitative Care (QuIRC), and the cost analysis was conducted using data obtained from a single-payer government medical service insurance (MSI) billing system.

Results

Of the 185 patients admitted over the study period, 158 were discharged. There was a significant reduction in readmission rate (64% decrease), LOS (6,585 fewer days spent in hospital), and ER presentations (166 fewer visits) (P < 0.0001), respectively. There were substantial subsequent cost savings in the post-rehabilitation year.

Conclusion and implications for practice

In the 3-year study, an inpatient psychiatric rehabilitation service in Nova Scotia, Canada, resulted in the successful discharge of most patients with severe and persistent mental illness to more socially inclusive environments. It also reduced their post-rehabilitation mental health service utilization, hence greatly enhancing the effectiveness and efficiency of these services.

Proprietary Model of Qualification for In-Hospital Rehabilitation after COVID-19

BACKGROUND

Since the beginning of the SARS-CoV-2 epidemic in Poland, 6,128,006 people have been diagnosed, of which 116,798 died. Patients who recovered from COVID-19 and require rehabilitation due to varied impairments should be provided an opportunity to participate in an individualized, complex rehabilitation program starting from acute care and being continued in the post-acute and long-term rehabilitation phase. It is recommended to offer out-patient and in-hospital rehabilitation procedures depending on the type and persistence of symptoms and dysfunctions. The aim of this paper is to present the qualification process of post-COVID19 patients for an in-hospital complex rehabilitation program developed on the basis of pulmonary physical therapy.

METHODS

The presented qualification program was developed on the basis of clinical experience of over 2000 patients participating in the pilot program of in-hospital rehabilitation launched in September 2020 and based on the Regulation of the Polish Minister of Health of 13 July 2020.

RESULTS

The proposed model of patients' qualification rests on well-known and validated tools for functional assessment: exercise tolerance assessment, dyspnea intensity assessment, functional fitness assessment, assessment of arterial blood saturation, lung ventilation function assessment, assessment of long-lasting COVID-19 symptoms, and patient's basic mental health condition.

CONCLUSIONS

The proposed qualification model for the post-COVID rehabilitation program allows us to introduce adequate qualifications followed by much needed assessment of the health effects.

Rehabilitation and In-Hospital Mortality in COVID-19 patients

BACKGROUND

COVID-19 guidelines endorse early rehabilitation to improve outcomes in hospitalized patients, but the evidence-base to support this recommendation is lacking. We examined the association between early rehabilitation and in-hospital deaths in COVID-19 patients.

METHODS

Single center retrospective study involving 990 COVID-19 patients (42·4% women, mean age 67.8 years) admitted between March 1, 2020 and May 31, 2020 to a community hospital. Association of rehabilitation during hospitalization with in-hospital mortality was examined using logistic regression analysis adjusted for demographics, length of stay, body mass index, comorbid illnesses, functional status as well as for COVID-19 presentations, treatments, and complications.

RESULTS

Over the 3-month study period, 475 (48·0%) in-patients were referred for rehabilitation. Patients who received rehabilitation were older (73·7 ± 14·0 vs. 62·3 ± 17·2). There were 61 hospital deaths (12·8%) in the rehabilitation group and 165 (32·0%) in the non-rehabilitation group. Receiving rehabilitation was associated with an 89% lower in-hospital mortality (OR 0·11, 95% CI 0·06-0·19) after adjusting for multiple confounders and COVID-19 disease markers. In sensitivity analyses, the results were significant in sub-populations defined by age group, sex, race, length of hospitalization, or pulmonary presentations. Each additional rehabilitation session was associated with a 29% lower risk of in-hospital mortality (OR per session 0·71, 95% CI 0·64-0·79) in the fully adjusted model.

CONCLUSION

Among hospitalized COVID-19 patients, receiving early rehabilitation was associated with lower in-hospital mortality. Our findings support implementation of rehabilitation services for COVID-19 patients in acute care settings, but further research from randomized clinical trials is needed.

Association between Mutuality and Health-Related Quality of Life in Patient-Caregiver Dyads Living with Schizophrenia

Background: Although caregivers are a crucial support in the recovery of patients with schizophrenia, little is known about how mutuality is related to health-related quality of life within the dyadic (patient and caregiver) context. This study aimed to investigate the dyadic relationship between mutuality and health-related quality of life in patients with schizophrenia and caregivers. Methods: A cross-sectional, correlational study was conducted with a sample of 133 dyads of patients with schizophrenia and caregivers. Structured questionnaires were used to collect data. Data were analyzed using descriptive statistics, paired sample t-tests, Pearson’s product-moment correlations, and the Actor–Partner Interdependence Model. Results: Mutuality of patients was significantly higher than that of caregivers. Compared with caregivers, patients had significantly lower total scores for health-related quality of life. Patients’ and caregivers’ mutuality was related to their own health-related quality of life (actor effect) and their partners’ health-related quality of life (partner effect). Conclusion: Mutuality plays a critical role in health-related quality of life in dyads of patients with schizophrenia and caregivers. Viewing a dyad as a unit of nursing care reveals a promising approach for developing recovery-oriented modalities targeted at stimulating mutuality that may enhance health-related quality of life for both patients and caregivers.

Factors associated with family functioning among people with a diagnosis of schizophrenia and primary family caregivers

WHAT IS KNOWN ON THE SUBJECT?: Families act not only as the primary support for people with a diagnosis of schizophrenia but also as partners in the healthcare system. Families who have members with mental disorders, particularly schizophrenia, experience challenges in family functioning. Research on families in relation to schizophrenia primarily focuses on the determinants that affect family functioning from primary family caregivers' perspectives. WHAT DOES THE PAPER ADD TO EXISTING KNOWLEDGE?: This report provides evidence that there is a concordance between family functioning and inpatient psychiatric rehabilitation facilities for the patient-caregiver dyad; both care-receivers and primary family caregivers considered family functioning as poor. Care-receivers with lower education levels, increased number of previous hospitalizations and poor quality of family-centred care experienced unhealthy family functioning. Primary family caregivers and care-receivers with higher education levels, lower suicidality and greater quality of family-centred care experienced healthier family functioning. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Understanding the degree of family functioning, particularly its concordance and correlates as perceived by patients and primary family caregivers, may serve as a platform for inculcating assessment of family functioning to achieve holistic patient care. Open dialogue in family-focused care planning is essential to facilitate collaborative partnerships and improve family functioning among people with a diagnosis of schizophrenia and their primary family caregivers. Further research on culturally relevant, evidence-based family interventions to enhance the functioning of affected families is warranted, especially for families with members in inpatient psychiatric rehabilitation facilities. ABSTRACT: Introduction Families provide frontline caregiving support for people with a diagnosis of schizophrenia. However, research primarily addresses correlates of family functioning from primary family caregivers' perspectives. Aim To examine perceived family functioning, particularly its concordance within patient-caregiver dyads and associated factors in families of people living with schizophrenia. Methods A cross-sectional, descriptive correlational design was used. A total of 133 dyads of patients and primary family caregivers from inpatient psychiatric rehabilitation services participated. Descriptive statistics, independent-sample t test, one-way ANOVA, Pearson's correlation coefficients, intraclass correlation coefficient and stepwise multiple linear regression analyses were applied. Results Family functioning was perceived as impaired by patient-caregiver dyads, and there existed a concordance in this regard. Patients' and family caregivers' education levels, patients' suicidality, number of previous hospitalizations and quality of family-centred care correlated with patients' and primary family caregivers' family functioning. Discussion Findings highlight the importance of patient- and family-reported family functioning with implications to address individual and collective concerns. Implications for Practice Evidence-based family interventions are crucial for assisting vulnerable families in promoting family functioning. Mental health nurses should facilitate collaboration and open dialogue concerning perspectives of patients and families to improve delivery of comprehensive mental health care.

Psychiatric morbidity and its correlates among primary family caregivers of individuals diagnosed with schizophrenia in Taiwan

BACKGROUND

Caregiving for patients with schizophrenia is often challenging and may increase the risk of psychiatric morbidity among primary family caregivers. However, the associated factors of psychiatric morbidity among caregivers have not been fully investigated.

AIMS

This study aimed to screen psychiatric morbidity and its correlates among primary family caregivers of persons with schizophrenia receiving inpatient psychiatric rehabilitation services.

METHODS

A cross-sectional, correlational design was used. A total of 184 Taiwanese primary family caregivers in inpatient psychiatric rehabilitation units participated in the study. Descriptive statistics, Chi-square tests, independent t-tests, and a stepwise binary logistic regression analysis were performed to examine the association among primary family caregivers' psychiatric morbidity and primary family caregivers' sociodemographic characteristics and mutuality and patients' sociodemographic and clinical characteristics.

RESULTS

The prevalence of psychiatric morbidity among primary family caregivers was 48.4%. Unemployment, lower mutuality, additional dependents in need of care, and caring for patients with more psychiatric hospitalizations were the most significant factors for psychiatric morbidity among primary family caregivers.

CONCLUSION

Mental healthcare professionals should recognize patients and their primary family caregivers as a unit of care. Primary family caregivers must receive increased assistance, including supportive resources and therapeutic interventions, to reduce psychiatric morbidity.

Community-care unit model of residential mental health rehabilitation services in Queensland, Australia: predicting outcomes of consumers 1-year post discharge

AIMS

Community care units (CCUs) are a model of residential psychiatric rehabilitation aiming to improve the independence and community functioning of people with severe and persistent mental illness. This study examined factors predicting improvement in outcomes among CCU consumers.

METHODS

Hierarchical regression using data from a retrospective cohort (N = 501) of all consumers admitted to five CCUs in Queensland, Australia between 2005 and 2014. The primary outcome was changed in mental health and social functioning (Health of the Nation Outcome Scale). Secondary outcomes were disability (Life Skills Profile-16), service use, accommodation instability, and involuntary treatment. Potential predictors covered service, consumer, and treatment characteristics. Group-level and individualised change were assessed between the year pre-admission and post-discharge. Where relevant and available, the reliable and clinically significant (RCS) change was assessed by comparison with a normative sample.

RESULTS

Group-level analyses showed statistically significant improvements in mental health and social functioning, and reductions in psychiatry-related bed-days, emergency department (ED) presentations and involuntary treatment. There were no significant changes in disability or accommodation instability. A total of 54.7% of consumers demonstrated reliable improvement in mental health and social functioning, and 43.0% showed RCS improvement. The majority (60.6%) showed a reliable improvement in psychiatry-related bed-use; a minority demonstrated reliable improvement in ED presentations (12.5%). Significant predictors of improvement included variables related to the CCU care (e.g. episode duration), consumer characteristics (e.g. primary diagnosis) and treatment variables (e.g. psychiatry-related bed-days pre-admission). Higher baseline impairment in mental health and social functioning (β = 1.12) and longer episodes of CCU care (β = 1.03) increased the likelihood of RCS improvement in mental health and social functioning.

CONCLUSIONS

CCU care was followed by reliable improvements in relevant outcomes for many consumers. Consumers with poorer mental health and social functioning, and a longer episode of CCU care were more likely to make RCS improvements in mental health and social functioning.

The Effectiveness of Mental Health Rehabilitation Services: A Systematic Review and Narrative Synthesis

Introduction: Mental health rehabilitation services provide essential support to people with complex and longer term mental health problems. They include inpatient services and community teams providing clinical input to people living in supported accommodation services. This systematic review included international studies evaluating the effectiveness of inpatient and community rehabilitation services. Methods: We searched six online databases for quantitative studies evaluating mental health rehabilitation services that reported on one or both of two outcomes: move-on to a more independent setting (i.e. discharge from an inpatient unit to the community or from a higher to lower level of supported accommodation); inpatient service use. The search was further expanded by screening references and citations of included studies. Heterogeneity between studies was too great to allow meta-analysis and therefore a narrative synthesis was carried out. Results: We included a total of 65 studies, grouped as: contemporary mental health rehabilitation services (n = 34); services for homeless people with severe mental health problems (n = 13); deinstitutionalization programmes (n = 18). The strongest evidence was for services for homeless people. Access to inpatient rehabilitation services was associated with a reduction in acute inpatient service use post discharge. Fewer than one half of people moved on from higher to lower levels of supported accommodation within expected timeframes. Conclusions: Inpatient and community rehabilitation services may reduce the need for inpatient service use over the long term but more high quality research of contemporary rehabilitation services with comparison groups is required. Review registration: This review was prospectively registered on PROSPERO (ID: CRD42019133579).

Factors Associated With Primary Family Caregivers' Perceptions on Quality of Family-Centered Care in Mental Health Practice

PURPOSE

This study aimed to examine the quality of family-centered care perceived by primary family caregivers and its influencing factors in mental healthcare practice.

DESIGN

A cross-sectional, correlational study.

METHODS

A convenience sample of 121 mental health nurses and 164 primary family caregivers of patients with schizophrenia was recruited from acute psychiatric wards and chronic psychiatric rehabilitation wards in three psychiatric hospitals in Taiwan. Structured questionnaires for mental health nurses were designed to examine nurses' attitudes toward schizophrenia and the importance of families in nursing care. Primary family caregivers were assessed to determine their perceptions of quality of family-centered care. At least one primary family caregiver of patients was matched to a nurse who took major responsibility for the patient during the hospitalization. Data were analyzed with descriptive statistics, Pearson's product-moment correlations, independent t-test, one-way analysis of variance, and stepwise regression analyses.

RESULTS

Quality of family-centered care perceived by primary family caregivers regarding the provision of general and specific information, as compared to enabling and partnership, coordinated and comprehensive care, and respectful and supportive care, was relatively inadequate. Younger and more educated primary family caregivers, having relatives with schizophrenia in acute wards, less supportive nurses' attitudes toward schizophrenia, and the importance of family in nursing care were correlated with poor primary family caregivers' perceptions of quality of family-centered care. Nurses' supportive attitudes toward schizophrenia and chronic psychiatric rehabilitation wards where patients received care were key factors in determining better quality of family-centered care.

CONCLUSIONS

Findings provide a platform for the development of effective continuing education and training programs to equip mental health nurses with supportive attitudes toward mental illness and an integration of the family in nursing care, which will ultimately improve mental health care for families experiencing mental health problems.

CLINICAL RELEVANCE

Efforts in professional training to address stigma and encourage a family-centered approach into recovery-oriented practice for practicing mental healthcare providers, including mental health nurses, are recommended.

Longitudinal analysis of statistical and clinically significant psychosocial change following mental health rehabilitation

Purpose: With appropriate mental health rehabilitation, schizophrenia is increasingly associated with reports of recovery and stability. However, there is little empirical evidence evaluating the efficacy of services delivering this care. This study evaluated the effectiveness of rehabilitation for improving psychosocial function in consumers with schizophrenia.Methods: An electronic database of standardized assessment instruments mandated and maintained by the health service was retrospectively reviewed to extract ratings of psychosocial function, daily living skills, and mood state from consecutive admissions to an inpatient rehabilitation service. Outcomes were compared at admission, discharge, and one-year follow-up to identify statistically significant change. Individual reliable and clinically significant change was also assessed by comparison with a normative group of clients functioning independently in the community.Results: From admission to discharge the rehabilitation group made statistically significant gains in psychosocial function and daily living skills. Improvements were reliable and clinically significant in one-quarter to one-third of individual consumers. Approximately half sustained their improvements at follow-up, although this represented only a small fraction of the overall cohort. Consumers not demonstrating gains exhibited psychometric floor effects at admission.Conclusions: Rehabilitation can produce statistically and clinically significant immediate improvement in psychosocial function for a sub-set of consumers with elevated scores at admission. The durability of any gains is less clear, and strategies promoting longer-term maintenance are encouraged. Furthermore, currently mandated outcome measures are confounded by issues of sensitivity and reporting compliance, and exploration of alternative instruments for assessing recovery is recommended.Implications for RehabilitationRoutinely collected standardized outcome measures can be used to investigate the effectiveness of mental health rehabilitationIn addition to statistical significance, the clinical significance of outcomes should be evaluated to identify change that is individually meaningfulCurrently mandated outcomes instruments do not adequately evaluate many individuals' recovery journeyMental health service evaluation and quality improvement processes would likely benefit from adoption of recovery-oriented measures.

A service evaluation of outcomes in two in-patient recovery units

Aims and method To evaluate outcomes for patients during their admission or in the first year of treatment in two in-patient recovery units. Changes in health and social functioning, service use and need (rated by patients and staff) were evaluated. Results In 43 patients treated, there was a large (30%) increase in patients discharged to their own tenancies, rather than supported accommodation. There was minimal change in Health of the Nation Outcome Scales (HoNOS) scores in the course of the admission but staff- and patient-rated unmet needs reduced and met needs increased. Needs changed mainly in domains relating to social functioning. Reductions in risk to self and others were rated by staff but not patients. There were no cases of patients being readmitted to acute hospital during the study period. Clinical implications Although these results offer some support to the treatment approach described in these in-patient recovery units, further research in larger samples is needed to identify how these services can best be deployed to help individuals with severe mental illness and complex needs.