Management by geographical area or management specialised by disorder? A mixed-methods evaluation of the effects of an organisational intervention on secondary mental health care for common mental disorder

Continuity of care and clinical outcomes in the community for people with severe mental illness

BACKGROUND

High continuity of care is prized by users of mental health services and lauded in health policy. It is especially important in long-term conditions like schizophrenia. However, it is not routinely measured, and therefore not often evaluated when service reorganisations take place. In addition, the impact of continuity of care on clinical outcomes is unclear.AimsWe set out to examine continuity of care in people with schizophrenia, and to relate this to demographic variables and clinical outcomes.

METHOD

Pseudoanonymised community data from 5552 individuals with schizophrenia presenting over 11 years were examined for changes in continuity of care using the numbers of community teams caring for them and the Modified Modified Continuity Index (MMCI). These and demographic variables were related to clinical outcomes measured with the Health of the Nation Outcome Scales (HoNOS). Data were analysed using generalised estimating equations and multivariate marginal models.

RESULTS

There was a significant decline in MMCI and significant worsening of HoNOS total scores over 11 years. Higher (worse) HoNOS scores were significantly and independently related to older age, later years and both lower MMCI and more teams caring for the individual in each year. Most HoNOS scales contributed to the higher total scores.

CONCLUSIONS

There is evidence of declining continuity of care in this 11-year study of people with schizophrenia, and of an independent effect of this on worse clinical outcomes. We suggest that this is related to reorganisation of services.Declaration of interestNone.

A preliminary service evaluation of a personality disorder case management service

AIMS

The aim of this study is to assess the impact of establishing a specialized community personality disorder team on out of area placements, local hospital admissions and out of hours crisis contacts for service users with borderline personality disorder.

METHOD

This is a before-after interim evaluation of a new service. We tested, through a paired t-test, whether the intervention generated statistically significant differences over a range of measures of service usage, including out of area placements, local hospital admissions and out of hours crisis contacts. Data from 12 months after the intervention started were compared with the previous 12 months of routine care, to determine the effect on crisis contacts, days in hospital and those returning from/or sent out of area for care. Finally, we have assessed the likelihood to generate cost savings.

RESULTS

All service users in out of area placements were repatriated to live in the community locally (100%), and there was a statistically significant decrease in inpatient admissions (80%). This was counterbalanced by a smaller but statistically significant increase in out of hours community crisis contacts (30%), although these reduced over time.

CONCLUSION

Reorganizing local care pathways can lead to less out of area placements and less hospital admissions. © 2019 John Wiley & Sons, Ltd.

In-patient treatment in functional and sectorised care: patient satisfaction and length of stay

BACKGROUND

Debate exists as to whether functional care, in which different psychiatrists are responsible for in- and out-patient care, leads to better in-patient treatment as compared with sectorised care, in which the same psychiatrist is responsible for care across settings. Aims To compare patient satisfaction with in-patient treatment and length of stay in functional and sectorised care.

METHOD

Patients with an ICD-10 diagnosis of psychotic, affective or anxiety/somatoform disorders consecutively admitted to an adult acute psychiatric ward in 23 hospitals across 11 National Health Service trusts in England were recruited. Patient satisfaction with in-patient care and length of stay (LoS) were compared (trial registration ISRCTN40256812).

RESULTS

In total, 2709 patients were included, of which 1612 received functional and 1097 sectorised care. Patient satisfaction was significantly higher in sectorised care (β = 0.54, 95% CI 0.35-0.73, P<0.001). This difference remained significant when adjusting for locality and patient characteristics. LoS was 6.9 days shorter for patients in sectorised care (β = -6.89, 95% CI -11.76 to -2.02, P<0.001), but this difference did not remain significant when adjusting for clustering by hospital (β = -4.89, 95% CI -13.34 to 3.56, P = 0.26).

CONCLUSIONS

This is the first robust evidence that patient satisfaction with in-patient treatment is higher in sectorised care, whereas findings for LoS are less conclusive. If patient satisfaction is seen as a key criterion, sectorised care seems preferable. Declarations of interest None.