Is more better? Examining whether enhanced consultation/coaching improves implementation

It is extremely challenging to implement evidence-based interventions in community-based agencies with sufficient quality, fidelity, and intensity to produce desired changes in practice and outcomes. This is particularly difficult to do within the confines of existing service providers' time, personnel, and resource constraints. Over the past 15 years, Together Facing the Challenge (TFTC) has been developed, tested, and disseminated in an effort to address this set of issues to improve treatment foster care (TFC). Data from the initial randomized trial showed improved practice and outcomes in TFTC compared to usual TFC. These initial results came from study-led training and follow-up consultation. Subsequent dissemination activities suggested potential need for more intensive support for TFTC supervisors to produce more consistent and sustained implementation of the model. The current randomized trial extends this work by comparing the previously tested standard consultation versus enhanced consultation that incorporated more of a coaching approach. Initial results suggest that enhanced coaching/consultation was associated with improvements in the small- to medium-effect size range. Results are promising, but require additional work to more fully understand how and whether to enhance supports as agencies implement new evidence-based approaches. (PsycINFO Database Record

Culture in Better Group Homes for People With Intellectual Disability at Severe Levels

Building on cultural dimensions of underperforming group homes this study analyses culture in better performing services. In depth qualitative case studies were conducted in 3 better group homes using participant observation and interviews. The culture in these homes, reflected in patterns of staff practice and talk, as well as artefacts differed from that found in underperforming services. Formal power holders were undisputed leaders, their values aligned with those of other staff and the organization, responsibility for practice quality was shared enabling teamwork, staff perceived their purpose as "making the life each person wants it to be," working practices were person centered, and new ideas and outsiders were embraced. The culture was characterized as coherent, respectful, "enabling" for residents, and "motivating" for staff. Though it is unclear whether good group homes have a similar culture to better ones the insights from this study provide knowledge to guide service development and evaluation.

Relocating people with intellectual disability to new accommodation and support settings: Contrasts between personalized arrangements and group home placements

Internationally the relocation of people with intellectual disability from institutions has brought significant gains to their quality of life. This study contrasted three groups of persons in Ireland who moved either to personalized arrangements (n = 29) or to community group homes (n = 31) with those who remained in congregated settings awaiting relocation (n = 29). Persons moving to rented accommodation with personalized support tended to be younger and had fewer support needs than those in group homes. They had greater control and choice in their lives, more community engagement and increased personal relationships compared to residents in group homes but those remaining in congregated settings fared worse of all. However, average staff costs were significantly higher in the latter settings. The implications for the future provision of group living arrangements are discussed along with the need for further longitudinal research to assess the sustained impact of personalized arrangements and their funding.

Consensus statement on group care for children and adolescents: A statement of policy of the American Orthopsychiatric Association

Group care for children and adolescents is widely used as a rearing environment and sometimes used as a setting in which intensive services can be provided. This consensus statement on group care affirms that children and adolescents have the need and right to grow up in a family with at least 1 committed, stable, and loving adult caregiver. In principle, group care should never be favored over family care. Group care should be used only when it is the least detrimental alternative, when necessary therapeutic mental health services cannot be delivered in a less restrictive setting.

Resettlement of individuals with learning disabilities into community care: a risk audit

This article describes a risk audit carried out on the support provided for 36 people with profound learning disabilities who had been resettled from hospital care to supported housing. The risks were those factors identified in the literature as associated with deleterious effects on quality of life. The audit was carried out with a specially designed tool that covered 24 possible risks and involved a support worker familiar with the service user choosing the most appropriate statement regarding each risk. Their judgements were verified by care managers and social needs assessors. Whilst one or more risks were identified for 32 of the 36 service users, the overall result showed relatively low risks for the group as a whole with 62 incidences (7%) from a possible 864, which nevertheless highlighted several areas that needed attention. The results of the audit have led to action plans for the provision and for the individual service users for whom risks were identified.

Stories of rediscovering agency: home-based occupational therapy for people with severe psychiatric disability

As part of a larger study, we offered Everyday Life Rehabilitation (ELR) as a model for integrated occupational therapy in sheltered or supported housing facilities, to enable meaningful daily occupations for people with psychiatric disabilities. Our aim with this study was to understand how participants made sense of their occupational transformations in the context of their everyday life and life history. We carried out qualitative interviews and field observations with 16 participants with psychosis-related disorders. We used narrative analysis and disclosed stories of "rediscovering agency," referring to occupational and identity transformations. A parallel outcome study has shown positive results for participants, and by using narrative inquiry we contribute with a deeper understanding of the meaning making of their transformations and mechanisms of the intervention; i.e., hope, extended value of reaching goals, reentering the majority world, transparency of process, and attunement to the individual. The findings support the use of the ELR intervention.

Duty of care and autonomy: how support workers managed the tension between protecting service users from risk and promoting their independence in a specialist group home

BACKGROUND

In the UK those paid to support adults with intellectual disabilities must manage two potentially conflicting duties that are set out in policy documents as being vital to their role: protecting service users (their duty of care) and recognising service users' autonomy. This study focuses specifically on the support of people with the genetically determined condition, Prader-Willi syndrome (PWS). Due to the behaviours associated with PWS, the support of this group of people vividly illustrates the tension between respect for autonomy and duty of care. This article explores how support workers working in a residential group home managed their competing duties of managing risk and promoting independence in practice.

METHODS

An ethnographic study, comprising of qualitative observations, semi-structured interviews and documentary analysis, was undertaken to investigate the work of support workers in a UK residential group home specialising in the support of adults diagnosed with PWS. The study focused on how support workers attempted to reconcile the tension between protecting service users from the risks associated with the syndrome and acknowledging service users' autonomy by enabling independence.

RESULTS

Findings demonstrate that risk was central to the structure of care delivery at the group home and support workers often adhered to standardised risk management procedures. The organisation also required support workers to promote service users' independence and many thought acknowledging service users' autonomy through the promotion of their independence was important. To manage tensions between their differing duties, some support workers deviated from standardised risk management procedures to allow service users a degree of independence.

CONCLUSIONS

There is a tension between the duty of care and the duty to recognise autonomy at the level of service delivery in residential homes. Support workers attempt to manage this tension; however, further work needs to be done by both residential services and policy makers to facilitate the reconciliation of the duty of care with the duty to recognise service users' autonomy in practice.

Incapable sex: a case study

Although it is well known that intimacy and sexual expression are an important part of being human and of healthy living, facilities such as nursing homes, adult group homes, or assisted living residences commonly struggle with knowing how to balance supporting residents who are incapable to have sexual lives with their duty to protect them from foreseeable harm. This article presents a challenging case and uses the British Columbia Supporting Sexual Health and Intimacy in Care Facility Guidelines to determine what should be done.

Linking structure, process, and outcome to improve group home services for foster youth in California

The California Youth Connection obtained funding from two foundations to evaluate the performance of group homes serving foster youth in Alameda County, California, in order to inform state policy-making. The evaluation team initially included 14 foster youth that personally experienced group home living. Three inter-related aspects of service were studied: structure, process, and client outcomes, specifically residents' increase in developmental assets leading to the ability to transition successfully to independent living by the age of 18 years. Data were collected at 32 group homes from 127 residents and 72 staff members using three questionnaires. Both structural and process aspects of services influenced residents' satisfaction with services. However, only the process of care predicted changes in residents' developmental assets. State-level regulatory agencies learned from these results that auditing only structural aspects of services was not sufficient to promote effective services. Further, one structure item and two process items were identified as less consistently occurring in the group homes: timely distribution of clothing allowances, healthy communication between staff and youth, and staff support of regular exercise for the residents. Focusing on these aspects of service first should promote more change in outcomes and satisfaction for foster youth residing in group homes.

The relationship between characteristics of supported housing and the quality of life of older adults with severe mental illness

This study examined whether group living (as opposed to single living), staff availability and degree of personal freedom are associated with the quality of life of older adults with severe mental illness. A cross-sectional study was carried out in 18 supported living programmes in residential homes for the elderly that differed in terms of these three characteristics. The study included 35 patients with a psychotic disorder and 38 with an anxiety or mood disorder. Quality of life was assessed with the Philadelphia Geriatric Centre Morale Scale (PGCMS) and the Manchester Short Assessment of Quality of Life (MANSA). No association was found between group living and quality of life. Availability of psychiatrically trained staff was associated with life quality only for patients with a psychotic disorder, and perceived amount of personal freedom was associated with life quality only for patients with a non-psychotic disorder. Both differences were seen only on the PGCMS Agitation subscale. Older people with psychotic disorders appear to have relatively high needs for professional psychiatric support, and those with non-psychotic disorders for control over their daily lives. Further research is needed in other settings for older people with severe mental illness, preferably using longitudinal designs.

End-of-life care at group homes for patients with dementia in Japan

In Japan, the number of group homes for patients with dementia (GHs) has been increasing in recent years. A growing number of elderly people now prefer to spend their final years in group homes or other long-term care facilities, a choice that their families support. The aim of this nationwide study is to clarify the current end-of-life care policies and practices of GHs. The subjects were 3701 managing directors of GHs. Data were collected through mailed, anonymous, self-reported questionnaires in 2003. The content of the questionnaires included: (1) general characteristics of the GH, (2) end-of-life care policies and experiences, (3) available end-of-life care services at the GH, (4) staff education concerning end-of-life care, and (5) types of information provided to users and families. The response rate was 45.6%. Many GHs had implemented progressive policies for end-of-life care. GHs with progressive policies for end-of-life care were found to have different backgrounds than those with regressive policies. Only a few GHs provided end-of-life care education for their staff. GHs with progressive policies for end-of-life care tended to have the following characteristics: availability of medical intervention within and outside of the GH, self-contained physical plant and staff education about end-of-life care. Further research is needed to determine the most effective end-of-life care systems for GHs.

"It's important to be proud of the place you live in": housing problems and preferences of psychiatric survivors

TOPIC

It is important to understand housing and mental health issues from the perspective of psychiatric survivors. This paper reports findings from a series of focus group meetings held with survivors of mental illness to address issues concerning housing preferences and housing needs.

METHODS

The discussions were recorded, transcribed, and analyzed using an ethnographic method of analysis. The themes that emerged related to oppression, social networks and social supports, housing conditions, poverty and finances, and accessing services. Participants described the ongoing stigma, discrimination, and poverty that reduced their access to safe, adequate housing.

FINDINGS

They preferred independent housing where supports would be available as needed. Participants described the dilemma of having to choose between the housing they wanted and the supports they needed, since supports were often contingent upon living in a less desirable housing situation.

CONCLUSIONS

Nurses and other mental healthcare workers need to be aware of these issues for discharge planning, community support, and ongoing advocacy. The survivor voices need to be heard by decision-makers at various levels of government in order for housing policy to become more receptive to their realities.

Facility charter and quality of care for board and care residents

In this investigation structure, process, and outcome measures of quality in for-profit and not-for-profit board and care homes are compared. We find one structural measure (providing nursing care), three process measures (food quality, staff treat residents with respect, and staff verbally abuse residents), and two outcomes measures (cleanliness of the facility and complaints to Ombudsman) to be significant. Moreover, the directions of these effects are all consistent, with for-profit facilities rated more poorly that not-for-profit facilities. These results are discussed emphasizing their implications for efficient and effective resident care.

[Nursing needs among recipients of community health care]

BACKGROUND

We aimed at investigating whether disabled old people can get sufficient care in residential facilities for the elderly.

MATERIALS AND METHODS

All residents in our community's care facilities for the elderly in 2001 were registered. Those living in their own homes with a substantial need for care were also registered. Burden of care was assessed by six items measuring activities of daily life and two items measuring cognitive decline.

RESULTS

309 persons were registered; mean age was 84. Those living in residential care facilities staffed 24 hours a day represented the highest average burden of care, though many elderly living in their own homes also need a great deal of care. In our community, the number of nursing home beds set aside for short-term stays has decreased from 24 to 11 over a eight-year period. The burden of care has increased since 1992 in nursing homes as well as in other residential care units.

INTERPRETATION

Group-dwelling unit staffed around the clock can be a good alternative to nursing homes for many demented patients. While a high number of such units have been built, the local authorities have found it increasingly difficult to provide a sufficient number of nursing home beds for short-term stays. Most changes observed can be related to the growing number of inhabitants above 80 years of age.

Measuring the impact of housing on people with schizophrenia

Review of the available literature, from various countries, on housing options indicates that, for people with a mental illness, boarding houses are the least desirable type of community accommodation and that living in their own home is the most desirable type of accommodation. The present research project provides a more in-depth examination of people with schizophrenia and the impact of living in their own home compared to living in a boarding house. In this Australian study there were 3231 subjects, 3033 who were living in their own homes and 201 living in boarding house accommodation. The study used two instruments from the Mental Health Classification and Service Cost Project, specifically the Health of the Nation Outcomes Scale, which is a measure of current symptoms, and a shortened version of the Life Skills Profile, which measures global level of functioning. Results indicated that while there were no differences in the level of psychiatric symptoms experienced, people living in boarding houses had less access to social support, meaningful activities and work; they also had a significantly lower level of global functioning. These findings contradict the conventional wisdom that people with schizophrenia resort to living in boarding houses because of their level of disability and highlights an area of potential intervention for community health services.

[Important to reduce the risk of infections in residential facilities]

In view of the fact that Swedish nursing home care represents an integrated form of residential housing and health care and it is not possible to classify infections as either "health-care-associated" or "community-acquired". Thus it is not appropriate to use the same surveillance systems as those used in hospitals. The presence of known risk factors for infection--either related to medical devices or due to underlying illness--could however be monitored. Antibiotic treatment favours selection of resistant bacterial strains and should thus be used with prudence. At December 8th, 2000, we investigated the presence of 20 risk factors and antibiotic treatment among 2,817 residents in nursing homes in Uppsala county. Seventeen out of 20 risk factors were all present in less than 1 per cent of the residents. Pressure ulcers or leg/foot-ulcers occurred among 3.2% each, and 7.6 per cent of the residents had an indwelling urinary catheter. About 6% of the residents were treated with at least one antibiotic. Urinary tract infection was the main reason for treatment. The investigation shows that training of nursing home staff by the infection control team should focus on hand hygiene and routines for wound care and urinary catheter care in order to minimize the risk for infections among residents.

Rational resourcing and productivity: relationships among staff input, resident characteristics, and group home quality

Relationships among staff input per resident, resident characteristics, setting characteristics, and service quality were investigated. Data were obtained from 51 group homes in Wales on (a) resident numbers, ages, gender, adaptive behavior, challenging behavior, and additional disabilities; (b) allocated staff hours and actual staff costs; (c) provider agency, date of provision, and internal operational arrangements; and (d) resident receipt of staff attention and resident activity. Variation in staff input was related to resident challenging behavior, smaller residence size, and provider agency or date of provision. Staffing input was associated with resident receipt of attention, as were operational arrangements. Resident activity was related to resident adaptive behavior and receipt of attention but not resource input. Cost-effectiveness implications are discussed.

Promoting a good life among people with Alzheimer's disease

AIM

To illuminate the meaning of offering care and a place to live to people with Alzheimer's disease in a special care unit.

RATIONALE

There is a need to gain a deeper understanding about so called 'homelike' care settings, and about how to promote experiences of being at home in residents with Alzheimer's disease. The study is part of a long-term study in a special care unit.

METHODS

The study comprises phenomenological hermeneutic interpretation of interviews with 10 care providers.

RESULTS

The analyses revealed a number of caring aspects such as, for example, 'viewing dignity and striving to preserve a sense of self in the resident', 'encouraging a sense of belonging', 'offering relief' and 'promoting a sense of power and control in the resident', although integrated and reflected in each other. The caring aspects constituted the themes confirmation, familiarity, communion and agency considered as dimensions of the good life.

CONCLUSION

To avoid simplification in which, for example, the furniture from a certain decade become the standard for good care, it seems important to focus upon the meaning of the good life. Care that promotes a good life of people with Alzheimer's disease seemed relationship centred.

Supported housing for people with severe mental disorders

BACKGROUND

There has been a significant reduction in the number of people with severe mental illness who spend extended periods in long-stay hospitals. Psychiatric and social services, both statutory and voluntary, aim to assist these people to stay in their local community. District health authorities, local authorities, housing associations and voluntary organisations are jointly expected to provide support for people with severe mental disorder/s. This 'support' may well involve some sort of special housing.

OBJECTIVES

To determine the effects of supported housing schemes compared with outreach support schemes or 'standard care' for people with severe mental disorder/s living in the community.

SEARCH STRATEGY

Cochrane Schizophrenia Group's Register of trials (February 2001) and the Cochrane Library (Issue 1, 2001) were searched using relevant phrases. These databases are compiled by methodical searches of BIOSIS, CINAHL, Dissertation abstracts, EMBASE, LILACS, MEDLINE, PSYNDEX, PsycINFO, RUSSMED, Sociofile, supplemented with hand searching of relevant journals and numerous conference proceedings. Reference list screening of relevant papers was performed.

SELECTION CRITERIA

Relevant randomised, or quasi-randomised, trials dealing with people with 'severe mental disorder/s' allocated to supported housing, outreach support schemes or standard care focusing on outcomes of service utilisation, mental state, satisfaction with care, social functioning, quality of life, and economic data, were sought.

DATA COLLECTION AND ANALYSIS

Studies were reliably selected, quality rated and data extracted. For dichotomous data, relative risks (RR) would have been estimated, with the 95% confidence intervals (CI). Where possible, the number needed to treat statistic (NNT) was to have been calculated. Analysis would have been by intention-to-treat. Normal continuous data were to have been summated using the weighted mean difference (WMD). Scale data were to have been presented for only those tools that had attained pre-specified levels of quality. Tests of heterogeneity and for publication bias were to have been undertaken.

MAIN RESULTS

No studies met the inclusion criteria although 139 citations were acquired from the searches.

REVIEWER'S CONCLUSIONS

Dedicated schemes whereby people with severe mental illness are located within one site or building with assistance from professional workers have potential for great benefit as they provide a 'safe haven' for people in need of stability and support. This, however, may be at the risk of increasing dependence on professionals and prolonging exclusion from the community. Whether or not the benefits outweigh the risks can only be a matter of opinion in the absence of reliable evidence. There is an urgent need to investigate the effects of supported housing on people with severe mental illness within a randomised trial.

Satisfaction with on-site boarding home consultation: a Washington State program

A Quality Improvement Consultation (QIC) program was implemented in Washington State to assist boarding home providers (N = 500) to comply with statutory requirements. Boarding homes (n = 126, 25%) volunteering for the on-site visits with state quality improvement (QI) consultants developed and implemented QI plans to address provider-identified issues. Satisfaction with the program was measured with a 15-item questionnaire given to boarding home administrators, managers, and facility staff. Most agreed that the consultation was helpful and provided them with helpful information to ensure their success.

Quality of life in boarding houses and hostels: a residents' perspective

In the last forty years deinstitutionalization has transferred the care of people with a serious mental illness from the psychiatric hospitals to community based facilities. More recently it has been questioned whether these new facilities offer the anticipated benefits of quality of life. This study examines the Quality of Life (QOL) of people diagnosed with schizophrenia living in two different accommodation facilities, hostels and boarding houses. QOL is examined from the resident's perspective. Lehman's (1988b) QOL Interview was used to measure objective, subjective, and global QOL of 60 participants in three hostels and two boarding house clusters. Hostel and boarding house data were compared and results showed that residents preferred boarding house accommodation. Overall, residents of both accommodation facilities reported satisfaction with QOL, and indicated that they regard them as asylum or sanctuary from the outside world.

Trauma-informed approaches to housing

Supportive housing providers can play a vital role in the recovery of persons exposed to abuse and violence. Specific modifications for delivering housing support services are recommended based on an emerging trauma-informed perspective.

An audit of drug incidents in learning disability group homes

The implementation of clinical governance (Department of Health, 1997) requires the review of practice by consideration of complaints and clinical incidents. A systematic review of the clinical incident forms in group homes for those with learning disabilities, within an NHS community trust, highlighted issues for concern. This led to an audit being conducted of drug administration procedures involving examination of records and observation of practice. It demonstrated that there was general adherence to the trust's policies. The audit stimulated debate, and a number of potential areas for action were identified. The review of drug administration with clients who have learning difficulties raised wider questions about the scarcity of evidence in this area to support practice, the culture of client-centred homes and whether monitoring systems are sufficiently robust.

Fair play on the housing front

People with disabilities are treated unfairly in many community-based housing programs. Forcing a person to participate in a program simply because he or she is a tenant is discriminatory and many advocacy groups are questioning the legality of the practice. People with disabilities must be able to choose where they wish to live and the services they need.

Housing placement and subsequent days homeless among formerly homeless adults with mental illness

OBJECTIVE

The study examined the influence of group or individual housing placement and consumer characteristics on the number of days subsequently homeless among formerly homeless mentally ill persons.

METHODS

A total of 303 homeless shelter residents with severe mental illness were screened for dangerousness, 118 were randomly assigned to either independent apartment or staffed group living sites, and 110 were followed for 18 months. Study participants' sociodemographic characteristics, diagnosis, and residential preferences and the residential recommendations made by clinicians were measured at baseline.

RESULTS

Overall, 76 percent of the study participants were housed at the end of the 18-month follow-up period, although 27 percent had experienced at least one episode of homelessness during the period. The number of days homeless was greater for individuals assigned to independent apartments than for those placed in staffed group homes, but only for members of minority groups. Substance abuse was the strongest individual-level predictor of days homeless. Individuals whom clinicians identified as needing group living experienced more days homeless, irrespective of the type of housing they received. Consumers who stated a strong preference for independent living had more days homeless than those who were amenable to staffed group homes.

CONCLUSIONS

Although consumers more frequently prefer independent living, placement in staffed group housing resulted in somewhat fewer days homeless for some groups of consumers. Further experience of homelessness by formerly homeless mentally ill individuals may be reduced by providing effective substance abuse treatment and by paying special attention to consumers identified by clinicians to be at particular risk for housing loss.

Serving the dually diagnosed homeless: program development and interventions

In this paper the authors present the specific characteristics of the dually diagnosed (severely mentally ill and substance abusers) population and describe a hybridized program and interventions which have been empirically shown to be effective in working with these multiply impaired individuals. The article is based upon a three-year federally funded demonstration project. The following interventions were found to be effective: engagement, care and nurturing, structure, limit setting and the development of responsibility, positive reinforcement, and self esteem. The authors describe these interventions and highlight their impact in both staff management and working with funding sources.

Comparison of two community alternatives to incarceration for chronic juvenile offenders

The relative effectiveness of group care (GC) and multidimensional treatment foster care (MTFC) was compared in terms of their impact on criminal offending, incarceration rates, and program completion outcomes for 79 male adolescents who had histories of chronic and serious juvenile delinquency. Results show that boys who participated in MTFC had significantly fewer criminal referrals and returned to live with relatives more often. Multiple regression analyses showed that assignment to a treatment condition (i.e., GC or MTFC) predicted official and self-reported criminality in follow-up beyond other well-known predictors of chronic juvenile offending (i.e., age at 1st offense, number of previous offenses, age at referral).

Comparative outcomes and costs of inpatient care and supportive housing for substance-dependent veterans

OBJECTIVE

This study examined the differential effectiveness and costs of three weeks of treatment for patients with moderately severe substance dependence assigned to inpatient treatment or to a supportive housing setting. Supportive housing is temporary housing that allows a patient to participate in an intensive hospital-based treatment program. Type and intensity of treatment were generally equivalent for the two groups.

METHODS

Patients were consecutive voluntary admissions to the substance abuse treatment program of a large metropolitan Veterans Affairs medical center. Patients with serious medical conditions or highly unstable psychiatric disorders were excluded. Patients in supportive housing attended the inpatient program on weekdays from 7:30 a.m. to 5 p.m. They were assessed at baseline and at two-month follow-up.

RESULTS

Baseline analyses of clinical, personality, and demographic characteristics revealed no substantive differences between the 62 patients assigned to inpatient treatment and the 36 assigned to supportive housing. The degree of treatment involvement and dropout rates did not differ between groups. Of the 55 inpatients completing treatment, 29 were known to be abstinent at follow-up, and of the 35 supportive housing patients completing treatment, 22 were abstinent. The proportion was similar for both groups, about 70 percent. The cost of a successful treatment for the inpatient group was $9,524. For the supportive housing group, it was $4,291.

CONCLUSIONS

Given the absence of differential treatment effects between inpatient and supportive housing settings, the use of supportive housing alternatives appears to provide an opportunity for substantial cost savings for VA patients with substance dependence disorders.

A matter of distinction

Two years after moving into a specialist unit, clients with autism displayed a significant reduction in antisocial behaviours. Services for people with autism should be distinct from those for people with learning disabilities. The accreditation process of the National Autistic Society proved a vital element in developing the new service.

The TAPS project 38: level of training and its availability to carers within group homes in a London district. Team for the Assessment of Psychiatric Services

This study investigates the professional characteristics of care staff working in group homes for the mentally ill in a north London region. Opportunities for training and staff attitudes with respect to training and career prospects are examined. The majority of care staff are unqualified and in many cases the training needs of staff are not being met. Staff viewed their career prospects as limited. Training that is on offer to staff in principle is often not accessed, possibly owing to budget restrictions. The need for more stringent guidelines on staff training to maintain standards across agencies is highlighted.

Impact of regulation and financing on small board-and-care homes in Maryland

States use forms of regulation in small board-and-care homes to control quality; however, quality varies in spite of these efforts. This study of 94 small facilities compared quality of care measures in homes regulated by a state-administered program with those in nonregulated homes. It also compared homes on those variables using average payment for services as the independent variable. Results indicate that higher payments for services had a greater impact on quality than did participation in a regulatory program. Adequate funding may be key to maintaining reasonable quality in these homes.

Team for the Assessment of Psychiatric Services (TAPS) Project 33: prospective follow-up study of long-stay patients discharged from two psychiatric hospitals

OBJECTIVE

The purpose of this study was to evaluate the policy of closing psychiatric hospitals and replacing their functions with community-based services.

METHOD

All long-stay nondemented patients in two U.K. hospitals scheduled for closure were assessed with a series of schedules. All patients in one hospital and a proportion of those in the other hospital were reassessed 1 year after discharge to community facilities.

RESULTS

Of the 737 patients discharged from the two hospitals, 24 died before follow-up, two by suicide. Follow-up was successful for 94.6% of the survivors. Only seven patients were lost to follow-up and are presumed to have become homeless. Only two patients went to prison, one briefly. There was very little change in patients' psychiatric symptoms or social behavior problems. The community homes provided a much less restrictive environment than the hospital wards. Discharged patients were very appreciative of their increased freedom, and over 80% wished to stay in their community homes. There was an increase in the proportion of patients with incontinence and immobility. The patients' social lives were enriched by an increase in friends, and some made contact with neighbors and others in the community. However, there was a decrease in contact with relatives following discharge.

CONCLUSIONS

When the capital and revenue resources of a psychiatric hospital are reinvested in community services, based on staffed houses, there are few problems with crime or homelessness. With such well-resourced services, the benefits greatly outweigh the disadvantages for both old and new long-stay patients.

Nutritional quality of foods served in contracted second level lodging homes

The food served in contracted Second Level Lodging Homes (SLLH) in Hamilton-Wentworth was studied to assess compliance with current by-law standards, make recommendations about nutrition standards and identify educational needs. Dietitians collected food frequency data in 62 SLLH and recorded food served during one day. Only 44% of homes provided the minimum servings recommended by 1982 Canada's Food Guide. Recommended nutrient intakes for ten nutrients were met by 20% of homes. Provision of therapeutic diets was inconsistent. The study indicates the need for better nutritional standards and strategies to ensure SLLH residents access to sufficient, nutritious and personally acceptable food.

Effectiveness of two training methods to improve the quality of foodservice in small facilities for adult care

OBJECTIVE

Community-based adult-care facilities (ACFs) with fewer than 25 beds provide homes for persons with disabilities who cannot live independently. The staff in these facilities are not required to have any formal foodservice training, yet they provide meals for the residents. The objective of this study was to evaluate the quality of foodservices before and after a foodservice training program.

DESIGN

Forty-six ACFs from six health-unit areas throughout the province of British Columbia were enrolled in the study, which involved a pretest-posttest design over a 5-month period. The health units were randomly assigned to one of three programs.

INTERVENTION

The ACFs received either a training workshop plus foodservice manual developed specifically for ACFs, the manual only, or no intervention.

MAIN OUTCOME MEASURES

Facilities were audited on performance in food purchasing, menu planning, food safety, and food storage. These areas were rated according to established minimum government regulations and other foodservice standards. Differences between the two audit scores (postintervention score minus preintervention score) were analyzed for each program section. Group comparisons were done using analysis of covariance procedures, with the initial score being the covariable.

RESULTS

No treatment effect was found on performance for food purchasing and food storage. Training via workshop plus manual resulted in a significant improvement in audit scores for menu planning and food safety compared with training via the manual alone.

APPLICATION

Dietitians should consider providing foodservice training workshops for similar types of facilities. The benefits of providing a manual alone are negligible.

Determinants of direct-care staff turnover in group homes for individuals with mental retardation

A model of direct-care human service staff turnover was proposed and tested with 236 direct-care staff members in nine private, nonprofit New Jersey agencies. A path analysis of the data was conducted. Four variables were found to contribute to current job satisfaction: agreement of the job with personal goals and values, burnout, satisfaction with supervision, and employment history. In turn, current job satisfaction led to intention to quit, which led to actual turnover. Implications for the human service field and future research were explored.

Personal characteristics and competence of people with mental retardation living in foster homes and small group homes

In this 1986-1987 study, the demographic and diagnostic characteristics, problem behaviors, self-care skills, community living skills, domestic expectations, and program goals for personal competence of 336 persons with mental retardation living in a national sample of 181 foster care and small group care settings with 6 or fewer residents was assessed. The findings indicated relatively more severe cognitive impairment among persons in small ICFs-MR, less severe cognitive impairment and fewer functional limitations among non-ICF-MR group home residents, and more functional limitations among residents in foster homes. Neighborhood integration was relatively high for foster home residents, but there were fewer expectations for their development of home and community living skills. Implications for future research and program development in small, community-based residential settings were discussed.

Patients' perceptions of their quality of life 11 years after discharge from a state hospital

OBJECTIVE

Fifty-three state hospital patients discharged to group homes in the community in 1978-79 were followed up at three and 11 years to assess their quality of life and several other dimensions of their community experience.

METHODS

A structured interview was used to obtain data on patients' perceptions of and degree of satisfaction with aspects of their lives one month before hospital discharge and at three and 11 years after. Group home staff rated patients' functioning at follow-up. Data on rehospitalizations over the 11-year period were collected.

RESULTS

At 11-year follow-up, 30 of the surviving 40 patients were living in noninstitutional settings: nine in independent or semi-independent settings and 21 in group homes. The 30 patients perceived that their quality of life outside the hospital had improved in several ways, including the extent of their social networks, the quality of their living environment, and their capacity to meet basic needs. When data were averaged over the 11 years and corrected for the shorter time in the study of subjects who died, patients spent only 2.6 percent of the follow-up period in the hospital. Only one patient at 11 years wanted to return to the hospital.

CONCLUSIONS

The finding that even the small minority of patients who required multiple rehospitalizations preferred community life may have important clinical and policy implications for setting the threshold of hospital discharge.