Tensions and challenges in the provision of emergency mental health services
1
192s A new paradigm: psychiatric disablements homesupport are at least as effectivefor the patient as traditional hospitalcare and follow-up, reducethe burdenon the family,and are also more economical. An analysis of the data of the case register of the South Verona Community Psychiatric Service (CPS) on home visiting during a IO-year period 0982-91) will be discussed in the presentation. South Verona CPS is a comprehensive and integrated community- based mental health service where staff members are divided into three multidisciplinary teams, each responsible for a subsector of the catchment area. They work both in the hospital ward and in the community. While not yet offering a 24-hour a day mobile crisis team, the service provides at-home interventions during working hoursand ongoing care as needed. Case registerdata showthat while an increase in out-patient communitycare and day care wastaking place over the years, there was a parallel fall in the use of publicand private hospital beds. Resultsof this study show that home-based care increasingly providedin the 1982-91 periodto all South Verona patients was associated with a decreasing use of hospital beds. How- ever, differences across age and sex groups appeared : the increase of home-based care regarded older females, but not younger females and males. and was associatedwith a decreasing use of hospital beds in female patients (all diagnoses) and in female patients with affective disorders and with other diagnoses, but not in those with schizophrenia and related disorders. In addition. the apparenteffect of this approach over the years was a distinct improvementof our psychiatric serviceintermsof workers' clinicalskillsandtherapeutic effectiveness. COST BENEFIT STUDY OF DAY CARE - TilE EFFECT OF AN ATTACHED COMMUNITY PSYCHIATRIC NURSE F. Creed. Department of Psychiatry. RawnsleyBuilding. Manchester Royal Infirmary. OxfordRoad. Manchester, GB-MI3 9WL, Great Britain Previous studies have demonstrated that 30-409::of admissions to a psychiatric in-patient unit with acute illnesscan be treated in a well- staffedday hospital. Inthiscost effectiveness study, 179patientswith acute psychiatric illness were randomlyallocated to day hospitalor in-patienttreatment. Nearly half the sample had schizophrenia. The groupswerewell matchedon baseline characteristics and clinicaland social outcome were similar at twelve months.exceptthat in-patients improved significantly fasterthanday patients(p < 0.05) and burden on relatives was significantly less in the day hospital group at one year (p < 0.05). Direct costs to the hospital were, on average, £2.786 (SE ...) per patient cheaper for day hospital treatment compared to in-patienttreatment. Patient travelcosts were significantly greater for day patientcare and there was a significantly greater loss of informant's income. When all direct and indirect costs were considered, day hospital treatment still proved to be £1,590 (SE = ..) cheaper. In addition to demonstrating that day hospital treatment is cheaper than in-patient care, this study highlights the very considerable distress experienced by carersof peoplewith acute psychiatric illness.This may amountto actualpsychiatric disorder in thecarer; it resolvesmoresatisfactorily with day hospital treatment than in-patient treatment. By contrast, acute psychiatric disorder appears to resolve faster in the in-patient unit. These findings only apply to those 40% of patientspresenting for admission who can be treated in the day hospital and require further study if we are to define optimal use of day and in-patient treatment for acute illness. FROM EMERGENCYTO SOCIAL PSYCHIATRIC SERVICE CENTERS; THE AMSTERDAM EXPERIENCE BertholdP.R.Gersons. Department of Psychiatry; AMClUniversity of Amsterdam. Tafelbergweg 25. JJ50 BC Amsterdam. Netherlands Outreaching emergency psychiatry has been the keystone in Dutch mental health to prevent admissions in mentalhospitals. There was comprehensiveness of acute service with its strong connection with pre- and aftercare. The expansion of the ambulatory mental health centers(RIAGG's)in the eighties, nowserving 3%of the population, resulted in a disconnection of the acute services from continuity of care for chronic patients in the community. The mental hospitals in reaction to the ambulatory expansion haveset up acutewardsto admit patientsas shortas possible. Thispolicywas viewed as a 'principle' of community mental healthcare. The unforeseen result was howeveran enormousincrease of 100% in ten years of the numberof admissions. The settingup of socialpsychiatric servicecenters with continuityof care, tailored treatment, partialhospitalization andrelatedtosheltered livingarrangements and day-activity centers for a catchment area of 100.000 are the new solutions to offer in- and outpatient acute care againrelatedto the principles of continuity, From research it became clear most outreach ing servicescould be betterviewedas a repetition of interventions for chronic patients. Continuityof care is now seen as the tool to counter the need for acute care. In Amsterdam5 Social Psychiatric ServiceCentersare operating. replacing the old hospitals andofferingambulatory andinpatientcare. TENSIONS AND CHALLENGES IN THE PROVISION OF EMERGENCY MENTAL HEALTH SERVICES Michael Phelan. Consultant Psychiatrist, Riverside Mento! Health Trust. Charing CrossHospital. London W88AF, UK Inevitable conflicts arise when trying to provide emergency mental health services. As a result patients often do not have a smooth pathway into care, and crisis services receive fierce criticism from service users. Difficult ies facingthose responsible for the provision of emergency care include: lackof any agreed definition of what con- stitutes a psychiatric emergency; rising demand as services become more accessible and less stigmatising: economiesof scale forcing out of hours services to be centralised and anonymous; limited multidisciplinary working and a 'lack of senior staff working with people in crisis. Numerous models of emergency care have been demonstrated to be effective in specificsettings.To provide effective routineservices it is essentialthat there is close integration between emergency servicesand other aspects of the local community ser- vices, and that services are planned on the basis of the needs of the local population, ratherthan applyinga universal model of care. 835. A new paradigm: psychiatric disablements Chairmen: C Pull, T Ustun DISABILITY IN THE GB SURVEYS OF PSYCHIATRIC MORBIDITY RachelJenkins. Department of Health, Wellington House. 133 -155 Waterloo Road. LondonSEI BUG Data will be presented from the GB surveysof psychiatricmorbidity,
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Transcript of Tensions and challenges in the provision of emergency mental health services
192s A newparadigm: psychiatric disablements
home support are at least as effective for the patient as traditionalhospitalcare and follow-up, reducethe burdenon the family,and arealso moreeconomical.
An analysis of the data of the case register of the South VeronaCommunity Psychiatric Service (CPS) on home visiting during aIO-year period 0982-91) will be discussed in the presentation.South Verona CPS is a comprehensive and integrated communitybased mental health service where staff members are divided intothree multidisciplinary teams, each responsible for a subsector ofthe catchment area. They work both in the hospital ward and in thecommunity. While not yet offering a 24-hour a day mobile crisisteam, the service provides at-home interventions during workinghoursand ongoing care as needed. Case registerdata showthat whilean increase in out-patient community care and day care was takingplaceover the years, there wasa parallel fall in the use of publicandprivate hospital beds. Results of this study show that home-basedcare increasingly providedin the 1982-91 periodto all SouthVeronapatientswas associatedwith a decreasinguse of hospital beds.However, differences across age and sex groups appeared: the increaseof home-based care regarded older females,but not youngerfemalesand males. and was associated with a decreasing use of hospitalbeds in female patients (all diagnoses) and in female patients withaffective disorders and with other diagnoses, but not in those withschizophrenia and related disorders. In addition. the apparenteffectof this approach over the years was a distinct improvement of ourpsychiatric service in termsof workers' clinicalskillsand therapeuticeffectiveness.
COST BENEFIT STUDY OF DAY CARE - TilE EFFECT OFAN ATTACHED COMMUNITY PSYCHIATRIC NURSE
F.Creed. Department ofPsychiatry. RawnsleyBuilding. ManchesterRoyalInfirmary. OxfordRoad.Manchester, GB-MI3 9WL,GreatBritain
Previous studies have demonstrated that 30-409::of admissions to apsychiatric in-patient unit with acute illnesscan be treated in a wellstaffedday hospital. In thiscost effectiveness study, 179patientswithacute psychiatric illness were randomlyallocated to day hospitalorin-patient treatment. Nearly half the sample had schizophrenia. Thegroupswerewell matchedon baseline characteristics andclinicalandsocialoutcomewere similarat twelve months.exceptthat in-patientsimproved significantly faster thanday patients(p < 0.05) and burdenon relatives was significantly less in the day hospital group at oneyear (p < 0.05). Direct costs to the hospital were,on average, £2.786(SE ...) per patient cheaper for day hospital treatmentcompared toin-patienttreatment.
Patient travelcosts were significantly greater for day patientcareand there was a significantly greater loss of informant's income.When all direct and indirect costs were considered, day hospitaltreatment still proved to be £1,590 (SE = ..) cheaper. In addition todemonstrating that day hospital treatment is cheaper than in-patientcare, this study highlights the veryconsiderable distress experiencedby carersof peoplewith acute psychiatric illness.Thismayamounttoactual psychiatric disorder in the carer; it resolvesmoresatisfactorilywith day hospital treatment than in-patient treatment. By contrast,acute psychiatric disorder appears to resolve faster in the in-patientunit. These findings only apply to those 40% of patients presentingfor admission who can be treated in the day hospital and requirefurther study if we are to define optimal use of day and in-patienttreatmentfor acute illness.
FROM EMERGENCY TO SOCIAL PSYCHIATRIC SERVICECENTERS; THE AMSTERDAM EXPERIENCE
BertholdP.R. Gersons. Department ofPsychiatry; AMClUniversityofAmsterdam. Tafelbergweg 25. JJ50 BC Amsterdam. Netherlands
Outreaching emergency psychiatry has been the keystone in Dutchmental health to prevent admissions in mental hospitals. There wascomprehensiveness of acute service with its strong connection withpre- and aftercare. The expansion of the ambulatory mental healthcenters(RIAGG's)in the eighties, nowserving3%of the population,resulted in a disconnection of the acute services from continuity ofcare for chronic patients in the community. The mental hospitals inreaction to theambulatory expansion haveset upacutewardsto admitpatientsas shortas possible. Thispolicywasviewed asa 'principle' ofcommunity mental healthcare. The unforeseen resultwashoweveranenormousincrease of 100% in ten yearsof the numberof admissions.The settingup of socialpsychiatric servicecenters withcontinuityofcare,tailored treatment, partialhospitalization andrelatedto shelteredlivingarrangements and day-activity centers for a catchmentarea of100.000are the new solutions to offer in- and outpatient acute careagain relatedto the principles of continuity, Fromresearch it becameclear mostoutreaching servicescould be betterviewedas a repetitionof interventions for chronic patients. Continuityof care is now seenas the tool to counter the need for acutecare. In Amsterdam5 SocialPsychiatric ServiceCentersare operating. replacing the old hospitalsandofferingambulatory and inpatientcare.
TENSIONS AND CHALLENGES IN THE PROVISION OFEMERGENCY MENTAL HEALTH SERVICES
Michael Phelan. Consultant Psychiatrist, Riverside Mento! HealthTrust. Charing CrossHospital. London W88AF, UK
Inevitable conflicts arise when trying to provide emergency mentalhealth services. As a result patients often do not have a smoothpathway into care, and crisis services receive fierce criticism fromservice users. Difficulties facing those responsible for the provisionof emergency care include: lackof anyagreeddefinitionof whatconstitutes a psychiatric emergency; rising demand as services becomemore accessible and less stigmatising: economies of scale forcingout of hours services to be centralised and anonymous; limitedmultidisciplinary working and a 'lack of senior staff working withpeople in crisis. Numerous models of emergency care have beendemonstrated to be effective in specificsettings.To provide effectiveroutine services it is essential that there is close integration betweenemergency services and other aspects of the local community services, and that servicesare plannedon the basis of the needs of thelocal population, rather than applyinga universal modelof care.
835. A new paradigm: psychiatricdisablements
Chairmen: C Pull, T Ustun
DISABILITY IN THE GB SURVEYS OF PSYCHIATRICMORBIDITY
RachelJenkins. Department ofHealth, Wellington House. 133-155Waterloo Road. LondonSEI BUG
Datawill be presented fromthe GB surveysof psychiatricmorbidity,
