86
ANZJP Correspondence
statistics/bod_schizophrenia.pdf (accessed 17 August 2014). Christensen H and Petrie K (2013) Suicide prevention: signposts for a new approach. Medical Journal of Australia 198: 472–474. Ferrari AJ, Somerville AJ, Baxter AJ, et al. (2013) Global variation in the prevalence and
incidence of major depressive disorder: a systematic review of the epidemiological literature. Psychological Medicine 43: 471–481. Goldsmith S, Pellmar T, Kleinman A, et al. (2002) Reducing Suicide: A National Imperative. Washington, DC: The National Academies Press.
Pridmore S (2015) Mental disorder and suicide: A faulty connection. Australian and New Zealand Journal of Psychiatry 49: 18–20. World Health Organization (2014) Global status report on alcohol and health 2014. Geneva: WHO.
Community based residential mental health services: What do we need to know? Stephen Parker1-4, Dan Siskind1-4 and Meredith Harris1,2
include crisis houses, alternative to admission services (Siskind et al., 2013) and step-up/step-down facilities, while non-acute services include community care units (Trauer et al., 2001) and transitional housing services. Being community based they are considered less restrictive and regimented models of care, and as such they may be less isolating and stigmatising. There is evidence to suggest that care in such non-hospital settings is preferred by consumers (Trauer et al., 2001, Thomas and Rickwood, 2013). However, it is less clear the extent to which these services should be regarded as an alternative to existing acute inpatient and extended treatment and rehabilitation hospital based care, or an additional option in the available array of needsbased service types. There remains a lack of consensus about what mental health services should be provided in hospital and community settings, and many of the established models of service remain largely untested. The ‘stepped care’ approach advocated by Thornicroft and Tansella (2013) suggests that, in high-income countries, non- and subacute residential bed based services should be added to the existing service array. This complementary approach to service planning and delivery has an inherent logic. However, the reality is that new service models may be implemented as replacements for existing modes of service provision before they have been adequately tested and eligibility issues clarified. Transferring funding to new services may lead to essential services being diminished, with new services meeting the needs of a different consumer group. This can place strain on other parts of the health system.
The recent commentary by Allison et al. (2014) highlights deficits in our understanding of the value and role of residential mental health service types, specifically the sub-acute services, within the existing and future mental health service array. These deficits relate to our understanding of: (1) whether new sub-acute models are servicing different populations to those met by existing acute inpatient services; (2) whether new sub-acute models achieve the comparable clinical outcomes compared to acute inpatient services; and (3) the impact of provision of these beds on emergency department presentations. These questions are especially relevant given the ongoing push towards delivery of mental health services in community settings and the impact of economic austerity on resource availability.
1Queensland
Centre for Mental Health Research, Brisbane, Australia 2The University of Queensland, School of Population Health, Brisbane, Australia 3The University of Queensland, School of Medicine, Brisbane, Australia 4Metro South Addiction and Mental Health Service, Brisbane, Australia Corresponding author: Stephen Parker, Queensland Centre for Mental Health Research, The Park Centre for Mental Health, Locked Bag 500, Sumner Park BC, QLD 4074, Australia. Email: [email protected] DOI: 10.1177/0004867414557163
Introduction Emerging models of residential mental health services have been the subject of attention in recent issues of the Australian and New Zealand Journal of Psychiatry (Allison et al., 2014, Siskind et al., 2013). These models aim to meet the bed-based care and rehabilitation needs of consumers in non-hospital settings. Although there are no agreed standard definitions, it is common to classify residential mental health services into sub-acute and non-acute service types. These services should span a continuum of consumer need based on acuity of illness. The distinction between sub-acute and non-acute is often expressed in terms of the duration of care, intensity of care required, and staffing level and type (Siskind et al., 2013). Examples of sub-acute services
Australian & New Zealand Journal of Psychiatry, 49(1)
What does the research tell us? In response to the three areas of limited understanding noted by Allison et al. (2014) we reviewed the findings from randomised controlled trials comparing sub-acute residential services to acute inpatient services. Nine studies were identified, all had been included in the systematic review by Thomas and Rickwood (2013) of residential alternatives to inpatient care. Our review (details available on request) found that these residential alternatives served only a select subgroup of patients. The alternative care was only offered to voluntary patients, with complexities such as violence risk, detoxification or medical comorbidity generally resulting in exclusion from participation. Outcomes, as measured on clinical measures and by length of stay, for consumers using
87
ANZJP Correspondence the alternative residential services were generally comparable to consumers admitted to acute inpatient services. However, two studies suggested that this was achieved with a longer length of stay. Similarly, the majority of papers suggested comparable outcomes in terms of emergency presentations and acute care use in the year post-discharge.
Implications Our brief review of the literature on community based residential alternatives to acute psychiatric care suggests that these services are not alternatives for all patients, and as such are not completely substitutable for acute care. These services are best classified as ‘sub-acute’ and appear to only be able to service the needs of a select sub-group of patients. This supports the call for hesitancy and concern, where new bed-based capacity is created at the expense of existing inpatient beds. Especially where the availability of acute inpatient beds is not expanding commensurate to population growth. There is a risk of increasing pressure for those with the highest level of care needs. Additionally, there are risks associated with the concentration of severe end of acuity and risk in
inpatient facilities. Such concentration may make these settings more traumatising, and reduce opportunities to learn and model more adaptive ways of coping from peers through the therapeutic milieu. There are multiple challenges to resolving questions about the right mix of services, and what service models should look like, with reference to existing literature. Lack of consistent terminology to describe service types impacts on the ability to compare findings across settings. For example, referring to these as ‘acute’ alternatives for inpatient care, when many of these options appear on face value to offer a ‘sub-acute’ service, adds to the confusion. Similar to what has been achieved with Assertive Community Treatment, improved definitional clarity might facilitate identification of the key components of existing service models, and aid services in working towards maintaining fidelity with best practice. Furthermore, there are issues relating to relevance shift that impact on the ability to meaningfully synthesise the literature as models of service and the consumers they serve change overtime in response to social, political and economic forces. Increased research efforts to understand and synthesise the existing literature are needed, as well as efforts to ensure
better coordination and comparability of services research in the future. Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. See Commentary by Allison et al., 2014, 48(10): 952-954; See also Research by Siskind et al., 2013, 47(7): 667–675.
References Allison S, Bastiampillai T and Goldney R (2014) Acute versus sub-acute care beds: Should Australia invest in community beds at the expense of hospital beds? Australian and New Zealand Journal of Psychiatry 48: 952–954. Siskind D, Harris M, Kisely S, Brogan J, Pirkis J, Crompton D, et al. (2013) A retrospective quasi-experimental study of a community crisis house for patients with severe and persistent mental illness. Australian and New Zealand Journal of Psychiatry 47: 667–675. Thomas KA and Rickwood D (2013) Clinical and cost-effectiveness of acute and subacute residential mental health services: a systematic review. Psychiatric Services 64: 1140–1149. Thornicroft G and Tansella M (2013) The balanced care model for global mental health. Psychological Medicine 43: 849–863. Trauer T, Farhall J, Newton R and Cheung P (2001) From long-stay psychiatric hospital to Community Care Unit: evaluation at 1 year. Social psychiatry and psychiatric epidemiology 36: 416–419.
Australian & New Zealand Journal of Psychiatry, 49(1)
Copyright of Australian & New Zealand Journal of Psychiatry is the property of Sage Publications, Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
ANZJP Correspondence
statistics/bod_schizophrenia.pdf (accessed 17 August 2014). Christensen H and Petrie K (2013) Suicide prevention: signposts for a new approach. Medical Journal of Australia 198: 472–474. Ferrari AJ, Somerville AJ, Baxter AJ, et al. (2013) Global variation in the prevalence and
incidence of major depressive disorder: a systematic review of the epidemiological literature. Psychological Medicine 43: 471–481. Goldsmith S, Pellmar T, Kleinman A, et al. (2002) Reducing Suicide: A National Imperative. Washington, DC: The National Academies Press.
Pridmore S (2015) Mental disorder and suicide: A faulty connection. Australian and New Zealand Journal of Psychiatry 49: 18–20. World Health Organization (2014) Global status report on alcohol and health 2014. Geneva: WHO.
Community based residential mental health services: What do we need to know? Stephen Parker1-4, Dan Siskind1-4 and Meredith Harris1,2
include crisis houses, alternative to admission services (Siskind et al., 2013) and step-up/step-down facilities, while non-acute services include community care units (Trauer et al., 2001) and transitional housing services. Being community based they are considered less restrictive and regimented models of care, and as such they may be less isolating and stigmatising. There is evidence to suggest that care in such non-hospital settings is preferred by consumers (Trauer et al., 2001, Thomas and Rickwood, 2013). However, it is less clear the extent to which these services should be regarded as an alternative to existing acute inpatient and extended treatment and rehabilitation hospital based care, or an additional option in the available array of needsbased service types. There remains a lack of consensus about what mental health services should be provided in hospital and community settings, and many of the established models of service remain largely untested. The ‘stepped care’ approach advocated by Thornicroft and Tansella (2013) suggests that, in high-income countries, non- and subacute residential bed based services should be added to the existing service array. This complementary approach to service planning and delivery has an inherent logic. However, the reality is that new service models may be implemented as replacements for existing modes of service provision before they have been adequately tested and eligibility issues clarified. Transferring funding to new services may lead to essential services being diminished, with new services meeting the needs of a different consumer group. This can place strain on other parts of the health system.
The recent commentary by Allison et al. (2014) highlights deficits in our understanding of the value and role of residential mental health service types, specifically the sub-acute services, within the existing and future mental health service array. These deficits relate to our understanding of: (1) whether new sub-acute models are servicing different populations to those met by existing acute inpatient services; (2) whether new sub-acute models achieve the comparable clinical outcomes compared to acute inpatient services; and (3) the impact of provision of these beds on emergency department presentations. These questions are especially relevant given the ongoing push towards delivery of mental health services in community settings and the impact of economic austerity on resource availability.
1Queensland
Centre for Mental Health Research, Brisbane, Australia 2The University of Queensland, School of Population Health, Brisbane, Australia 3The University of Queensland, School of Medicine, Brisbane, Australia 4Metro South Addiction and Mental Health Service, Brisbane, Australia Corresponding author: Stephen Parker, Queensland Centre for Mental Health Research, The Park Centre for Mental Health, Locked Bag 500, Sumner Park BC, QLD 4074, Australia. Email: [email protected] DOI: 10.1177/0004867414557163
Introduction Emerging models of residential mental health services have been the subject of attention in recent issues of the Australian and New Zealand Journal of Psychiatry (Allison et al., 2014, Siskind et al., 2013). These models aim to meet the bed-based care and rehabilitation needs of consumers in non-hospital settings. Although there are no agreed standard definitions, it is common to classify residential mental health services into sub-acute and non-acute service types. These services should span a continuum of consumer need based on acuity of illness. The distinction between sub-acute and non-acute is often expressed in terms of the duration of care, intensity of care required, and staffing level and type (Siskind et al., 2013). Examples of sub-acute services
Australian & New Zealand Journal of Psychiatry, 49(1)
What does the research tell us? In response to the three areas of limited understanding noted by Allison et al. (2014) we reviewed the findings from randomised controlled trials comparing sub-acute residential services to acute inpatient services. Nine studies were identified, all had been included in the systematic review by Thomas and Rickwood (2013) of residential alternatives to inpatient care. Our review (details available on request) found that these residential alternatives served only a select subgroup of patients. The alternative care was only offered to voluntary patients, with complexities such as violence risk, detoxification or medical comorbidity generally resulting in exclusion from participation. Outcomes, as measured on clinical measures and by length of stay, for consumers using
87
ANZJP Correspondence the alternative residential services were generally comparable to consumers admitted to acute inpatient services. However, two studies suggested that this was achieved with a longer length of stay. Similarly, the majority of papers suggested comparable outcomes in terms of emergency presentations and acute care use in the year post-discharge.
Implications Our brief review of the literature on community based residential alternatives to acute psychiatric care suggests that these services are not alternatives for all patients, and as such are not completely substitutable for acute care. These services are best classified as ‘sub-acute’ and appear to only be able to service the needs of a select sub-group of patients. This supports the call for hesitancy and concern, where new bed-based capacity is created at the expense of existing inpatient beds. Especially where the availability of acute inpatient beds is not expanding commensurate to population growth. There is a risk of increasing pressure for those with the highest level of care needs. Additionally, there are risks associated with the concentration of severe end of acuity and risk in
inpatient facilities. Such concentration may make these settings more traumatising, and reduce opportunities to learn and model more adaptive ways of coping from peers through the therapeutic milieu. There are multiple challenges to resolving questions about the right mix of services, and what service models should look like, with reference to existing literature. Lack of consistent terminology to describe service types impacts on the ability to compare findings across settings. For example, referring to these as ‘acute’ alternatives for inpatient care, when many of these options appear on face value to offer a ‘sub-acute’ service, adds to the confusion. Similar to what has been achieved with Assertive Community Treatment, improved definitional clarity might facilitate identification of the key components of existing service models, and aid services in working towards maintaining fidelity with best practice. Furthermore, there are issues relating to relevance shift that impact on the ability to meaningfully synthesise the literature as models of service and the consumers they serve change overtime in response to social, political and economic forces. Increased research efforts to understand and synthesise the existing literature are needed, as well as efforts to ensure
better coordination and comparability of services research in the future. Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. See Commentary by Allison et al., 2014, 48(10): 952-954; See also Research by Siskind et al., 2013, 47(7): 667–675.
References Allison S, Bastiampillai T and Goldney R (2014) Acute versus sub-acute care beds: Should Australia invest in community beds at the expense of hospital beds? Australian and New Zealand Journal of Psychiatry 48: 952–954. Siskind D, Harris M, Kisely S, Brogan J, Pirkis J, Crompton D, et al. (2013) A retrospective quasi-experimental study of a community crisis house for patients with severe and persistent mental illness. Australian and New Zealand Journal of Psychiatry 47: 667–675. Thomas KA and Rickwood D (2013) Clinical and cost-effectiveness of acute and subacute residential mental health services: a systematic review. Psychiatric Services 64: 1140–1149. Thornicroft G and Tansella M (2013) The balanced care model for global mental health. Psychological Medicine 43: 849–863. Trauer T, Farhall J, Newton R and Cheung P (2001) From long-stay psychiatric hospital to Community Care Unit: evaluation at 1 year. Social psychiatry and psychiatric epidemiology 36: 416–419.
Australian & New Zealand Journal of Psychiatry, 49(1)
Copyright of Australian & New Zealand Journal of Psychiatry is the property of Sage Publications, Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
