for flexibility raises a second general question. Given the diverse service needs of chronic mental patients, how may we know high quality when we see it? Stated differently, what outcome measures should we em ploy as we seek to evaluate services for chronic mentally ill individuals? Unfortunately, we have grown somewhat accustomed to the use of outcome measures that are superfi
The Chronic Patient
PlanningHigh-QualityServices
cial. We have historically equated favorable outcome with patients' member “¿by accident―in the local ability to engage in gainful employ supermarket; that is what fits cul ment and, even more often, with What does mean to provide “¿high turally. However, in otherplaces this their nonadmission to state mental kind of informality might well be quality― servicesto chronic mental hospitals (6), even though these par regarded as distinctly unprofessional patients? Surely, quality depends not ticular indices may have little to do and not at all indicative of high only on the availability ofa full array with the actual quality of care. An quality care. accessible services but also on the agency may be providing high The specific features ofquality in existence of provisions that ensure quality services even when individ service provision are also likely to continuity of care (1). The idea of ual patients are unemployed and differ for different subgroups within quality also implies the pursuit of even when substantial numbers of the diverse population of individuals such widely endorsed desiderata as called chronic mental patients. “¿Old them are admitted to state mental appropriate programming, individ hospitals, because precipitants for long-stay― patients—persons who ually prescribed interventions, and both of these events may be unre have resided in state hospitals for supportive social networks, al lated to service quality per se. years or decades (2)—often need though theseconcepts are difficult to Surely the general availability of traditional kinds of aftercare pro operationalize. jobs within a community affects the grams that allow them to make a In fact, high qualityin service pro employability ofindividual patients, vision is an elusive concept—an comfortable transition to life in the as does the fact that some in the pop community. However, these same abstraction that suggests different ulation, quite justifiably, may avoid programs may hold little relevance forces and events to different peo working for fear oflosing their Sup for the subpopulation of never-in pie. To understand its meaning in plemental Security Income allow stitutionalized individuals, which has any particular context, we must ances (7). Similarly, patients are reportedly been increasing in recent know something about the specific often admitted to state hospitals for years (3,4). patients to whom itapplies. We must reasons that are quite unrelated to Even among never-institutional also know something about a given deficiencies in their clinical care but ized individuals, programmatic service system's goals on behalf of are very much the result of external
Leona L Bachrach,
those patients
Ph.D.
needs are highly variable.
and about the specific
outcome indices that are used to as sess the realization ofthose goals. Thus, for example, practices re flecting high quality may vary among urban and rural communities. Or
they may may take on a distinctive directionforethnic populations.
orracial minority
In a neighborhood
I
know in Arizona, delivering high quality services sometimes means ar ranging to meet a patient or family
Dr. Bachrach is researchprofessor of psychiatry at the Maryland Psychiatric Research Center of the University of Maryland School of Medicine in Catons ville. Her address is 19108 An
Some pa
tients, who are screened for place ment in established community based alternative programs, are ap propriately diverted from state hos pital admission. Others, however, are claimed
by no agency
and have
never been institutionalized as the result of less positive gatekeeping practices (5). Many are undomiciled; they sleep on our streets and corn monly avoid traditional service set tings. For them, providing high
quality services may imply meeting them on their own ground, both literally and figuratively. The con cept of outreach may provide a productive focus in assessing the quality of care for these so-called n@i chronic patients.
changes affecting their support sys tems. They may, for example, become hospitalized on the death or tern porary
indisposition
of a parent
or
other caretaker in the community (8). Indeed, selection ofoutcome cri teria is a complicated endeavor, and it often suffers from inadequate
at
tention to incremental progress on the part of some patients (9). Be
cause they are simple and relatively easy to measure, outcome indices like employment status and rehospi talization sometimes appeal to cer
tamlegislatorsandfundingagents,
land 20879.
oping concepts ofquality. This need
but they do not necessarily reflect the realities that affect the lives of many chronic mental patients. Men tal health professionals must do a better job of impressing nonprofes sionals with the fact that, for some
268
March 1991
Hospital and Community Psychiatry
napolis Way, Gaithersburg,
Mary
We must thusbe flexible in devel
Vol. 42
No. 3
patients, progress is at best nearly imperceptible and that the quality of care cannot always be measured by dramatic results. These concerns bring up the question ofprogrammatic goals. The selection of outcome measures depends largely on what particular
tisans on this issue. Indeed, they often go beyond prescribing what is
service planners
patients is neither unitary nor easily measured. Its presence depends on a number of contextual variables and on the answers, at a minimum, to
and service
provid
ers want to accomplish in their pro grams for chronic mental patients. Thus, we must also know something
about the philosophical principles
desirable
for their own community
and strongly criticize other corn munities and other planners who do not share their views. In summary, then, the concept of
quality in services for chronic mental
three complex questions. First, we
that govern service development
must ask for whom—for which pa
about the cultural context of care
tients—quality
in a given community. Specific ideas of what constitutes high-quality 5cr vices inevitably derive from such an ideological framework. One area where differences are apparent is the use of pharmaco therapies in the care ofchronic men tal patients. Agencies, planners, cli nicians, and patients
themselves
hold
widely disparate views about how and when medications should be used. They also subscribe to a variety of solutions concerning how and where to treat homeless mentally ill individuals. Another areaofphilosophical dif ference involves attitudes toward state mental hospitals. Some individ uals strongly object to using these facilities for anything except “¿last resort―purposes, if at all. Others view episodes of hospitalization as clinically productive for some pa tients and see state hospitals as oc cupying an important and positive niche in the system of care.
To complicate the matter further, the perception ofappropriateness of state hospital care is notonly a matter of one's ideological preference; it may also depend, more rationally, on whether alternative programs for chronic mental patients have been established in the community. Nonetheless, state hospital use is commonly evaluated from the vantage point of one's own philo sophical
perspective,
even
though
no single view may be considered intrinsically correct. One might wish that, after 35 years ofdepopulating our state men tal hospitals, there could be greater tolerance for opposing positions, but humility
is not the strong suit of par
Hospital
and Community
Psychiatry
is being
assessed.
Second, we must have clearly delineated, realistic outcome mea sures that tell us how to recognize
quality in the services that we pro vide. And, third, we must be certain that those outcome measures are, in their turn, relevant to the goals that our service system espouses. The last ofthese points implies an even more difficult question. Not only must we be able to articulate and evaluate our own service dcliv cry goals, we must also consider
Oxford, England, Oxford University Press, 1981
3. BachrachU: A conceptual approach to deinstitutoonalization. Hospitaland Corn munity Psychiatry 29:573—578, 1978
4. BachrachU: Sociological factorsassoci ated with substance abuse among new chronic
patients,
in Adolescent
try: Developrnental
Psychia
and Clinical Studies.
Edited by Feinstein SC. Chicago, Uni versity
ofChicago
Press,
1989
5. Cohen NL (ed): Psychiatry Takes to the Streets. New York, Guilford, 1990 6. BachrachU: Assessrnentofoutcome in community
support
systems:
results,
problems, and limitations. Schizophre ma Bulletin
8:39—61, 1982
7. DeJong G, Batavia A!: Next step for the disabled. Washington Post, July 28, 1990, A19 8. Harris M, Bergman HC, Bachrach U: Psychiatric and nonpsychiatric
indicators
for hospitalization in a chronic patient population. Hospital and Community Psychiatry 37:630—631, 1986
9. Bachrach U: Measuring program out comes in Tucson. Hospital and Commu nityPsychiatry 38:1151—1152, 1987
10. Torrey EF,Wolfe SM: Care ofthe Seri ously MentallyIll:A RatingofState Pro grams,
2nd ed. Washington,
DC, Public
Citizen Health Research Group, 1988
how
to respond to differences in goals when we attempt to assess services in other communities. How much variability in goals is justified, and, conversely, at what point should we consider alternative goals to be viola tions of what is permissible, ethical, or humane? It is the relativity of goals and the precariousness of ab solute standards for evaluating them that decrease the value of nationwide ratings like those undertaken by Torrey and Wolfe (10). These questions are difficult ones, yet they must be considered if the words “¿high-quality services―are to hold any real meaning. In this mat terwe are once again reminded of the complexities inherent in planning and delivering services to chronic mental
patients. We may wish it were not so, but it seems that there are no easy answers in this business.
Need Expert Help? Try the Consultation Experienced American
Service
consultants
Psychiatric
from the
Association's
Consultation Service can help ad ministrators and clinicians in mental health facilities solve a wide range of problems that impinge on the dcliv cry ofhigh-quality
patient
care. The
service has provided consultation in such areas as long-term planning, program development, accredita tion, medical staffing, and adminis trative structure in both public and private settings. The Consultation Service is di rected by Bert Pepper, M.D., clinical professor of psychiatry at the New York University School of Mcdi cine in New York City. Stephen Green, M.D., clinical associate pro fessor of psychiatry
at Georgetown
University in Washington, D.C., is References 1. Bachrach planning
fl: The challenge of service for chronic mental patients.
Community Mental Health Journal 22: 170—174, 1986 2. WingJK, Morris B: Clinical basis of reha
bilitation, in Handbook ofPsychiatric Re habilitation. Edited byWingJK, Morris B.
March
1991
Vol. 42
No. 3
chairman of the Consultation 5cr vice board. For more information, write Susan Kuper, Consultation Service, APA, 1400 K Street, N.W., Wash ington, D.C. 20005, orcall 202-6826203.
269
The Chronic Patient
PlanningHigh-QualityServices
cial. We have historically equated favorable outcome with patients' member “¿by accident―in the local ability to engage in gainful employ supermarket; that is what fits cul ment and, even more often, with What does mean to provide “¿high turally. However, in otherplaces this their nonadmission to state mental kind of informality might well be quality― servicesto chronic mental hospitals (6), even though these par regarded as distinctly unprofessional patients? Surely, quality depends not ticular indices may have little to do and not at all indicative of high only on the availability ofa full array with the actual quality of care. An quality care. accessible services but also on the agency may be providing high The specific features ofquality in existence of provisions that ensure quality services even when individ service provision are also likely to continuity of care (1). The idea of ual patients are unemployed and differ for different subgroups within quality also implies the pursuit of even when substantial numbers of the diverse population of individuals such widely endorsed desiderata as called chronic mental patients. “¿Old them are admitted to state mental appropriate programming, individ hospitals, because precipitants for long-stay― patients—persons who ually prescribed interventions, and both of these events may be unre have resided in state hospitals for supportive social networks, al lated to service quality per se. years or decades (2)—often need though theseconcepts are difficult to Surely the general availability of traditional kinds of aftercare pro operationalize. jobs within a community affects the grams that allow them to make a In fact, high qualityin service pro employability ofindividual patients, vision is an elusive concept—an comfortable transition to life in the as does the fact that some in the pop community. However, these same abstraction that suggests different ulation, quite justifiably, may avoid programs may hold little relevance forces and events to different peo working for fear oflosing their Sup for the subpopulation of never-in pie. To understand its meaning in plemental Security Income allow stitutionalized individuals, which has any particular context, we must ances (7). Similarly, patients are reportedly been increasing in recent know something about the specific often admitted to state hospitals for years (3,4). patients to whom itapplies. We must reasons that are quite unrelated to Even among never-institutional also know something about a given deficiencies in their clinical care but ized individuals, programmatic service system's goals on behalf of are very much the result of external
Leona L Bachrach,
those patients
Ph.D.
needs are highly variable.
and about the specific
outcome indices that are used to as sess the realization ofthose goals. Thus, for example, practices re flecting high quality may vary among urban and rural communities. Or
they may may take on a distinctive directionforethnic populations.
orracial minority
In a neighborhood
I
know in Arizona, delivering high quality services sometimes means ar ranging to meet a patient or family
Dr. Bachrach is researchprofessor of psychiatry at the Maryland Psychiatric Research Center of the University of Maryland School of Medicine in Catons ville. Her address is 19108 An
Some pa
tients, who are screened for place ment in established community based alternative programs, are ap propriately diverted from state hos pital admission. Others, however, are claimed
by no agency
and have
never been institutionalized as the result of less positive gatekeeping practices (5). Many are undomiciled; they sleep on our streets and corn monly avoid traditional service set tings. For them, providing high
quality services may imply meeting them on their own ground, both literally and figuratively. The con cept of outreach may provide a productive focus in assessing the quality of care for these so-called n@i chronic patients.
changes affecting their support sys tems. They may, for example, become hospitalized on the death or tern porary
indisposition
of a parent
or
other caretaker in the community (8). Indeed, selection ofoutcome cri teria is a complicated endeavor, and it often suffers from inadequate
at
tention to incremental progress on the part of some patients (9). Be
cause they are simple and relatively easy to measure, outcome indices like employment status and rehospi talization sometimes appeal to cer
tamlegislatorsandfundingagents,
land 20879.
oping concepts ofquality. This need
but they do not necessarily reflect the realities that affect the lives of many chronic mental patients. Men tal health professionals must do a better job of impressing nonprofes sionals with the fact that, for some
268
March 1991
Hospital and Community Psychiatry
napolis Way, Gaithersburg,
Mary
We must thusbe flexible in devel
Vol. 42
No. 3
patients, progress is at best nearly imperceptible and that the quality of care cannot always be measured by dramatic results. These concerns bring up the question ofprogrammatic goals. The selection of outcome measures depends largely on what particular
tisans on this issue. Indeed, they often go beyond prescribing what is
service planners
patients is neither unitary nor easily measured. Its presence depends on a number of contextual variables and on the answers, at a minimum, to
and service
provid
ers want to accomplish in their pro grams for chronic mental patients. Thus, we must also know something
about the philosophical principles
desirable
for their own community
and strongly criticize other corn munities and other planners who do not share their views. In summary, then, the concept of
quality in services for chronic mental
three complex questions. First, we
that govern service development
must ask for whom—for which pa
about the cultural context of care
tients—quality
in a given community. Specific ideas of what constitutes high-quality 5cr vices inevitably derive from such an ideological framework. One area where differences are apparent is the use of pharmaco therapies in the care ofchronic men tal patients. Agencies, planners, cli nicians, and patients
themselves
hold
widely disparate views about how and when medications should be used. They also subscribe to a variety of solutions concerning how and where to treat homeless mentally ill individuals. Another areaofphilosophical dif ference involves attitudes toward state mental hospitals. Some individ uals strongly object to using these facilities for anything except “¿last resort―purposes, if at all. Others view episodes of hospitalization as clinically productive for some pa tients and see state hospitals as oc cupying an important and positive niche in the system of care.
To complicate the matter further, the perception ofappropriateness of state hospital care is notonly a matter of one's ideological preference; it may also depend, more rationally, on whether alternative programs for chronic mental patients have been established in the community. Nonetheless, state hospital use is commonly evaluated from the vantage point of one's own philo sophical
perspective,
even
though
no single view may be considered intrinsically correct. One might wish that, after 35 years ofdepopulating our state men tal hospitals, there could be greater tolerance for opposing positions, but humility
is not the strong suit of par
Hospital
and Community
Psychiatry
is being
assessed.
Second, we must have clearly delineated, realistic outcome mea sures that tell us how to recognize
quality in the services that we pro vide. And, third, we must be certain that those outcome measures are, in their turn, relevant to the goals that our service system espouses. The last ofthese points implies an even more difficult question. Not only must we be able to articulate and evaluate our own service dcliv cry goals, we must also consider
Oxford, England, Oxford University Press, 1981
3. BachrachU: A conceptual approach to deinstitutoonalization. Hospitaland Corn munity Psychiatry 29:573—578, 1978
4. BachrachU: Sociological factorsassoci ated with substance abuse among new chronic
patients,
in Adolescent
try: Developrnental
Psychia
and Clinical Studies.
Edited by Feinstein SC. Chicago, Uni versity
ofChicago
Press,
1989
5. Cohen NL (ed): Psychiatry Takes to the Streets. New York, Guilford, 1990 6. BachrachU: Assessrnentofoutcome in community
support
systems:
results,
problems, and limitations. Schizophre ma Bulletin
8:39—61, 1982
7. DeJong G, Batavia A!: Next step for the disabled. Washington Post, July 28, 1990, A19 8. Harris M, Bergman HC, Bachrach U: Psychiatric and nonpsychiatric
indicators
for hospitalization in a chronic patient population. Hospital and Community Psychiatry 37:630—631, 1986
9. Bachrach U: Measuring program out comes in Tucson. Hospital and Commu nityPsychiatry 38:1151—1152, 1987
10. Torrey EF,Wolfe SM: Care ofthe Seri ously MentallyIll:A RatingofState Pro grams,
2nd ed. Washington,
DC, Public
Citizen Health Research Group, 1988
how
to respond to differences in goals when we attempt to assess services in other communities. How much variability in goals is justified, and, conversely, at what point should we consider alternative goals to be viola tions of what is permissible, ethical, or humane? It is the relativity of goals and the precariousness of ab solute standards for evaluating them that decrease the value of nationwide ratings like those undertaken by Torrey and Wolfe (10). These questions are difficult ones, yet they must be considered if the words “¿high-quality services―are to hold any real meaning. In this mat terwe are once again reminded of the complexities inherent in planning and delivering services to chronic mental
patients. We may wish it were not so, but it seems that there are no easy answers in this business.
Need Expert Help? Try the Consultation Experienced American
Service
consultants
Psychiatric
from the
Association's
Consultation Service can help ad ministrators and clinicians in mental health facilities solve a wide range of problems that impinge on the dcliv cry ofhigh-quality
patient
care. The
service has provided consultation in such areas as long-term planning, program development, accredita tion, medical staffing, and adminis trative structure in both public and private settings. The Consultation Service is di rected by Bert Pepper, M.D., clinical professor of psychiatry at the New York University School of Mcdi cine in New York City. Stephen Green, M.D., clinical associate pro fessor of psychiatry
at Georgetown
University in Washington, D.C., is References 1. Bachrach planning
fl: The challenge of service for chronic mental patients.
Community Mental Health Journal 22: 170—174, 1986 2. WingJK, Morris B: Clinical basis of reha
bilitation, in Handbook ofPsychiatric Re habilitation. Edited byWingJK, Morris B.
March
1991
Vol. 42
No. 3
chairman of the Consultation 5cr vice board. For more information, write Susan Kuper, Consultation Service, APA, 1400 K Street, N.W., Wash ington, D.C. 20005, orcall 202-6826203.
269
