Acute mental health care according to recent mental health legislation Part II. Activity-based costing

Objective: This is the second of three reports on the follow-up review of mental health care at Helen Joseph Hospital (HJH). Objectives for the review were to provide realistic estimates of cost for unit activities and to establish a quality assurance cycle that may facilitate cost centre management. Method: The study described and used activity-based costing (ABC) as an approach to analyse the recurrent cost of acute in-patient care for the financial year 2007-08. Fixed (e.g. goods and services; staff salaries) and variable recurrent costs (including laboratory'; 'pharmacy') were calculated. Cost per day; per user and per diagnostic group was calculated. Results: While the unit accounted for 4.6of the hospital's total clinical activity (patient days); the cost of R8.12 million incurred represented only 2.4of the total hospital expenditure (R341.36 million). Fixed costs constituted 90of the total cost. For the total number of 520 users that stayed on average 15.4 days; the average cost was R1;023.00 per day and R15748.00 per user. Users with schizophrenia accounted for the most (35) of the cost; while the care of users with dementia was the most expensive (R23;360.68 per user). Costing of the application of World Health Organization norms for acute care staffing for the unit; projected an average increase of 103in recurrent costs (R5.1 million); with the bulk (a 267increase) for nursing. Conclusion: In the absence of other guidelines; aligning clinical activity with the proportion of the hospital's total budget may be an approach to determine what amount should be afforded to acute mental health in-patient care activities in a general regional hospital such as HJH. Despite the potential benefits of ABC; its continued application will require time; infrastructure and staff investment to establish the capacity to maintain routine annual cost analyses for different cost centres

Acute mental health care according to recent mental health legislation. Part III. Structuring space for acute mental health care

Objective: This is the third of three reports on the follow-up review of mental health care at Helen Joseph Hospital (HJH). The study reviewed existing South African standards for mental health care facilities. Architectural principles and implications for the use of space were deducted from recent legislation. Objectives were to evaluate the use of space in the existing physical facilities; to identify appropriate architectural solutions considering identified human rights requirements and to provide provisional cost estimates to align the unit towards its designated functions. Method: Personal interviews were conducted. An on-site assessment and survey was made of existing and potential new spaces. Results: Spatial requirements for implementing the Mental Health Act; No. 17 of 2002 (MHCA) were explored. Principles for spatial design of acute facilities include that: - spaces should communicate clear individual identity; - space should be segregated into zones according to user functionality and privacy; - communal leisure spaces should open into safe contained outdoor spaces; - circulation routes should preferably be circular; - sufficient visual connection should exist between circulation space and group activities; and - open lines of sight should be provided to all access points. The potential options for extension included: - an extensive unused single storey structural shell for a potential office wing on the same floor; - a huge vacant double volume space which could be accessed across the existing flat roof for potential occupational therapy activities; and - the existing roof area could be altered and secured to become an adequate outside leisure and garden area. A proposed concept design in two phases - based on these principles - was submitted to hospital and provincial management. Conclusion: To implement the MHCA without violating the human rights of mental health care users at HJH will require specific adjustment and extension of the current use of space at HJH

Acute mental health care and South African mental health legislation Part 1- morbidity, treatment and outcome

Objective: This is the first of three reports on a follow-up review of mental health care at Helen Joseph Hospital (HJH). In this first part; qualitative and quantitative descriptions were made of the services and of demographic and clinical data on acute mental health care users managed at HJH; in a retrospective review of clinical records over a four year period. Objectives for this review were to provide information on mental health care outcome; to do a cost analysis and to establish a quality assurance cycle that may facilitate a cost centre management approach. The operational areas identified were service delivery; teaching; and research. Activities within each area were in-patient care; out-patients and consultation/liaison; under- and postgraduate teaching and self initiated or contract research. Method: The study reviewed the existing mental health care program and activities in context of relevant policy and legislation. Results: Norms from a World Health Organization model for acute mental health care showed that significant staff shortages existed; especially for nursing. A total of 520 users were admitted for in-patient mental health care during the financial year 2007/08. The average length of stay was 15.4 days and ranged from 1 to 85 days. Ninety users (17) had an extended period of stay of 25 days and more; while 39 users had multiple admissions during the 12 month period. The most common Axis I diagnoses made were schizophrenia n=138 (29); substance-related conditions n=99 (21) and bipolar mood disorder n=69 (14). After discharge; 139 users (27) were referred back to the HJH out-patient department for follow-up. Conclusion: The information from these reports may be used in the allocation of adequate resources to align this acute unit with its responsibilities according to recent legislation