Structures and processes necessary for providing effective home treatment to severely mentally ill persons: a naturalistic study.

BACKGROUND: Home treatment for severely mentally ill persons is becoming increasingly popular. This research aims to identify structures and processes in home treatment that impact on patient-related outcomes. METHODS: We analysed 17 networks that provide home treatment to severely mentally ill persons using a naturalistic approach. The networks were similar with regard to central components of home treatment such as case management, 24 h crisis hotline and home visits, but differed in all other aspects such as the multidisciplinary teams, time spent with patients, etc. To determine treatment outcome, patients' psychosocial functioning was measured using the Health of the Nation Outcome Scales (HoNOS). Structures and processes were assessed using claims data and questionnaires answered by the different networks. Primary outcome was highlighted by the change in HoNOS scores from the start of home treatment compared with 6 months later. We sought to explain this outcome through patient and network characteristics using regression analysis. Data on 3,567 patients was available. RESULTS: On average, psychosocial functioning improved by 0.84 across networks between t0 and t1. There were more similarities than differences between the networks with regard to the structures and processes that we tested. A univariate regression analysis found staff's prior experience in mental health care and the effort that they invested in their work correlated positively with patient outcome. This needs to be interpreted under considering that univariate analysis does not show causal relationship. A high case load per case manager, increased and longer patient contact and more family intervention were correlated with worse patient outcome, probably indicating that sicker patients receive more care and intervention. CONCLUSION: Home treatment networks succeed in delivering care tailored to the needs of patients. In order to improve the quality of care in home treatment, this study suggests employing experienced staff who is ready to invest more effort in their patients. Further research needs to consider a longer follow-up time.

Assessing the performance of mental health service facilities for meeting patient priorities and health service responsiveness.

The World Health Organisation has defined health service responsiveness as one of the key-objectives of health systems. Health service responsiveness relates to the ability to respond to service users' legitimate expectations on non-medical issues when coming into contact with the services of a healthcare system. It is defined by the areas showing respect for persons and patient orientation. Health service responsiveness is particularly relevant to mental health services, due to the specific vulnerability of mental health patients but also because it matches what mental health patients consider as good quality of care as well as their priorities when seeking healthcare. As (mental) health service responsiveness applies equally to all concerned services it would be suitable as a universal indicator for the quality of services' performance. However, performance monitoring programs in mental healthcare rarely assess health service performance with respect to meeting patient priorities. This is in part due of patient priorities as an outcome being underrepresented in studies that evaluate service provision. The lack of studies using patient priorities as outcomes transmits into evidence based guidelines and subsequently, into underrepresentation of patient priorities in performance monitoring. Possible ways out of this situation include more intervention studies using patient priorities as outcome, considering evidence from qualitative studies in guideline development and developing performance monitoring programs along the patient pathway and on key-points of relevance for service quality from a patient perspective.

Pathologic gambling.

Pathologic gambling is recognized and clearly defined by the American Psychiatric Association. However, many Americans suffer from an addiction to gambling that is undiagnosed and, therefore, untreated. Pathologic gambling, like any other addiction, can be devastating. Because of the personality characteristic of the pathologic gambler, detecting and diagnosing the problem is difficult. In many cases, the symptoms of gambling addiction, although distinct, are not recognized until a devastating event occurs. The older adult in particular is at great risk for addiction to gambling. Health care providers must be aware of the warning signs and symptoms of addiction to gambling and be ready to provide information that will assist their clients in addressing it. Unfortunately, few programs exist in this country to treat the many people suffering from this addiction. With the current movement to legalize gambling and the increasing popularity of lotteries in many states, the problem of pathologic gambling is sure to escalate.

Admission health status differences of black and white indigent nursing home residents.

OBJECTIVE: To compare the health status of newly admitted lower socioeconomic status (SES) southern black (n = 81) and white (n = 53) nursing home residents. DESIGN: The study data were part of a larger prospective study on the health of newly admitted nursing home residents. SETTING: A 575-bed, government-funded nursing home providing care for indigent residents in a large southern city. PARTICIPANTS: Newly admitted black and white nursing home residents aged 60 and older. MEASUREMENTS: Mental status was measured using the Short Portable Mental Status Questionnaire, activities of daily living by Scaled Outcome Criteria, and medical status by medical diagnoses and medications. MAIN RESULTS: Blacks entering the nursing home were more cognitively and functionally impaired and had 3.7 years less education than white residents, but average age was not significantly different for black and white residents. CONCLUSIONS: Many common health status measures showed no significant black-white differences for institutionalized older adults when region and SES were constants. However, mental status, self-care activities, and marital status were significantly different. These findings indicate a possible impact of lifelong poverty or low educational attainment on the increased disability of indigent black older adults. Black residents in our study had less spousal support to remain in the community.