Is Deinstitutionalization Working In

Feature Article_726 274..283

Is deinstitutionalization working inour community?

Ann Hamden,1 Richard Newton,2 Kay McCauley-Elsom3 and Wendy Cross41Community Mental Health, Latrobe Regional Hospital, Traralgon, 2Mental Health CSU, Austin Health, 3School ofNursing, Monash University, Peninsula Campus, and 4School of Nursing and Midwifery, Monash University,Melbourne, Victoria, Australia

ABSTRACT: This exploratory study examined the impact of deinstitutionalization on consumersadmitted to a regional community care unit (CCU) between 1996 and 2007, and looked at lengths ofstay and re-admissions to acute psychiatric care units and the impact this might have on quality of life.The results showed that the original and current residents of CCU have improved quality of lifethrough friendships, a home-like environment, and reduced re-admissions to acute psychiatric careunits; however, further improvements can be made with more emphasis on employment/vocationalservices and social inclusion. More concerning is those who are unable to access a CCU bed due tochronic CCU bed shortages. This group, referred to as the new chronic patients, tend to becomevictims of the revolving door phenomenon, homelessness, and substance abuse. The assertive com-munity treatment model of care and community packages are recommended for people on waiting listsfor CCU, or those who do not fit the CCU criteria, to try and reduce the level of disability that is likelyto occur from frequent relapses.

KEYWORDS: assertive community treatment, community care unit, deinstitutionalization, psycho-social treatment, revolving door, substance abuse.

INTRODUCTION

To many, deinstitutionalization was the closing down ofpsychiatric health institutions and placing the occupantsinto the community with or without follow-up care. Tothe reformist, it meant both the closure of the institutionsand their replacement with a range of community-basedservices, including residential and inpatient services andtreatment within the home.

In early 1990 under the Labor Government mul-tiple asylums across Victoria, Australia were consuming

a large proportion of the state budget. As part of abroader policy of deinstitutionalization community careunits (CCU) were established in Victoria to accommo-date people remaining in long-term psychiatric settings.The CCU in this study is a 20-bed cluster housing devel-opment in a residential setting, staffed on a 24-hourbasis by a multidisciplinary team. It was establishedwith the twin goals of clinical care and rehabilitationof the residents. Little is known about the long-termoutcomes for these consumers and the impact on theyounger generation with chronic, severe mental illness(SMI).

A study by Farhall et al. (1999) concluded that after1 year, there was little change in the symptoms or disabil-ity levels of the residents, although residents reportedimproved levels of quality of life, particularly in theirliving environment.

Relatives and carers also reported a preference for theCCU setting for their relatives over hospitalization.

Correspondence: Ann Hamden, General Manager CommunityMental Health, Latrobe Regional Hospital, 20 Washington Street,Traralgon, Vic. 3844, Australia. Email: [email protected]

Ann Hamden, RN, RPN, MN.Richard Newton, MBChB, MRCPsych, AFRACMA, FRANZCP.Kay McCauley-Elsom, RN, RM, PhD.Wendy Cross, RN, PhD.Accepted November 2010.

International Journal of Mental Health Nursing (2011) 20, 274283 doi: 10.1111/j.1447-0349.2010.00726.x

2011 The AuthorsInternational Journal of Mental Health Nursing 2011 Australian College of Mental Health Nurses Inc.

Background and literature review

Deinstitutionalization began as far back as the 1950s andhas led to the downsizing and closing of multiple asylumsacross the world (Fakhoury & Priebe 2002). However,Mechanic and Rochfort (1990) believe that deinstitu-tionalization has not been implemented consistentlyacross geographic areas, and policy does not stipulate theexpected outcomes.

Although, globally, deinstitutionalization began some60 years ago, Sealy and Whitehead (2004) assert that it isnot complete because there are no measures to determinewhen the expansion of community-based services hasbeen completed. Furthermore, Fakhoury and Priebe(2007) stated that there are still many large tertiary long-term care facilities and no community-based mentalhealth services in many countries, despite deinstitution-alization occurring in several countries.

The process of deinstitutionalization in mental healthservices seems to be progressing at different paces inseveral countries where the problems vary in relation tosocioeconomic situations, funding arrangements, and spe-cific traditions. According to Fakhoury and Priebe (2002)and Sealy and Whitehead (2004), the quality of mentalhealth systems depends on these factors as well associal acceptance of deinstitutionalization. The AustralianNational Mental Health Strategy (1992) was the drivingforce behind deinstitutionalization in Victoria. In additionto the establishment of CCU, it also included the deve-lopment of the crisis assessment and treatment teams,mobile support and treatment services, continuing careservices, and community mental health clinics. Acuteinpatient services were co-located and mainstreamed withgeneral hospitals along with secure extended-care unitswhich provide medium- to long-term inpatient treatmentand rehabilitation for people who have unremittingand severe symptoms of mental illness with an associ-ated significant disturbance in behaviour that precludetheir living in a less restricted environment (VictorianGovernment 2007).

According to Newton et al. (2000) in the early 1990slarge metropolitan psychiatric services were reportedlyconsuming 45% of the budget of mental and generalhealth services, through administration and infrastruc-ture. To address this issue, the Victorian Governmentestablished CCU across the state. The development ofsupported accommodation in the community has hadsome encouraging outcomes for residents, at least in theshort term, both here and overseas (Farhall et al. 1999;Hobbs et al. 2000; Leff & Trieman 2000). The emergenceof consumer and family self-help and advocacy groups

also assisted in the development of a more humani-stic treatment system (Lamb et al. 2003). An increase inopportunities for long-stay residents to regain social inclu-sion was anticipated to be another positive aspect ofdeinstitutionalization (Newton et al. 2000).

Unfortunately, the evidence for the success of deinsti-tutionalization has not all been positive. There is growingacknowledgement that the mental health system in Aus-tralia is failing to adequately support some of the mostdisadvantaged members of our community (Groom et al.2003; Meadows & Singh 2003). The largest flaw, accord-ing to Feldman et al. (2003) was that consumers weredischarged to the community without appropriatehousing and follow up, resulting in neglect. This is sup-ported by Moxham and Pegg (2000), who suggest thatimplementation over the past 20 years has resulted in alack of appropriate accommodation, and it is this conse-quence that appears central to the ongoing difficultiesrelated to deinstitutionalization.

Affordable, secure housing for people with mentalillness is integral to the provision of mental health care.Importantly mental health care must be provided inthe least restrictive manner for those who require it. Theprovision of appropriate housing has been the leastwell-developed component of the deinstitutionalizationprocess. Secure, appropriate and affordable housing pro-vides people with an increased chance of effective treat-ment and rehabilitation and without this the morbidityand mortality rates arising from homelessness or inappro-priate housing is compromised (Moxham & Pegg 2000)and often leads to relapse and consequent re-admission tohospital (Lamb & Weinberger 2001).

In acute settings in mental health services the revolv-ing door phenomenon is commonplace (de Girolama &Cozza 2000; Dixon & Goldman 2004; Razali 2004; Sawyer2005). This phenomenon refers to the rapid and repeatedadmission and discharge of people with mental healthproblems. Front-end services such as emergency depart-ments (ED) and acute inpatient units are largely gov-erned by key performance output indicators includinglength of stay (LOS) in hospital (in both ED and inpatientunits) and re-admissions to hospital within 28 days ofdischarge. These two factors, along with an increase indemand for mental health care since the closure of insti-tutions, have contributed to the premature discharge ofpeople who still have acute symptoms of mental illness. Inaddition comorbidities such as substance misuse andsocial issues such as homelessness and unemployment areall factors that contribute to relapse and the revolvingdoor syndrome (de Girolama & Cozza 2000; Dixon &Goldman 2004; Razali 2004; Sawyer 2005).

IS DESINSTITUTIONALIZATION WORKING? 275


Sheth (2009) believes that the deinstitutionali-zation movement has actually resulted in trans-institutionalization, where large numbers of people with amental illness have landed in the prison system or home-less shelters. Sheth (2009) estimates that up to 40% ofpeople in homeless shelters have an SMI. There is also aview that CCU are mini institutions. More evidence forthat view is needed, especially in Australia. Nevertheless,those who have been admitted to CCU in Victoria havehad a welcome change to the previous institutional living.Many consumers experienced psychiatric institutions inVictoria that were locked, had dilapidated buildings, andhad scant privacy and dignity. CCU are relatively moderncluster homes, where residents have their own unit or ashared unit with one other resident. The psychosocialrehabilitation programmes have improved significantlyand include more social activities, promoting social inclu-sion. Moreover, LOS ranges from a few weeks or monthsto over 1 year, rather than for the whole of life, as evi-denced in the demographic data from this study.

New long-term patients (Lamb & Weinberger 2001)refers to consumers who have spent minimal time in acuteinpatient care with little opportunity for initiation of therecovery process. Recovery is viewed by many as regain-ing a fulfilling life, with or without symptoms, being ableto manage symptoms, retaining ones identity, and accept-ing ones illness (Bonney & Stickley 2008). Lamb andWeinberger (2001), highlight the needs of a small propor-tion of people with SMI who might still require 24-hourcare including the provision of ongoing, structured envi-ronments in order to promote recovery.

A key consideration following the reform in mentalhealth care and its effect on those receiving care, iswhether the LOS in CCU is reducing for new residentsand whether there is an impact on outcomes such asquality of life. This study sought to identify aspects ofquality of life for those currently in CCU and for thosewho were deinstitutionalized and have since left the CCUenvironment. Notably, Quality of life, as a concept, overthe last two decades become a focal point for mentalhealth services, research and service planning for peoplewho experience psychiatric disabilities (Priebe et al.1999a, p111). Priebe et al. (1999a) also argued that theultimate outcome for residents is their quality of life asthis is the basis of the biopsychosocial model of servicedelivery that dominates mental health programmingtoday. Priebe et al. (1999a), along with other authors(Bigelow & Young 1991; Bigelow et al. 1991; Brunt &Hansson 2004; Chan et al. 2003; Nieuwenhuizen et al.1998) support the evaluation of mental health servicesthrough quality-of-life studies; however, with less empha-

sis on symptoms and social functioning assessments.There is however, a paucity of current Australian quality-of-life studies reporting on outcomes for those who expe-rienced deinstitutionalization in this country, with theTrauer et al. (2001) study being the only Australian studyfound in the literature.

The study by Trauer et al. (2001) concluded thatdespite minimal change in symptoms and disability levelsthere were improvements for the residents quality of lifein terms of living environment. The majority of consum-ers preferred the CCU setting to hospital. Relatives andcarers also reported preferring CCU to hospitals. Staff toowhile initially sceptical of the move, reported changes inthe way they related to consumers and their views onrehabilitation. The older age and chronicity of a largemajority of the sample could be largely related to theminimal change in levels of disability and symptoms.Trauer et al. (2001) also discussed the need for furtherstudies to look at the function of CCU and their emergingneeds now that there is a significant reduction in theavailability of inpatient beds, and this is the motivationbehind this research. A further study seeking CCU staff sviews about rehabilitation practices within the workplace,their expectations of consumer improvement, and therole of CCU, as well as job satisfaction and stress wasconducted but not included in this article.

METHOD

Study designThis study is a descriptive, exploratory design using quan-titative approaches.

AimThe research aimed to identify: (i) the quality-of-lifevariables for past and present residents of CCU; (ii) theattitudes of past and current residents regarding CCU;(iii) if there is a reduction in LOS in CCU; and (iv) theimpact on re-admissions to hospital.

SampleA convenience sample was utilized in this study. Therewere two key cohorts of eligible participants. The firstgroup comprised current residents in the CCU (n = 16),and the second group comprised residents admitted tothe CCU between 1996 and 2007 (n = 15), as identifiedvia the client management interface (CMI) system.

DataData were gathered using the database data of hospitaladmissions (CMI), which produced the information

276 A. HAMDEN ET AL.


regarding residents demographics and contact details.This was followed with interviews of current CCU resi-dents and a survey of previous CCU residents. Data wereanalysed using SPSS version 14 (SPSS, Chicago, IL,USA).

Demographic dataTwo different streams of demographic data were identi-fied in this study.

Previous residentsA retrospective examination of medical record data onCCU residents from 1996 to 2007, relating to LOS, diag-noses and re-admissions to acute psychiatric care unitswas performed to determine changes in admission pat-terns over time. This involved identifying and analys-ing data on residents demographic information (e.g. age,sex, location), as well as diagnoses, LOS in the CCU, andre-admissions to acute care. The CMI was used to collectthese data.

Current residentsThe same demographic data were also collected onall current residents of the CCU and comparisons werethen made between the two groups (discharged vs currentresidents).

InstrumentsTwo key instruments used in the study were the PatientAttitude Questionnaire (PAQ) (Thornicroft et al. 1993)and the Manchester Short Assessment for the Quality ofLife (MANSA) (Priebe et al. 1999b).

The PAQ was developed for the Team Assessment ofPsychiatric Services (TAPS) project in the UK. Thisproject evaluated the policy of replacing psychiatric hos-pitals with district-based services (Leff & Trieman 2000).The PAQ is a 19-item instrument developed to measureconsumers views towards hospitals and communityservices.

The MANSA was designed to assess the degreeof satisfaction/dissatisfaction with different areas of life(present job/school, financial situation, personal safety,quality and number of personal friends, relations withinthe family, mental and somatic health.)

Validity and reliability of the instrumentsPAQThe reliability and validity of the PAQ were reported byThornicroft et al. (1993). Forty-three long-stay consumerswere interviewed on two occasions (test, retest). Kappastatistics were used to analyse reliability and the kappa

coefficient (with 95% confidence intervals) measured theextent of agreement between the first and second inter-views. Of the 13 items in the PAQ, all had kappa values inexcess of 0.7 showing good agreement. Results from thePAQ show convincingly that consumers prefer the com-munity to hospital living and have far more autonomy,which suggest that in addition to reliability the PAQalso has face validity. The study showed that long-termpsychiatric consumers can give clear and concise viewsregarding their experiences.

MANSAThe validity and reliability of the quality-of-life tool,the MANSA was reported by Priebe et al. (1999b). Well-being and life satisfaction are referred to as the subjec-tive component, determined by using satisfaction scalesrelated to different areas of life. The objective data arerelated to areas such as employment, health, safety, rela-tionships, leisure, finances and accommodation. Priebeet al. (1999b) interviewed 55 people with several satisfac-tion tools including the MANSA. The Pearsons correla-tions of the subjective quality of life were all 0.83 orhigher (0.94 mean score) and Cronbachs alpha for satis-faction ratings was 0.74. The authors concluded that theMANSA is a satisfactory brief instrument for assessingquality of life.

ProceduresThis study was undertaken in a regional mental healthservice. Ethics approval was obtained from the institu-tional ethics committee prior to data collection. Two keystaff working in the CCU were recruited to assist with therecruitment and interviewing of the current CCU resi-dents. These clinicians were trained in the use of the PAQand MANSA. They also obtained consent from all 16participants who were current CCU residents. The studywas conducted in the residents own environment pre-dominantly in their own residential unit or in the staffoffice.

Ex-residents were phoned and invited to participate inthe study. For those who were interested in participatinga participant information sheet and consent form wereposted, along with a simple brief letter asking them theirpreferred times for interview and a copy of the ratingscales to be used for the study. With the rating scales infront of them while being interviewed over the phoneit was thought the participants might find it easier torespond with one of six responses. A stamped, self-addressed envelope was also included to encouragethe return of the consent form. These participants wereinterviewed via phone or in person.



All residents admitted to the CCU between 1996 and2007 were identified via the (CMI) system and the result-ing data printed out onto a spreadsheet. The current resi-dents of the CCU were extracted and placed on a separatespreadsheet. The clinicians assisting with recruitmentobtained consent from 16 of the 20 residents. The inter-views were completed over a 6-week period. The samplerepresented 70% of the current residents.

The recruitment of the ex-residents for the interviewwas more complex than for the current residents. Once thecurrent CCU residents (n = 20) were taken from the origi-nal spreadsheet, there were 101 potential ex-residents whocould be participants for the study. The data through CMIare updated when there is some form of contact with themental health services. Commonly this would occur onadmission and discharge to hospital on assessment of apreviously discharged consumer or each contact that a casemanager or doctor has with a consumer. Therefore, if anex-resident who has been discharged from the service hasleft the area or is deceased, this might not be entered intothe CMI database thus the contacting of ex-residentsneeded to be managed sensitively. The researcherattempted to phone all previous residents but found that29 of the phone numbers were incorrect; 18 were notanswered despite several attempts to call; 12 declined to beinvolved in the study; three had died; and four were in amedium secure unit, with one in a psychogeriatric nursinghome. The remaining 31 agreed to participate in the study.Of this 31 who were sent information sheets and consentforms, only 11 returned them. The researcher providedone follow-up reminder call and was able to obtain anotherfive participants, resulting in a sample group of 15 (15%).

RESULTS

Participant demographicsThe demographic data, in relation to the sex of the indi-viduals, showed that 81 were males and only 40 werefemales. When separated into age groups, the older group(4170 years old) had equal numbers of females to males,but this changed significantly in the 40 years and under agegroup where the weighting showed 75% male and 25%female. The demographics including sex and age of currentand past CCU residents, are outlined in Tables 1 and 2.

Quality-of-life variables for past and presentresidents of CCUMANSAIn the study by Trauer et al. (2001) the MANSA wascompleted pre-move to the CCU and 12 months

post-move, with the only significant changes being inthe living situation. The present study shows resultsfor 10 years post-move. There are some further pleas-ing improvements as well as disappointments in otherdomains found in this study. The domains of friendshipsand employment are the two significant areas resultingfrom findings in the MANSA.

FriendshipsTrauer et al. (2001) showed a mean score of 55% satisfac-tion with friendships (n = 84) 1 year post-move which wasactually a decline from the pre-move score (n = 45) of62.2%, suggesting that residents might have been sepa-rated from their friends during the move into CCU. Thecurrent and past residents in the present study showed animprovement from those of Trauer et al.s (2001) studywith 79.6% expressing happiness with their friendshipsand 72% of respondents had actually seen a friend in thelast week.

These data suggest that the deinstitutionalizationprocess has been conducive to residents improvement insocialization and friendship building.

Close friendsMost respondents had a close friend in their lives (Fig. 1).

Satisfaction with number and quality of friendshipsRespondents were asked how satisfied they were withthe number and quality of their friendships. Responsesshowed higher levels of satisfaction in the past group(Fig. 2).

EmploymentTrauer et al.s (2001) study found that none of theresidents in the hospitals, prior to moving and at the

TABLE 1: Mean age and sex of respondents

Respondents sex Age

n Mean Standarddeviation

Standarderror mean

Male 81 36.68 9.721 1.080Female 40 39.90 14.069 2.225

TABLE 2: Ratio of males to females per age group

Respondents sex Age group Total

1825 2633 3441 4170Male 11 32 23 15 81Female 7 12 6 15 40



12-month follow up after the move, were employed.Information from the present study is not much moreencouraging, in that only two (n = 31) were gainfullyemployed and they were ex-CCU residents. Further-more, 34% commented that they would like gainfulemployment, when asked for suggestions that couldimprove the CCU programme through the PAQ.

Attitudes of past and current residents regardingthe CCUPAQIt was important to understand the participants identifi-cation and understanding of changes in their self sinceadmission to the CCU and whether they would recom-mend the CCU setting to others. The findings relating tothis topic area suggest that despite the severity and chro-nicity of mental illness in CCU participants there was anappreciation and insight into the benefits of CCU. Someresidents commented that they would not be able to liveindependently if it were not for the CCU. This is sup-ported by the responses of several respondents, whobelieved they were changed for the better by their stay inCCU and would be recommending CCU to others. This

question was not reported by Trauer et al. (2001), so wewere unable to draw comparisons.

LOS in CCU and re-admission to acute psychiatriccare unitsThere is evidence from the data that the LOS and numberof admissions to acute psychiatric care units reduces sig-nificantly after spending time in CCU. There is a reducedLOS in acute psychiatric care units while residingin CCU (P = 0.035) and admissions to hospital beforeCCU (P = 0.011). These findings indicate that receiving24-hour care and having qualified staff and access tomedical intervention when required can assist in keepingresidents who are unwell out of acute psychiatric careunits (Figs 3,4).

Re-admissions to hospital after discharge from CCUalso showed a significant reduction. Although a smallgroup of residents required secure residential care, theidea that a shorter LOS causes increased re-admissions tohospital cannot be validated (Figs 3,4).

0

2

4

6

8

10

12

14

NoYes

Res

po

nd

ents

(n

)

Close friends

FIG. 1: Close friends. ( ), current; ( ), past.

0

1

2

3

4

5

6

7

Displeased MostlyDispleased

Mixed Mostlysatisfied

Pleased Could not bebetter

Res

po

nd

ents

(n

)

Satisfaction with number and quality of friends

FIG. 2: Satisfaction with number and quality of friends. ( ), current;

( ), past.

0

10

20

30

40

50

60

70

80

Number ofadmissionsbefore CCU

75.88%

7.7%16.42%

Number ofadmissions

while in CCU

Number ofadmissions after

discharge from CCU

Res

pond

ents

(%

)

FIG. 3: Number of admissions to hospital. CCU, community care units.

LOS in hospitalbefore CCU

80.51%

3.66%

15.83%

LOS in hospitalduring CCU

LOS in hospitalafter CCU

Res

pond

ents

(%

)

0

20

40

60

80

100

FIG. 4: Number of in-hospital bed days. CCU, community care units;LOS, length of stay.



Importantly, there has been a marked reduction inadmissions to acute psychiatric care units while residingin CCU and after discharge from CCU, with a significantincrease in the number of male residents over the past10 years. The LOS in CCU has decreased over the years,with more discharges occurring each year. An ANOVAwas also used to identify the significant changes in LOSand number of admissions to acute psychiatric care units.Admissions to acute psychiatric care units before CCUand LOS in wards of CCU showed significance (Table 3).

Furthermore, there is sufficient evidence through theresident questionnaires and demographic data to showthat a majority of past residents are living independentlyor in supported accommodation and that CCU are help-ful in providing residents with the skills required to liveindependently.

DISCUSSION

This study examined CCU in relation to quality of lifefor past and present residents, attitudes of residentsregarding the CCU, LOS in the CCU, and re-admissionsto hospital. Demographic data were also gathered andshowed more males than females using CCU. Althoughstatistically the incidence of SMI in males compared tofemales is even (National Centre for Health Statistics1996), the demographics reported here suggest that menare more likely to require long-term care than women,and this is supported in the literature. The younger, pre-dominantly male group had higher rates of re-admissionto hospital, frequently related to substance abuse andhomelessness (Treiman et al. 1999).

Only two respondents were employed. Notably one ofthem was employed by the Area Mental Health service towash the fleet cars 2 days per week, 4 hours per day.Although there are generic employment services withinthe region of this study setting, case managers reporta lack of accessibility and employment options dueto potential employers poor understanding of mentalillness, consequently reducing opportunities of gainfulemployment for this group of people.

Crowther et al. (2006) and Mueser et al. (2004) sug-gest that having specific employment staff co-located atthe same site as the mental health service would enablemore frequent interaction and encourage a collaborativeapproach to assisting with employment issues for indi-viduals, and would be far more beneficial than having theemployment service belonging to another service and in adifferent location.

Several references in the literature have been madeto the need for the provision of long-term care to thisvulnerable group of people; however the likelihood ofavailability of more CCU beds is not promising (Councilof Australian Governments 2006; Victorian Government2002). In light of this information, alternate models ofpsychiatric rehabilitation in the community also need tobe explored if people with SMI are to be appropriatelycared for in the community.

The assertive community treatment (ACT) modelhas a strong focus on keeping this group of patientsengaged with treatment and out of hospital. Thirtyyears of research has repeatedly demonstrated that ACTreduces hospital admissions and improves quality oflife for people with SMI (Phillips et al. 2001). ACT hasa strong focus on keeping this group of patients engagedwith treatment and out of hospital (Bermingham1999; Garske & McReynolds 2001). Psychiatric rehabi-litation including psychosocial treatment approacheshas become more prevalent since deinstitutionalization,enhancing interpersonal and social functioning, pro-moting independent living and community tenure andimproving illness symptoms and management. ACT pro-vides treatment within the clients home assists peoplewith SMI to become involved with community agencies,links in with housing and employment services, providesfamily support, and teaches coping skills so that thisvulnerable group is able to live and function in thecommunity. Staff initiating contact rather than waitingfor people to keep appointments, continuity, and consis-tency in an integrated service and combining treatmentwith rehabilitation, are the hallmarks of ACT (Garske &McReynolds 2001).

TABLE 3: Number of hospital admissions before community care units (CCU) and lengths of stay (LOS) in wards during CCU stay

Sum of squares df Mean square F P-value

Admissions before CCU Between groups 2 323.887 34 68.350 1.874 0.011Within groups 3 063.575 84 36.471Total 5 387.462 118

LOS in ward of CCU Between groups 76 124.781 32 2378.899 1.687 0.035Within groups 100 141.373 71 1410.442Total 176 266.154 103



Other government initiatives that can be utilized forthis group of people are the Home Based OutreachSupport and Intensive Home Based Outreach Support(IHBOS) programmes through Psychiatric Disability andSupport Services (PDRS), which provide rehabilitationand disability support to people with SMI. The IHBOS ismore intensive and targets people who are homeless or atrisk of homelessness but there are only a limited numberof these packages available in each region (Victorian Gov-ernment 2007). The Personal Helpers and MentorsProgram (Council of Australian Governments 2006) isanother initiative that assists people with SMI to managedaily activities and to access services and supports.

Strengths and limitations of the studyThe demographic data collection provided a good sourceof information and was all available via a database. Thefact that it was a follow-up study gave the researcher abaseline of information to focus on and the study providesseveral opportunities for conducting further research.The limitations include the ongoing need to continue thefollow up of previous residents. While it had beenintended to interview the majority of the 101 past resi-dents, this was a very difficult task to achieve in thetimeframes of this study.

Importantly there were issues with the response ratethat hindered the ability to gain consent and which wouldneed to be considered if this study were to be expanded inthe future. First, most past residents who were able to becontacted via telephone agreed to participate in the studybut several did not send back the signed consent formsdespite a stamped, self-addressed envelope being pro-vided and a follow-up phone call. Several offered to com-plete the questionnaire over the phone at the time of thecall, thus this method should be considered in furtherfollow up within this population of people. The lack ofsigned consents was not necessarily due to unwillingnessto participate in the study but could be due to negativeillness symptoms, such as apathy and poor motivation.Nevertheless, poor response rates are found among otherresearch groups as well, and in this study could have beenmitigated by face-to-face consenting of participants.

The small sample size also inhibits stronger conclu-sions being drawn regarding the clinical significance ofthe findings. Certainly, statistical significance was foundbut with a small sample this must be examined cautiouslywhen drawing conclusions about the true clinical impactof CCU.

Further research is required to complete the trackingof ex-CCU residents from the area to further strengthenthe findings of this study. A broadening to include other

mental health services might provide more robust evi-dence about Victorian demographic data and the qualityof life of all residents of CCU. Consideration must begiven to the methodology and ethical issues identifiedwithin this study, in particular a change to how consent isobtained. The inclusion of phone consent to enable theex-resident to be engaged in the study during the initialphone call and offering reimbursements of expensesmight encourage increased participation.

CONCLUSION

This study showed that CCU have a positive effect onhospital re-admission rates to acute psychiatric care units,improved LOS, and positive outcomes with regard tosocial inclusion, employment, and housing. The presentstudy examined the quality of life and attitudes of currentand past CCU residents, as well as demographic data inrelation to LOS and re-admissions to hospital.

Other service provisions that would enhance the workof the CCU and that of Area Mental Health services thatare now caring for this group of people in the communityas a result of deinstitutionalization include:

An evaluation of the CCU model of care and the explo-ration of more evidence-based models of care, with astrong focus in the areas of vocation and social inclusion

Review of discharge policies and procedures to includeplans for long-term residents unlikely to improve intheir psychosocial functioning. This is required toenable long-term residents who are unlikely to improvein psychosocial functioning to be moved to appropriatecommunity accommodation, thereby freeing up bedsfor the wait-listed residents

Utilization of the ACT model of care for peopleon waiting lists for CCU in order to try to reduce thelevel of disability that is likely to occur with frequentrelapses

Exploration of collaborative options with the psychiat-ric disability and rehabilitation services sector aiming toprovide community packages and outreach services topeople with SMI who are either not able to access aCCU bed or do not fit the criteria for CCU placement

ACKNOWLEDGEMENTS

The authors would like to thank the staff at CCUfor supporting and assisting with this important study, aswell as the past and current residents of CCU for theirwillingness to participate.



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