OPERATIONS RESEARCH IN MENTAL HEALTH ADMINISTRATION By John H. Burgess

Operations research methods have been powerful analyticcd tools for administrators in the military, i~- dustry and business. Possibly holding m~jor promise for mental health administrators, such methods arc applied in this study to a sustaining-care problem.

Applying limited resources to achieve desired results most effectively is basic to sound administrative strategies in mental health. Methodologies must be developed or adapted continuously to aid the adminis- trator. Operations research technology may be such an aid (Churchman 1968; Barn- hart 1970; Fox 1970). I t originated early in World War II when the British required maximal deployment of limited military re- sources to defend themselves effectively, as in increasing the kill probability of depth charges in antisubmarine warfare. Part ly because of operations research and maximal deployment of British airpower, Church- hill was able to acclaim the Royal Air Force: "Never before have so many owed so much to so few."

After the war, several commercial com- panies applied operations research success- fully to business and sales activities. Tlle methods became firmly established as man- agement tools for maximizing cost/effective- ness in industry. Recently, a .definite effort was made to encourage use of opera- tions research techniques by mental health administrators (Halpert, Horvath, and Young 1970). Specific application, however, seems to be emerging only slowly.

Operations research basically requires an administrative commitment to a problem- solving mode, or management style oriented to defining a problem, fact gathering, analysis, and pursuit of alternative modes of

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Operations research basically re- quires administrative commit- ment to a problem-solving mode.

solution. Mental health administrators preparing to use the new tool will, first, have to define the problems for which opera- tions research is applicable in designing new and alternative programs. Sustaining care is one such problem area.

Since 1963, and since the advent of the community mental health movement, State hospital inpatient populations have con- tinued to dwindle. Former mental patients have been placed in the community. This resulted in a continuing rise in readmission rates. Evidence is accumulating, however, that timely and intensive aftercare or sustaining-care programs can reduce read- mission rates. In the judgment of State hos- pital staff throughout Pennsylvania, the readmissions of 1,231 of 2,781 former pa- tients could have been prevented with after- care services (Silverstein 1968). In fact, medication has proven successful in keeping three out of every five former patients out of the hospital over a 2-year period (Pas- manick et al. 1967). Other pilot projects,

John H. Burgess is alrecmr of research and evaluation at the Adolf Meyer Center in Decatur, Illinois, a regional division of the State Department of Mental Health.

Sustaining-care p r o g r a m s . . . surely could benefit from analy- sis of the operational implica- tions of readmission cycles.

such as that of Fountain House in New York City (Malamud 1971), also have shown tha t intensive services in occupational and social support can reduce relapse rates by as much as 30 percent.

Sustaining-care programs, it would ap- pear, surely could benefit f rom analysis of the cycles, possibly permi t t ing administrators to direct resources to where they may ac- complish the most meaningful results. In the present study, an operations research prob- lem in sustaining care was defined in order (1) to demonstrate the operations research technique, and (2) to develop a functional operations research model for practical use by mental health administrators.

were traced for readmissions over the 5-year period from July 1, 1966, to June 30, 1971. Figure 1 shows the percentages readmitted to State facilities during this period as well as estimates of other likely outcomes for the rest of the cohort.

In developing the model further, a fre- quency count was obtained by "months to readmission" for 420 pat ients readmitted during the 5 years. Figure 2 illustrates the curve and the critical periods during which the greatest number of readmissions oc- curred. To assure that the curve presents a consistent and reliable datum, a fur ther sample was obtained of 384 patients read- mitred between July 1, 1970, and June 30, 1971. In t racing previous discharge rec- ords to obtain "months to readmission" statistics, essentially the same curve was obtained. A meaningful operations re- search model emerges f rom developing such a datum. And an optimal sustaining-care program can be based on it.

THE OPERATIONS RESEARCH PROBLEM IN SUSTAINING-CARE

Community mental health centers (CMHCs) and clinics frequently receive con- tracts to give sustaining-care services, often without clear specification of the target popu- lation. Released mental patients and their family and community involvements require an aggressively oriented program of home care and community work by the serving agency. Office visits by the pat ient alone will not suffice (Atthowe 1972). To focus the in- tensive effort appropriately, the portion of the population at most critical risk must be identified before service allocations are made. This constitutes the operations re- search problem of the present study.

DEVELOPING THE MODEL The operations research model developed

for sustaining care was based on a study of 1,100 mental patients f rom an 18-county area in East Central Illinois. They had been released from State facilities between July 1, 1966, and June 30, 1967. Their records

A MODEL BASED SYSTEM The rationale for such an operations

research, sustaining-care model may be simply stated: the pat ient population most cri t ically at risk of relapse or readmission should receive the most intensive care in order to minimize or reduce the incidence of readmission. Thus, the management of sustaining-care programs may be most optimally related to the critical portions of the curve illustrated in figure 2. t t can be seen that the highest incidence of patient failure in the community occurs in the first quarter (and, indeed, the first month) af ter release. The incidence falls progressively through the four th quarter after release. The implications for the service system are that (1) the greatest payoff potential oc- curs during the first 3 months after dis- charge, (2) requirements for intensive care fall during the second, third, and four th quarters, and (3) former patients released for more than a year have minimum prob- ability of re turn or readmission.

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An operational model derived from these data features the following de- velopmental steps:

1. Identify all individually released pa- tients (together with address of place- ment) within one year of release. Maintain quarterly updates.

2. Survey patients released during each quarter and maintain status records as governed by principles of confi- dentiality. Select those of highest risk for sustaining care.

3. Continue monitoring all released pa- tients for a full year while providing sustaining care as necessary to pa- tients identified as highest risk in step 2.

4. Discontinue monitoring released pa- tients who move, with minimally ap- pearing risk, past the fourth quarter since discharge, Add newly released patients every quarter.

5. Continue steps 2, 3 and 4 in main- taining the sustaining-care system.

MAINTAINING THE OPERATIONAL DATA BASE

An administrative commitment to a problem-solving or operations research mode in sustaining-care must include provi- sions to make data available. Data on read- mission and on time lapse between admission and previous discharge are, of course, gen- erally available in hospital records. How- ever, cohort studies frequently are frag- mented by incomplete followup data on both the sustaining-care and control groups. Col- lecting followup data is impeded by practi- cal constraints of patient rights and the danger of reviving the stigma of mental illness and confounding the adjustment prob- lems of the former patient. Special strategies may be required to avoid confi- dentiality issues by using indirect sources for data on former patients' current status or by followup by persons without Depart- ment of Mental Health affiliation.

Operations research may have considerable va!ue to adminis- trators as a potentially powerful administrative tool.

CONCLUSION Operations research may have consider-

able value to CMHC administrators as a potentially powerful administrative tool. Various operations research techniques could be utilized to enhance efficiency and effectiveness of resource expenditures. In this study, a sustaining-care model was de- veloped and can be readily made opera- tional for improving program effectiveness.

REFERENCES Atthowe, J. Behavior innovation and persistence.

American Psychologist, 27 (1) : 34-41, 19"/2. Barnhart, G. Social design and operations research.

Public Health Reports, 85(3): 247-250, 1970. Churchman, C. The Systems Approach. New York:

Delacorte Press, 1968. Fox, H. Toward an understanding of operations re-

search concepts. Management Services, July-Aug. 1970, 23-28.

Halpert, H.; Horvath, William J.; and Young, John P. The Application of Operations Research to the Administration of Mental Health Systems. Wash- ington: National Clearinghouse for Mental Health Information, NIMH, 1970.

Malamud, T. An EvaIuat~n of Rehabilitation Serv- ices and the Role of Indusbry in the Community Adjustment of Psychiatric Patients Following Hos- pitalization. New York: Fountain House Founda- tion, 1971.

Pasamanick, B. eL al. Schizophrenics in the Com- munity: An Experimental Study in the Prevention of Hospitalization. New York: Appleton-Century- Crofts, 1967.

Silverstein, M. Psychiatric Aftercare Planning for a Community Mental Health Service. Philadelphia: University of Pennsylvania Press, 1968.

ADMINISTRATION IN MENTAL HEALTH SUMMER 1974

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