Shortening hospital stay for psychiatric care: effect on patients and their families. Description and evaluation of a short-stay admission ward. Psychiatric hospitalizations, arrests, emergency room visits, and homelessness of clients with serious and persistent mental illness: findings from a randomized trial of two ACT programs vs. usual care. The effect on hospital admissions of psychiatric case management involving general practitioners: preliminary results.
A one-year cohort of patients from a defined catchment area with acute functional disorders were allocated at random to brief care (experimental group) or standard care (control group) in hospital to examine the effect of shortening hospital stay on the clinical and social functioning of patients and the distress abnormal functioning caused to others. A total of 127 patients were interviewed on entry to the study, and 106 were followed up. The brief care group had significantly shorter mean and median lengths of stay than the control group, but there was no difference between the groups in the number of days spent in hospital during subsequent admissions. The groups were well matched for clinical and social variables. Rates of improvement over 13 weeks were essentially the same by all measures of outcome, including the Present State Examination and Patient's Behaviour Assessment Scale, which was developed for the study to measure deterioration in behaviour and social functioning and adverse effects and distress on others. There was no difference between the two groups in burden to the community supporting services, social security requirements, or GP attendances. Improvement rates were nearly identical on all measures within and across diagnostic subgroups. Brief care resulted in a 33% reduction in average length of stay compared with the year before but was associated with a corresponding increase in day hospital use. The short-stay policy continued the year after the study finished.The findings confirm the value of shortening hospital stay and improving day care facilities for most localities. Duration of stay for unselected admissions to an acute psychiatric ward was reduced to an average of 11 days. The clinical methods by which this was achieved are described. Comparing patients randomly allocated to this experimental ward and other admission wards: (i) the readmission rate to the experimental ward was higher but readmissions were briefer so that total in-patient experience per patient over the course of one year remained substantially lower; (ii) symptom levels and burden on the family had improved equally at three weeks and at four months after discharge; (iii) experimental ward patients made fewer demands on their general practitioners and reported fewer parasuicides. Beds can be released for other purposes in this way. This investigation examined several adverse outcomes in clients with serious mental illness in a randomized trial of Assertive Community Treatment (ACT) versus usual care.
                163 subjects were randomized to one of two ACT experimental conditions (staffed by consumers or non-consumers) or usual community care. Conditions were compared on psychiatric hospitalization, emergency room visit, arrest, and homelessness, within the two-year study period. Demographic, program, and client variables were examined for significant associations with outcomes.
                Significant differences were found between ACT and usual care in time to first arrest, but not hospitalization, homelessness or ER visits. Shorter time to first hospitalization was associated with male gender, diagnoses other than schizophrenia, high psychiatric symptomatology and lower provider case load. ER visits were associated with increased client symptomatology. Shorter times to homelessness were predicted by poorer therapeutic alliance between case manager and clients. Shorter time to first arrest was predicted by client minority status and enrollment in usual care.
                The paucity of significant main effects may have been due to a prolonged "start-up" phase of the ACT programs, poor ACT implementation, restricted availability of psychiatric hospital beds, or changes in usual care services delivered over the study period. A two year follow-up of two matched groups of subjects with chronic severe mental illness was performed in order to evaluate a new psychiatric case management system. One group (n = 59) received care through psychiatric case management, using an assertive community treatment model that directly involved general practitioners. The other group, matched for age, sex, diagnostic group and number of hospital admissions, received standard outpatient care. Comparing the two years before and after case management, the experimental group showed a dramatic fall in inpatient admission days while the control group admission days remained the same (median difference in admission days across matched subject pairs = 64.5, 95% C.I. from 134.5 to 16). The experimental group remained out of hospital longer before first readmission (Kaplan-Meier survival analysis, P = 0.002). This type of case management programme can shorten or prevent admissions to psychiatric hospitals of patients with chronic mental illness, and increase their time before readmission.
The effects of hospital care and the length of stay is important for mental health policy. We found limited data, although outcomes do suggest that a planned short stay policy does not encourage a 'revolving door' pattern of admission and disjointed care for people with serious mental illness. More large, well-designed and reported trials are justified.