An Acute Inpatient Alternative: Preliminary Findings from a Randomized Trial

1. An Acute Inpatient Alternative: Preliminary Findings from a Randomized Trial Funded by VA Health Services Research and Development (HSR&D PCC 98-051-2)

2. Presentation Overview • Introduction to the Study • Comparison of Hospital and Short-Term Acute Residential Treatment Programs (START) • Study design & methods • Preliminary results

3. A Collaboration of: • Veterans Affairs San Diego Healthcare System • San Diego County Adult and Older Adult Mental Health Services • UCSD Department of Psychiatry • Community Research Foundation

4. Investigation Team • James Lohr, MD • William Hawthorne, PhD • Elizabeth Green, PhD • Kathy Lyttle, RN • Piedad Garcia, EdD

5. Investigation Team (Cont.) • Richard Hough, PhD • Brian Mittman, PhD • Todd Gilmer, PhD • Martin Lee, PhD

6. Study Overview The Study compares services, outcomes, and costs of care for Veterans in need of acute psychiatric care who are randomly assigned to either the VASDHS Psychiatric Unit or a START program in San Diego County.

7. START Six 11 to 14 bed programs CARF accredited Psychiatric services by UCSD physicians ALOS = 9 days VA Hospital 37-bed acute psychiatric hospital JCAHO accredited Psychiatric services by UCSD physicians ALOS = 9 days Program Comparison

8. Short-Term Acute Residential Treatment (START) Programs • Alternative to acute psychiatric hospitalization • Community-Based • CARF Accredited • Licensed Crisis Residential Facilities • Medicaid Certified by California Department of Mental Health • VA Approved • Kaiser Permanente Approved

9. START Environment • Home-like atmosphere in large homes in residential neighborhoods • Peer orientation • Program is flexible and provides individualized care

10. START Environment (Cont.) • Opportunities for recreational and social activities • Cooking, shopping, cleaning and minor maintenance is often done by clients and staff working together • Focus on strengths to encourage independence, initiative, and recovery

11. START Environment (Cont.) • Supportive community with opportunities for clients to learn, restore, and apply interpersonal and independent living skills • Opportunities for success to raise self-esteem and restore hope • Arranging access to community support systems and other preparations for discharge begin at admission

12. 18 to 59 years old Voluntary only Crisis of sufficient severity to indicate hospitalization Outpatient medical services only Veterans 18 and older Voluntary & Involuntary Crisis of sufficient severity to indicate hospitalization Can provide inpatient medical care Admission Criteria START VA Hospital

13. Multi-Disciplinary Staff

14. Multi-Disciplinary Staff

15. Clinical Staffing Pattern

16. Access

17. On-Site Services

18. On-Site Services (Cont.)

19. On-Site Services (Cont.)

20. On-Site Services (Cont.)

21. Major Components • Qualitative component includes client and staff interviews and client-reported assessments of program and services. • Quantitative outcome component includes objective measures such as standardized instruments, readmission episodes, living situation, and employment status. • Cost-effectiveness component incorporates cost and outcomes.

22. Methods • Consenting Veterans in need of acute psychiatric care are randomly assigned to either the VA Hospital or a START program. • Study participants are interviewed and complete several instruments usually within 24 hours of admission and discharge • Participants are followed-up at two months, six months, and one year after discharge

23. Measures • Structured Clinical Interview for Positive and Negative Syndrome Scale (SCI-PANSS) • Short Form-36 for Veterans (SF-36V) • Addiction Severity Index (ASI) • Quality of Well-Being (QWB)

24. Measures (Cont.) • Perceptions of Care (POC) • Ward Atmosphere Scale (WAS) • Structured Clinical Interview for DSM-IV (SCID)

25. Data Sources • Participant Self-Report • Trained Research Staff Assessments • VASDHS Database • San Diego County Mental Health Services Database

26. Study Participants (n=61) • Between 18 and 59 years old • Psychotic or Major Affective Disorder • Judged to be in need of acute psychiatric admission by attending psychiatrists at VA • Not in need of more than outpatient medical services

27. Participant Demographics

28. Participant Demographics (Cont.)

29. Diagnostic Categories Other 15, 25% Bipolar 13, 21% Major Depression 16, 26% Schizophrenia 17, 28% Concomitant Substance-Related Diagnoses = 45, 74%

30. Preliminary Findings • 6 of the 10 Ward Atmosphere Subscales were significantly more favorable for START • At the 2-month FU, 95% of START and 71% of Hospital Participants reported taking medication as prescribed • 3 Participants (5%) died: 1 of suicide, 1 of accidental overdose, one of natural causes

31. Preliminary Findings (Cont.) • 74% of participants (45) had concomitant substance-related diagnoses • No significant differences were found between groups on the PANSS or the MCS at admission, discharge, or the 2-month follow-up • Mean episode costs (mean LOS X daily cost) were $6,976 for the hospital group and $2,775 for the START group

32. Mean SF-36 Mental Component Summary Scores at Admission, Discharge, and 2-Month Follow-Up 45 40 35 30 25 20 Hospital 15 START 10 Admission (n=61) Discharge (n=58) 2 Month F/U (n=42)

33. Mean Total SCI-PANSS Scores at Admission, Discharge, and 2-Month Follow-Up 90 85 80 75 70 65 60 Hospital START 55 50 Admission (n=61) Discharge (n=58) 2 Month F/U (n=42)

34. Mean Ward Atmosphere Scale Relationship Dimension P values (Eta Sq) .000 (.3) .000 (.2) .04 (.1)

35. Mean Ward Atmosphere Scale System Maintenance Dimension P values (Eta Sq) .001 (.2) .001 (.2) NS

36. Mean Ward Atmosphere Scale Personal Growth Dimension P values (Eta Sq) NS NS .03 (.1) NS

37. Perceptions of Care Items Proportion of Favorable Responses Items with larger differences Mann Whitney (P) 243 (.003) 291 (.03) * 330 (.02) * Q17 = score data: ANOVA, p<.07, Eta Sq=.06