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
• (HSRD 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

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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.
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Program Comparison

• 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

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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

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START Environment

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

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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

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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

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Admission Criteria
START
VA Hospital

• 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

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Multi-Disciplinary Staff
VA Hospital START
Social Workers Yes Yes
Counselors No Yes
Interns Practicum Students No Yes
Medical Specialists On-Site No
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Multi-Disciplinary Staff
VA Hospital START
Psychiatrists Yes Yes
Nurses Yes Yes
RPRP No Yes
Psychologists On-Call Yes
Occupational Therapists Yes No
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Clinical Staffing Pattern
START (14 beds) VA Hospital (37 beds)
One staff for every 3 4 clients One staff for every 4 5 clients
Two staff during overnights Two staff during overnights
Nurse 800 am to midnight 24-hour nursing staff
Psychiatrist 3 days/ Wk, on call 24 Hrs Psychiatrist 7 days/ Wk, on call 24 Hrs
Psychologist 3 days/ Wk, on call 24 Hrs By special order
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Access
VA Hospital START
24-hour referrals Yes Yes
Medical problems More severe Yes
Risk of mild to moderate detox OK Yes Yes
Handicapped access Yes Yes
Services for mono-lingual Latino clients N/A Yes
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On-Site Services
VA Hospital START
Medical Assessment Yes Yes
TB Test Available Yes
Medication Evaluation Yes Yes
Discharge Planning Yes Client-directed

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On-Site Services (Cont.)
VA Hospital START
Client-directed service plans No Yes
Treatment Planning Meetings with staff and individual clients No Yes
Flexible program able to change as needed to meet the needs of clients No Yes
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On-Site Services (Cont.)
VA Hospital START
Individual Counseling PRN Yes
Groups 3-5 p/ day 2 p/day
Community Meetings 1 p/day 2 p/day
Activities Yes Yes
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On-Site Services (Cont.)
VA Hospital START
Medication Consultation Yes Yes
Substance Abuse Track No Yes
On-site AA and NA meetings Yes Yes
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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.

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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

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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)

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Measures (Cont.)

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

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Data Sources

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

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Study Participants (n61)

• 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

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Participant Demographics
START START Hospital Hospital
Ethnicity
- Euro-Am 19 59 21 72
- African-Am 9 28 6 21
- Latino 1 3 1 3
- Other 3 9 1 3
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Participant Demographics (Cont.)
START START Hospital Hospital
Marital Status
- Never Married 10 31 10 34
- Married 3 9 2 7
- Not Married 19 59 17 59
Employed 4 12 4 14
Mean Age (SD) 48 (6.7) 46 (6.7)
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Diagnostic Categories
Other 15, 25
Bipolar 13, 21
Major Depression 16, 26
Schizophrenia 17, 28
Concomitant Substance-Related Diagnoses 45, 74
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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

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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

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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 (n61)
Discharge (n58)
2 Month F/U (n42)
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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 (n61)
Discharge (n58)
2 Month F/U (n42)
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Mean Ward Atmosphere Scale Relationship Dimension
P values (Eta Sq) .000 (.3)
.000 (.2) .04 (.1)
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Mean Ward Atmosphere Scale System Maintenance
Dimension
P values (Eta Sq) .001 (.2)
.001 (.2) NS
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Mean Ward Atmosphere Scale Personal Growth
Dimension
P values (Eta Sq) NS NS
.03 (.1) NS
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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, plt.07, Eta Sq.06