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7/31/2019 Alonso-Surez, Bravo-Ortiz, Fernndez-Liria,. Gonzlez-Jurez, Effectiveness of Continuity-of Care Programs, 2011

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Effectiveness of Continuity-of-Care Programs toreduce time in hospital in persons with schizophrenia

M. Alonso Surez 1 * , M.F. Bravo-Ortiz 2 , A. Fernndez-Liria 3 and C. Gonzlez-Jurez 4

1 Hospital de Da, Hospital General, c/ Tomelloso s/n 13002 Ciudad Real, Castilla la Mancha, Spain2 5th Area Psychiatric and Mental Health Services, La Paz University Hospital, Madrid, Spain3 3rd Area Mental Health Services, Principe de Asturias University Hospital, Madrid, Spain4 Jose Germain Psychiatric Institute, Legans, Madrid, Spain

Aims. To assess the impact of the Continuity-of-Care Program (CCP; a clinical case management model) on hospitaluse of persons with schizophrenia in three Community Mental Health Services in Madrid (Spain).

Methods. Using data provided by the Psychiatric Case Register, we analyzed the use of hospitalization in 250 individ-uals before and after the date of inclusion in this program.

Results. During the first year after launching the program, there was a 40 69% reduction in the number of admissions,length of each hospital stay, proportion of admitted patients, total number of days in-hospital, proportion of patients

visiting the emergency room, and emergency room visits. This drop was maintained over the subsequent 3 years of program functioning.

Conclusions. These results encourage the development and implementation of such programs, even though morestudies evaluating the effectiveness of these programs for other endpoints are needed.

Received 19 February 2010; Revised 31 May 2010; Accepted 6 June 2010

Key words: Clinical case management, effectiveness, hospitalization, schizophrenia.

Introduction

Deinstitutionalization in Spain brought a substantialchange in care for mental disorders, from a hospital-centered model of care to community care. Its mainachievement has been the development of a networkof community mental health and psychosocial rehabi-litation services. Nevertheless, substantial deficienciesand inequalities in implementation among commu-nities are still present (Salvador-Carulla et al. 2002,AEN, 2003).

One of the goals of the Mental Health Strategy of Spanish National Health System (Ministerio deSanidad y Consumo, 2007) is to emphasize organiz-ational systems directed toward reducing the number

of hospital admissions of severely mentally ill patientsand improve their social functioning and quality of life. This document puts forward two standardmodels: Assertive Community Treatment (ACT) andContinuity-of-Care Programs (CCP). The CCP of the3rd Mental Health Area of Madrid, which participated

in the present study, was presented in this NationalStrategy as an example of good practice.

These programs were developed to organize theaccess to therapeutic resources and treatments avail-able in a territory. They supposedly enhance theresults of such treatments since they facilitate optimalusage of such resources. The establishment of a sup-port relationship with the case manager facilitates amore frequent and flexible follow-up than the usualsupport, which is based solely on the psychiatrist srevisions. This facilitates more frequent symptomsmonitoring, interventions to enhance treatment adher-ence, and training to improve patient coping skills incrisis prevention. Moreover, the CCP team coordinateswith the hospital and collaborates on admission anddischarge decisions, in a way such that individualizedsupport mechanisms to prevent re-hospitalization can be established (family conflict, lack of residence, conti-nuity of treatment at the community, etc.).

A search in the literature suggests that CCPs areeffective in the setting of a community-based mentalhealth-care delivery system (Marshall et al. 1997;Marshall & Lockwood, 1998; Mueser et al. 1998; Smith& Newton, 2007; Van Os, 2009; Ziguras & Stuart,2000). Several reviews point out improvements in treat-ment compliance, reductions in hospital admissions,

* Address for correspondence: Mara Alonso Surez, Hospital deDa, Hospital General, c/ Tomelloso s/n 13002 Ciudad Real, Castillala Mancha, Spain.

(Email: [email protected])

Epidemiology and Psychiatric Sciences(2011), 20 , 65 72. Cambridge University Press 2011 ORI GI NAL ART I CL Edoi:10.1017/S2045796011000138


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each contact was usually between 10 and 30 min.Different topics suited to the patient s needs were cov-ered. These mainly included treatment compliance,checking of clinical status, daily living activities, socialrelationships, and physical health.

The three programs were based on the clinical CMmodel. The fidelity of these programs to ACT wasassessed with Dartmouth Assertive CommunityTreatment Fidelity Scale (DACTS). As expected, alow score was found (Teague et al. 1998). On thisscale, the score ranges from 1 to 5, the highest value being maximal fidelity to ACT. Our programs wererated between 2.1 and 2.4. CCPs included in thestudy scored with high fidelity to the ACT model(>3) on the following items: Practicing Team Leader,Continuity of Staffing, Staff Capacity, Psychiatrist onStaff, Intake Rate, Time-Unlimited Services, NoDrop-Out Policy, Assertive Engagement Mechanisms,and Dual-Disorders (DD) Model. The CCPs scored

with low fidelity (


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year after inclusion were still significant ( p = 0.016 and0.035, respectively).

Comparison of mean admissions and days in hospi-tal per individual in the years pre-post of CCP

inclusion showed a statistically significant drop of 0.18 admissions per individual (95% CI = 0.06 0.03; p = 0.003), and a 8.93 decrease in in-hospital days persubject (95% CI = 2.74 15.11; p = 0.005). This amountsto 53.8% fewer admissions and a 65.8% reduction of days in hospital per subject.

Reduction in hospital use observed in the first yearafter CCP inclusion was maintained during the sub-sequent 3 years (Figs. 1 3).

Discussion

Persons with schizophrenia included in our studyexperienced a drop in hospital use after their inclusionin this program. Generally, these results concur withreviews suggesting that CM programs are effective(Mueser et al. 1998; Ziguras & Stuart, 2000), but donot agree with Marshall s (Marshall et al. 1997). Asnot every review shows data on our outcomemeasures, we address each of these.

Admissions per subject

The reduction in admissions per subject observed inour study is at odds with the review by Ziguras &Stuart (2000), which states that only those programswith fidelity to ACT are able to reduce admissions,while patients in CM-based programs have moreadmissions after inclusion. Our results also contradictthose of a recent semi-randomized study on clinicalCM by the CMHS (akin to the programs of the presentstudy) on revolving door patients, which concludedthat Clinical CM did not prove itself superior to stan-dard care in terms of hospital use (Lichtenberg et al.2008).

Different authors suggest that the contradictionsstem from the low rates of admissions in CM studies.Ziguras & Stuart (2000) warn that both types of pro-grams may care for different patient populations,

since the number of prior admissions was higher inACT studies (7.4 admissions) than in Clinical CMstudies (4.7 admissions). Commenting on Curtis sstudy (Curtis et al. 1992), Mueser (Mueser et al. 1998)points out that in low-service users, CM is not effec-tive. A recent study by Burns (Burns et al. 2007) con-cludes that the benefits of intensive CM might bemarginal in settings that have already achieved lowrates of bed use. According to these authors, low hos-pitalization rates point to a good use of communityresources and to hospital admission only as a lastresort.

Our data with CCP based on clinical CM contradictthose hypotheses. In our sample, the mean prioradmission number was even lower than in thosestudies (0.37 admissions per subject in previousyear), yet a significant reduction of number of admis-sions per subject was achieved.

In-hospital days

Ziguras & Stuart (2000) conclude that CM is effective because it reduces total number of hospital days,despite an increase in admissions. Our results show areduction in mean in-hospital days per year and peradmission. This is smaller than in other studies per-formed in Anglo-Saxon countries but in agreementwith the low use of hospitalization in Spain. Forinstance, subjects in the REACT study (Killaspy et al.2006) had a mean in-patient bed use of 176 days inthe year prior to intervention, and patients in theUK700 study (Burns et al. 1999) spent an average of 60 in-hospital days in the two previous years, bothfar from the 13.56 in-hospital days before CCPinclusion found in our study. Another reference forthis comparison is mean days in-hospital after CM

Table 2. Number of admissions, days in hospital per subject and per admission, and ER visits per patient in the year prior to, and the yearsafter, inclusion in CC P

Year (relativeto inclusiondate in CCP)

Individualsat risk of admission Admissions

Mean (S.D.)number of admissionsper subject

Days inhospital

Mean (S.D.)of days inhospital persubject

Mean lengthof stay (days) ER visits

Mean (S.D.)ER visitsper subject

1 240 90 0.37 (0.70) 3256 13.56 (45.22) 36.18 (65.46) 125 0.52 (1.16)1 218 43 0.19 (0.61) 1010 4.63 (17.28) 23.49 (21.63) 74 0.34 (1.22)2 188 43 0.22 (0.85) 784 4.17 (16.83) 18.23 (15.97) 61 0.32 (1.19)3 174 37 0.21 (0.72) 713 4.09 (19.91) 19.27 (23.58) 61 0.35 (1.12)4 159 22 0.13 (0.50) 317 1.99 (8.41) 14.41 (11.57) 54 0.34 (1.24)

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intervention in Marshall s review (Marshall et al. 1997):25.8 days per year v. 2 5 days in the 4 years afterinclusion in intervention for our sample.

Percentage of subjects admitted

Data on the proportion of subjects admitted to hospitalled Marshall et al. (1997) to the conclusion that CMprograms are not effective in terms of hospital use.They rely on the results of six experimental studies:in five of the studies, the group receiving CM had ahigher proportion of subjects admitted than didthose under standard care. Our results, however,show that after inclusion in CCP the proportion of admitted subjects dropped. The proportion of subjectsadmitted pre post-intervention in our study was alsosmaller than in Anglo-Saxon samples (Table 1). Forinstance, in the PRISM study (Thornicroft et al. 1998),

between 39% and 47% of the subjects had beenadmitted after 2 years of follow-up. In the six studiesreviewed by Marshall, 30.38% of the patients underCM were admitted during follow-up.

Emergency room utilization

In our literature review, we did not find studies on theimpact of CCP on emergency room visits in the specific

population of persons with psychiatric disorders. Theresults of the present study show that after inclusionin CCP, both the number of visits to the emergencyroom per subject and the proportion of subjects turn-ing to the emergency room diminished.

A remarkable finding was that the reduction in hos-pital use was sustained during the 3 years followinginclusion. The program remained available to all indi-viduals during that period, although not necessarilywith the same intensity. Follow-up was flexible, andthe degree of support by the case manager was tai-lored to the subject s needs at a certain time. Somepatients requiring very intensive intervention at theinitial phase did not receive such a high degree of attention in other periods. Therefore, this study agreeswith others that found no advantage for continuingintensive and assertive follow-up after the initialphase of intervention over less costly interventionswhich ensure continued supervision of the patient sneeds (Salyers et al. 1998; Ford et al. 2001). Our resultsdiffer from studies that found a rapid loss of achievedimprovement when subjects were transferred to lessintensive programs (Stein & Test, 1980; McRae et al.1990; Audini et al. 1994). It is possible that this

Fig. 1. Percentage of subjects admitted to hospital andvisiting the emergency room. Significant year-to-yeardifferences ( p < 0.05) are depicted with a thicker line betweenthose points in which a difference exists. The differenceachieved between ( 1) and (1) is sustained in the followingyears.

Fig. 2. Number of admissions and emergency room (ER)visits per subject in the year prior to, and 4 years after,inclusion in CCP. Significant year-to-year differences ( p

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