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International Journal of Mental Health Nursing (2011) 20, 274–283

doi: 10.1111/j.1447-0349.2010.00726.x

Feature Article



Is deinstitutionalization working in our community?
Ann Hamden,1 Richard Newton,2 Kay McCauley-Elsom3 and Wendy Cross4
1 Community Mental Health, Latrobe Regional Hospital, Traralgon, 2Mental Health CSU, Austin Health, 3School of Nursing, Monash University, Peninsula Campus, and 4School of Nursing and Midwifery, Monash University, Melbourne, Victoria, Australia

ABSTRACT: This exploratory study examined the impact of deinstitutionalization on consumers admitted to a regional community care unit (CCU) between 1996 and 2007, and looked at lengths of stay and re-admissions to acute psychiatric care units and the impact this might have on quality of life. The results showed that the original and current residents of CCU have improved quality of life through friendships, a home-like environment, and reduced re-admissions to acute psychiatric care units; however, further improvements can be made with more emphasis on employment/vocational services and social inclusion. More concerning is those who are unable to access a CCU bed due to chronic CCU bed shortages. This group, referred to as the ‘new chronic patients’, tend to become victims of ‘the revolving door phenomenon’, homelessness, and substance abuse. The assertive community treatment model of care and community packages are recommended for people on waiting lists for CCU, or those who do not fit the CCU criteria, to try and reduce the level of disability that is likely to occur from frequent relapses. KEY WORDS: assertive community treatment, community care unit, deinstitutionalization, psychosocial treatment, revolving door, substance abuse.

To many, deinstitutionalization was the closing down of psychiatric health institutions and placing the occupants into the community with or without follow-up care. To the reformist, it meant both the closure of the institutions and their replacement with a range of community-based services, including residential and inpatient services and treatment within the home. In early 1990 under the Labor Government multiple asylums across Victoria, Australia were consuming

Correspondence: Ann Hamden, General Manager Community Mental Health, Latrobe Regional Hospital, 20 Washington Street, Traralgon, Vic. 3844, Australia. Email: Ann Hamden, RN, RPN, MN. Richard Newton, MBChB, MRCPsych, AFRACMA, FRANZCP. Kay McCauley-Elsom, RN, RM, PhD. Wendy Cross, RN, PhD. Accepted November 2010.

a large proportion of the state budget. As part of a broader policy of deinstitutionalization community care units (CCU) were established in Victoria to accommodate people remaining in long-term psychiatric settings. The CCU in this study is a 20-bed cluster housing development in a residential setting, staffed on a 24-hour basis by a multidisciplinary team. It was established with the twin goals of clinical care and rehabilitation of the residents. Little is known about the long-term outcomes for these consumers and the impact on the younger generation with chronic, severe mental illness (SMI). A study by Farhall et al. (1999) concluded that after 1 year, there was little change in the symptoms or disability levels of the residents, although residents reported improved levels of quality of life, particularly in their living environment. Relatives and carers also reported a preference for the CCU setting for their relatives over hospitalization.

© 2011 The Authors International Journal of Mental Health Nursing © 2011 Australian College of Mental Health Nurses Inc.

(2003) was that consumers were discharged to the community without appropriate housing and follow up. Meadows & Singh 2003). In acute settings in mental health services the revolving door phenomenon is commonplace (de Girolama & Cozza 2000. Leff & Trieman 2000). the quality of mental health systems depends on these factors as well as social acceptance of deinstitutionalization. and it is this consequence that appears central to the ongoing difficulties related to deinstitutionalization. Dixon & Goldman 2004. funding arrangements. However. both here and overseas (Farhall et al. According to Newton et long-term inpatient treatment and rehabilitation for people who have unremitting and severe symptoms of mental illness with an associated significant disturbance in behaviour that preclude their living in a less restricted environment (Victorian Government 2007). along with an increase in demand for mental health care since the closure of institutions. This is supported by Moxham and Pegg (2000). Hobbs et al. 2003). There is growing acknowledgement that the mental health system in Australia is failing to adequately support some of the most disadvantaged members of our community (Groom et al. and policy does not stipulate the expected outcomes. despite deinstitutionalization occurring in several countries. Secure. To address this issue. Sawyer 2005). continuing care services. Although. Razali 2004. it also included the development of the crisis assessment and treatment teams. Unfortunately. Affordable. The emergence of consumer and family self-help and advocacy groups also assisted in the development of a more humanistic treatment system (Lamb et al. The development of supported accommodation in the community has had some encouraging outcomes for residents. mobile support and treatment services. Fakhoury and Priebe (2007) stated that there are still many large tertiary longterm care facilities and no community-based mental health services in many countries. resulting in neglect. These two factors. secure housing for people with mental illness is integral to the provision of mental health care. Sawyer 2005). have contributed to the premature discharge of people who still have acute symptoms of mental illness. 1999. The Australian National Mental Health Strategy (1992) was the driving force behind deinstitutionalization in Victoria. Dixon & Goldman 2004. Front-end services such as emergency departments (ED) and acute inpatient units are largely governed by key performance output indicators including length of stay (LOS) in hospital (in both ED and inpatient units) and re-admissions to hospital within 28 days of discharge. through administration and infrastructure. 2000. and specific traditions. the Victorian Government established CCU across the state. This phenomenon refers to the rapid and repeated admission and discharge of people with mental health problems. Mechanic and Rochfort (1990) believe that deinstitutionalization has not been implemented consistently across geographic areas. Razali 2004. Furthermore. (2000) in the early 1990s large metropolitan psychiatric services were reportedly consuming 45% of the budget of mental and general health services. appropriate and affordable housing provides people with an increased chance of effective treatment and rehabilitation and without this the morbidity and mortality rates arising from homelessness or inappropriate housing is compromised (Moxham & Pegg 2000) and often leads to relapse and consequent re-admission to hospital (Lamb & Weinberger 2001). at least in the short term. 2000). . the evidence for the success of deinstitutionalization has not all been positive. The largest flaw. In addition comorbidities such as substance misuse and social issues such as homelessness and unemployment are all factors that contribute to relapse and the ‘revolving door’ syndrome (de Girolama & Cozza 2000. according to Feldman et al. The provision of appropriate housing has been the least well-developed component of the deinstitutionalization process. The process of deinstitutionalization in mental health services seems to be progressing at different paces in several countries where the problems vary in relation to socioeconomic situations. Importantly mental health care must be provided in the least restrictive manner for those who require it. According to Fakhoury and Priebe (2002) and Sealy and Whitehead (2004). deinstitutionalization began some 60 years ago.IS DESINSTITUTIONALIZATION WORKING? 275 Background and literature review Deinstitutionalization began as far back as the 1950s and has led to the downsizing and closing of multiple asylums across the world (Fakhoury & Priebe 2002). who suggest that implementation over the past 20 years has resulted in a lack of appropriate accommodation. Acute inpatient services were co-located and mainstreamed with general hospitals along with secure extended-care units which provide medium. 2003. Sealy and Whitehead (2004) assert that it is not complete because there are no measures to determine when the expansion of community-based services has been completed. © 2011 The Authors International Journal of Mental Health Nursing © 2011 Australian College of Mental Health Nurses Inc. An increase in opportunities for long-stay residents to regain social inclusion was anticipated to be another positive aspect of deinstitutionalization (Newton et al. and community mental health clinics. In addition to the establishment of CCU. globally.

with less empha- sis on symptoms and social functioning assessments. structured environments in order to promote recovery. The psychosocial rehabilitation programmes have improved significantly and include more social activities. Trauer et al. along with other authors (Bigelow & Young 1991. The study by Trauer et al. This study sought to identify aspects of quality of life for those currently in CCU and for those who were deinstitutionalized and have since left the CCU environment. p111). Bigelow et al. and had scant privacy and dignity. as identified via the client management interface (CMI) system. retaining one’s identity. Sheth (2009) believes that the deinstitutionalization movement has actually resulted in transinstitutionalization. however. Lamb and Weinberger (2001). Priebe et al. being able to manage symptoms. More evidence for that view is needed. promoting social inclusion. with or without symptoms. Data Data were gathered using the database data of hospital admissions (CMI). . Many consumers experienced psychiatric institutions in Victoria that were locked. There is also a view that CCU are mini institutions. Priebe et al. Moreover. (2001) concluded that despite minimal change in symptoms and disability levels there were improvements for the residents’ quality of life in terms of living environment. is whether the LOS in CCU is reducing for new residents and whether there is an impact on outcomes such as quality of life. where large numbers of people with a mental illness have landed in the prison system or homeless shelters. where residents have their own unit or a shared unit with one other resident. and the role of CCU. METHOD Study design This study is a descriptive. and accepting one’s illness (Bonney & Stickley 2008).276 A. reported changes in the way they related to consumers and their views on rehabilitation. Recovery is viewed by many as regaining a fulfilling life. as well as job satisfaction and stress was conducted but not included in this article. Nevertheless. CCU are relatively modern cluster homes. (1999a) also argued that the ultimate outcome for residents is their quality of life as this is the basis of the biopsychosocial model of service delivery that dominates mental health programming today. research and service planning for people who experience psychiatric disabilities’ (Priebe et al. and the second group comprised residents admitted to the CCU between 1996 and 2007 (n = 15). 1991. rather than for the whole of life. ‘New long-term patients’ (Lamb & Weinberger 2001) refers to consumers who have spent minimal time in acute inpatient care with little opportunity for initiation of the recovery process. There is however. Chan et al. The first group comprised current residents in the CCU (n = 16). those who have been admitted to CCU in Victoria have had a welcome change to the previous institutional living. Sample A convenience sample was utilized in this study. (ii) the attitudes of past and current residents regarding CCU. There were two key cohorts of eligible participants. HAMDEN ET AL. Notably. highlight the needs of a small proportion of people with SMI who might still require 24-hour care including the provision of ongoing. as a concept. ‘Quality of life. and (iv) the impact on re-admissions to hospital. Nieuwenhuizen et al. 1999a. exploratory design using quantitative approaches. 2003. Staff too while initially sceptical of the move. A further study seeking CCU staff’s views about rehabilitation practices within the workplace. 1998) support the evaluation of mental health services through quality-of-life studies. (2001) study being the only Australian study found in the literature. a paucity of current Australian qualityof-life studies reporting on outcomes for those who experienced deinstitutionalization in this country. as evidenced in the demographic data from this study. over the last two decades become a focal point for mental health services. especially in Australia. LOS ranges from a few weeks or months to over 1 year. their expectations of consumer improvement. had dilapidated buildings. (1999a). (2001) also discussed the need for further studies to look at the function of CCU and their emerging needs now that there is a significant reduction in the availability of inpatient beds. and this is the motivation behind this research. which produced the information © 2011 The Authors International Journal of Mental Health Nursing © 2011 Australian College of Mental Health Nurses Inc. The older age and chronicity of a large majority of the sample could be largely related to the minimal change in levels of disability and symptoms. Relatives and carers also reported preferring CCU to hospitals. Brunt & Hansson 2004. The majority of consumers preferred the CCU setting to hospital. with the Trauer et al. Aim The research aimed to identify: (i) the quality-of-life variables for past and present residents of CCU. (iii) if there is a reduction in LOS in CCU. Sheth (2009) estimates that up to 40% of people in homeless shelters have an SMI. A key consideration following the reform in mental health care and its effect on those receiving care.

The Pearson’s correlations of the subjective quality of life were all 0. A stamped. 1993) and the Manchester Short Assessment for the Quality of Life (MANSA) (Priebe et al. Of the 13 items in the PAQ. The authors concluded that the MANSA is a satisfactory brief instrument for assessing quality of life. determined by using satisfaction scales related to different areas of life. Forty-three long-stay consumers were interviewed on two occasions (test. The study was conducted in the residents’ own environment predominantly in their own residential unit or in the staff office.94 mean score) and Cronbach’s alpha for satisfaction ratings was 0.) Procedures This study was undertaken in a regional mental health service. as well as diagnoses. along with a simple brief letter asking them their preferred times for interview and a copy of the rating scales to be used for the study. safety. diagnoses and re-admissions to acute psychiatric care units was performed to determine changes in admission patterns over time. The validity and reliability of the quality-of-life tool. Two key staff working in the CCU were recruited to assist with the recruitment and interviewing of the current CCU residents. (1999b). This project evaluated the policy of replacing psychiatric hospitals with district-based services (Leff & Trieman 2000). the MANSA was reported by Priebe et al. Validity and reliability of the instruments PAQ The reliability and validity of the PAQ were reported by Thornicroft et al. Kappa statistics were used to analyse reliability and the kappa © 2011 The Authors International Journal of Mental Health Nursing © 2011 Australian College of Mental Health Nurses Inc.g. USA). and re-admissions to acute care. quality and number of personal friends. financial situation. Instruments Two key instruments used in the study were the Patient Attitude Questionnaire (PAQ) (Thornicroft et al. Current residents The same demographic data were also collected on all current residents of the CCU and comparisons were then made between the two groups (discharged vs current residents). The CMI was used to collect these data. For those who were interested in participating a participant information sheet and consent form were posted. Data were analysed using SPSS version 14 (SPSS. personal safety.83 or higher (0. Ex-residents were phoned and invited to participate in the study. These participants were interviewed via phone or in person. The PAQ is a 19-item instrument developed to measure consumers’ views towards hospitals and community services. Priebe et al. This involved identifying and analysing data on residents’ demographic information (e. retest). all had kappa values in excess of 0. Demographic data Two different streams of demographic data were identified in this study. LOS in the CCU. relations within the family. The study showed that long-term psychiatric consumers can give clear and concise views regarding their experiences. finances and accommodation.7 showing good agreement. Wellbeing and life satisfaction are referred to as the subjective component. mental and somatic health. sex. location). . This was followed with interviews of current CCU residents and a survey of previous CCU residents. Previous residents coefficient (with 95% confidence intervals) measured the extent of agreement between the first and second interviews. age. With the rating scales in front of them while being interviewed over the phone it was thought the participants might find it easier to respond with one of six responses. selfaddressed envelope was also included to encourage the return of the consent form. IL. which suggest that in addition to reliability the PAQ also has face validity. Ethics approval was obtained from the institutional ethics committee prior to data collection. 1999b). The objective data are related to areas such as employment. These clinicians were trained in the use of the PAQ and MANSA. The MANSA was designed to assess the degree of satisfaction/dissatisfaction with different areas of life (present job/school. health. They also obtained consent from all 16 participants who were current CCU residents. Chicago.74. (1999b) interviewed 55 people with several satisfaction tools including the MANSA. leisure. Results from the PAQ show convincingly that consumers prefer the community to hospital living and have far more autonomy.IS DESINSTITUTIONALIZATION WORKING? 277 regarding residents’ demographics and contact details. The PAQ was developed for the Team Assessment of Psychiatric Services (TAPS) project in the UK. relating to LOS. MANSA A retrospective examination of medical record data on CCU residents from 1996 to 2007. (1993). relationships.

721 14. Friendships RESULTS Participant demographics The demographic data. prior to moving and at the © 2011 The Authors International Journal of Mental Health Nursing © 2011 Australian College of Mental Health Nurses Inc. the older group (41–70 years old) had equal numbers of females to males. (2001) showed a mean score of 55% satisfaction with friendships (n = 84) 1 year post-move which was actually a decline from the pre-move score (n = 45) of 62.’s (2001) study found that none of the residents in the hospitals. Of this 31 who were sent information sheets and consent forms. .225 All residents admitted to the CCU between 1996 and 2007 were identified via the (CMI) system and the resulting data printed out onto a spreadsheet. are outlined in Tables 1 and 2.68 39. (2001) the MANSA was completed pre-move to the CCU and 12 months’ Trauer et al. The clinicians assisting with recruitment obtained consent from 16 of the 20 residents. with the only significant changes being in the living situation. Commonly this would occur on admission and discharge to hospital on assessment of a previously discharged consumer or each contact that a case manager or doctor has with a consumer. only 11 returned them. HAMDEN ET AL. Trauer et al.6% expressing happiness with their friendships and 72% of respondents had actually seen a friend in the last week. this might not be entered into the CMI database thus the contacting of ex-residents needed to be managed sensitively. if an ex-resident who has been discharged from the service has left the area or is deceased. resulting in a sample group of 15 (15%).278 A. The recruitment of the ex-residents for the interview was more complex than for the current residents.080 2. 1). TABLE 1: Mean age and sex of respondents Age n Male Female 81 40 Mean 36. The present study shows results for 10 years’ post-move. 18 were not answered despite several attempts to call. The domains of friendships and employment are the two significant areas resulting from findings in the MANSA. showed that 81 were males and only 40 were females. Therefore. When separated into age groups. The demographics including sex and age of current and past CCU residents. The current residents of the CCU were extracted and placed on a separate spreadsheet. 12 declined to be involved in the study. Once the current CCU residents (n = 20) were taken from the original spreadsheet.’s (2001) study with 79. but this changed significantly in the 40 years and under age group where the weighting showed 75% male and 25% female. Responses showed higher levels of satisfaction in the past group (Fig. Satisfaction with number and quality of friendships Quality-of-life variables for past and present residents of CCU MANSA Respondents were asked how satisfied they were with the number and quality of their friendships. there were 101 potential ex-residents who could be participants for the study. The researcher provided one follow-up reminder call and was able to obtain another five participants.2%.90 Standard deviation 9. and four were in a medium secure unit. The interviews were completed over a 6-week period. suggesting that residents might have been separated from their friends during the move into CCU. 2). The researcher attempted to phone all previous residents but found that 29 of the phone numbers were incorrect. Close friends Most respondents had a close friend in their lives (Fig. Employment In the study by Trauer et al. The remaining 31 agreed to participate in the study. The current and past residents in the present study showed an improvement from those of Trauer et al. The data through CMI are updated when there is some form of contact with the mental health services.069 Standard error mean 1. The sample represented 70% of the current residents. There are some further pleasing improvements as well as disappointments in other domains found in this study. in relation to the sex of the individuals. Respondents’ sex TABLE 2: Ratio of males to females per age group Age group 18–25 11 7 26–33 32 12 34–41 23 6 41–70 15 15 Total 81 40 Respondents’ sex Male Female post-move. These data suggest that the deinstitutionalization process has been conducive to residents’ improvement in socialization and friendship building. with one in a psychogeriatric nursing home. three had died.

LOS in CCU and re-admission to acute psychiatric care units Attitudes of past and current residents regarding the CCU PAQ It was important to understand the participants’ identification and understanding of changes in their self since admission to the CCU and whether they would recommend the CCU setting to others.42% FIG. the idea that a shorter LOS causes increased re-admissions to hospital cannot be validated (Figs 3.035) and admissions to hospital before CCU (P = 0. FIG.83% 80. CCU. Satisfaction with number and quality of friends. Re-admissions to hospital after discharge from CCU also showed a significant reduction. © 2011 The Authors International Journal of Mental Health Nursing © 2011 Australian College of Mental Health Nurses Inc. current. LOS. These findings indicate that receiving 24-hour care and having qualified staff and access to medical intervention when required can assist in keeping residents who are unwell out of acute psychiatric care units (Figs 3. This There is evidence from the data that the LOS and number of admissions to acute psychiatric care units reduces significantly after spending time in CCU. 4: Number of in-hospital bed days. CCU. This is supported by the responses of several respondents. current. so we were unable to draw comparisons. 12-month follow up after the move.4). There is a reduced LOS in acute psychiatric care units while residing in CCU (P = 0. Although a small group of residents required secure residential care.66% 0 LOS in hospital before CCU LOS in hospital during CCU LOS in hospital after CCU 15. Number of Number of admissions admissions after while in CCU discharge from CCU Number of admissions to hospital.4). who believed they were changed for the better by their stay in CCU and would be recommending CCU to others. Furthermore. when asked for suggestions that could improve the CCU programme through the PAQ. ( ). in that only two (n = 31) were gainfully employed and they were ex-CCU residents. ( ). community care units. past. 34% commented that they would like gainful employment. community care units.51% Displeased Mostly Displeased Mixed Mostly satisfied Pleased Could not be better Satisfaction with number and quality of friends FIG. 100 Respondents (%) 80 60 40 20 3. 1: 7 6 Respondents (n) 5 4 3 2 1 0 Close friends. Information from the present study is not much more encouraging. (2001).7% 0 Number of admissions before CCU FIG.IS DESINSTITUTIONALIZATION WORKING? 14 12 279 80 70 Respondents (%) 60 50 40 30 20 10 7. past. . 3: 75.88% Respondents (n) 10 8 6 4 2 0 Yes Close friends No 16. were employed. Some residents commented that they would not be able to live independently if it were not for the CCU. ( ). length of stay. question was not reported by Trauer et al. 2: ( ).011). The findings relating to this topic area suggest that despite the severity and chronicity of mental illness in CCU participants there was an appreciation and insight into the benefits of CCU.

the demographics reported here suggest that men are more likely to require long-term care than women.687 0. LOS in the CCU. consequently reducing opportunities of gainful employment for this group of people. Number of hospital admissions before community care units (CCU) and lengths of stay (LOS) in wards during CCU stay Sum of squares df 34 84 118 32 71 103 Mean square 68. 4 hours per day. and would be far more beneficial than having the employment service belonging to another service and in a different location. ACT provides treatment within the client’s home assists people with SMI to become involved with community agencies. enhancing interpersonal and social functioning.874 P-value 0. Furthermore. there is sufficient evidence through the resident questionnaires and demographic data to show that a majority of past residents are living independently or in supported accommodation and that CCU are helpful in providing residents with the skills required to live independently. Several references in the literature have been made to the need for the provision of long-term care to this vulnerable group of people. however the likelihood of availability of more CCU beds is not promising (Council of Australian Governments 2006. Crowther et al. Staff initiating contact rather than waiting for people to keep appointments. Demographic data were also gathered and showed more males than females using CCU. . The LOS in CCU has decreased over the years. Only two respondents were employed. Although there are generic employment services within the region of this study setting. Thirty years of research has repeatedly demonstrated that ACT reduces hospital admissions and improves quality of life for people with SMI (Phillips et al. Although statistically the incidence of SMI in males compared to females is even (National Centre for Health Statistics 1996).442 F 1.280 TABLE 3: A. 2001). and teaches coping skills so that this vulnerable group is able to live and function in the community.575 5 387. An ANOVA was also used to identify the significant changes in LOS and number of admissions to acute psychiatric care units. Garske & McReynolds 2001).471 2378.350 36.887 3 063.154 1. and this is supported in the literature. continuity.373 176 266. attitudes of residents regarding the CCU. frequently related to substance abuse and homelessness (Treiman et al. and consistency in an integrated service and combining treatment with rehabilitation. with more discharges occurring each year. are the hallmarks of ACT (Garske & McReynolds 2001). there has been a marked reduction in admissions to acute psychiatric care units while residing in CCU and after discharge from CCU.899 1410. Admissions to acute psychiatric care units before CCU and LOS in wards of CCU showed significance (Table 3). Victorian Government 2002). DISCUSSION This study examined CCU in relation to quality of life for past and present residents. The younger. In light of this information. 1999).035 Importantly. alternate models of psychiatric rehabilitation in the community also need to be explored if people with SMI are to be appropriately cared for in the community. and re-admissions to hospital. Notably one of them was employed by the Area Mental Health service to wash the fleet cars 2 days per week. © 2011 The Authors International Journal of Mental Health Nursing © 2011 Australian College of Mental Health Nurses Inc. (2004) suggest that having specific employment staff co-located at the same site as the mental health service would enable more frequent interaction and encourage a collaborative approach to assisting with employment issues for individuals.011 Admissions before CCU LOS in ward of CCU Between groups Within groups Total Between groups Within groups Total 2 323. predominantly male group had higher rates of re-admission to hospital.462 76 124. The assertive community treatment (ACT) model has a strong focus on keeping this group of patients engaged with treatment and out of hospital. Psychiatric rehabilitation including psychosocial treatment approaches has become more prevalent since deinstitutionalization. HAMDEN ET AL. case managers report a lack of accessibility and employment options due to potential employers’ poor understanding of mental illness. promoting independent living and community tenure and improving illness symptoms and management.781 100 141. provides family support. links in with housing and employment services. ACT has a strong focus on keeping this group of patients engaged with treatment and out of hospital (Bermingham 1999. (2006) and Mueser et al. with a significant increase in the number of male residents over the past 10 years.

and housing. This is required to enable long-term residents who are unlikely to improve in psychosocial functioning to be moved to appropriate community accommodation. this was a very difficult task to achieve in the timeframes of this study. improved LOS. self-addressed envelope being provided and a follow-up phone call. with a strong focus in the areas of vocation and social inclusion • Review of discharge policies and procedures to include plans for long-term residents unlikely to improve in their psychosocial functioning. thus this method should be considered in further follow up within this population of people. The Personal Helpers and Mentors Program (Council of Australian Governments 2006) is another initiative that assists people with SMI to manage daily activities and to access services and supports. First. Certainly. in particular a change to how consent is obtained. Importantly there were issues with the response rate that hindered the ability to gain consent and which would need to be considered if this study were to be expanded in the future. The present study examined the quality of life and attitudes of current and past CCU residents. Other service provisions that would enhance the work of the CCU and that of Area Mental Health services that are now caring for this group of people in the community as a result of deinstitutionalization include: • An evaluation of the CCU model of care and the exploration of more evidence-based models of care. Nevertheless. as well as the past and current residents of CCU for their willingness to participate. © 2011 The Authors International Journal of Mental Health Nursing © 2011 Australian College of Mental Health Nurses Inc. The small sample size also inhibits stronger conclusions being drawn regarding the clinical significance of the findings. Several offered to complete the questionnaire over the phone at the time of the call. .IS DESINSTITUTIONALIZATION WORKING? 281 Other government initiatives that can be utilized for this group of people are the Home Based Outreach Support and Intensive Home Based Outreach Support (IHBOS) programmes through Psychiatric Disability and Support Services (PDRS). Further research is required to complete the tracking of ex-CCU residents from the area to further strengthen the findings of this study. Consideration must be given to the methodology and ethical issues identified within this study. employment. The lack of signed consents was not necessarily due to unwillingness to participate in the study but could be due to negative illness symptoms. and positive outcomes with regard to social inclusion. The fact that it was a follow-up study gave the researcher a baseline of information to focus on and the study provides several opportunities for conducting further research. mental health services might provide more robust evidence about Victorian demographic data and the quality of life of all residents of CCU. The IHBOS is more intensive and targets people who are homeless or at risk of homelessness but there are only a limited number of these packages available in each region (Victorian Government 2007). A broadening to include other ACKNOWLEDGEMENTS The authors would like to thank the staff at CCU for supporting and assisting with this important study. which provide rehabilitation and disability support to people with SMI. CONCLUSION This study showed that CCU have a positive effect on hospital re-admission rates to acute psychiatric care units. thereby freeing up beds for the wait-listed residents • Utilization of the ACT model of care for people on waiting lists for CCU in order to try to reduce the level of disability that is likely to occur with frequent relapses • Exploration of collaborative options with the psychiatric disability and rehabilitation services sector aiming to provide community packages and outreach services to people with SMI who are either not able to access a CCU bed or do not fit the criteria for CCU placement Strengths and limitations of the study The demographic data collection provided a good source of information and was all available via a database. statistical significance was found but with a small sample this must be examined cautiously when drawing conclusions about the true clinical impact of CCU. While it had been intended to interview the majority of the 101 past residents. and in this study could have been mitigated by face-to-face consenting of participants. as well as demographic data in relation to LOS and re-admissions to hospital. The limitations include the ongoing need to continue the follow up of previous residents. such as apathy and poor motivation. The inclusion of phone consent to enable the ex-resident to be engaged in the study during the initial phone call and offering reimbursements of expenses might encourage increased participation. most past residents who were able to be contacted via telephone agreed to participate in the study but several did not send back the signed consent forms despite a stamped. poor response rates are found among other research groups as well.

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