Establishing modified mental health assertive treatment programs in a developing country

Thesis (PhD)--Stellenbosch University, 2016.ENGLISH SUMMARY : An increasing demand for acute inpatient beds has put pressure on psychiatric services in the Western Cape Province of South Africa. While this is not unusual compared to elsewhere in the world, this project aims to find an assertive intervention that not only successfully reduces inpatient usage, but is also sustainable in a low-resource setting. It also attempts to address the repercussions of the deinstitutionalization process, which include a rise in homelessness, an increase in “revolving door” (RD) patients, inadequate discharge planning and a reliance on poor community resources. RD patients also contribute markedly to the need for inpatient beds and costs associated with acute inpatient care, placing an additional burden on health care. Interventions that reduce readmissions in high frequency users (HFUs) help decrease costs associated with inpatient care and improve bed availability. Assertive Community Treatment (ACT) refers to initiatives that incorporate capped caseloads, frequent contacts, home visits and pro-active follow-up. Results from international studies show that ACT interventions may be effective in reducing readmission rates in HFUs in settings where standard care is less comprehensive. The project was divided into four studies, each contributing to inform the final conclusion. Study 1: This was a randomized control trial, which compared a group of low frequency users (LFUs) of mental health services with a group of HFUs. The purpose was to ascertain if local HFUs shared the same characteristics as described in international literature, as we intended to modify a model that had been proven to be effective in an international sample of HFUs. Our results indicated that local HFUs had similar characteristics to those described in the literature; they were more likely to be young males, were more severely ill and more likely to use illicit substances. Study 2: In this study we assessed the effect of a modified intervention on inpatient usage, illness severity and social functioning by comparing intervention participants to a control group over a 12-month period. The intervention was a modified ACT service, with intervention patients receiving fortnightly contacts, pro-active follow-up and 50% of all visits at home. At 12-month follow-up, patients in the intervention group were significantly less ill, reported higher levels of functioning and had significantly less readmissions and overall days spent in hospital (DIH). Study 3: In this study we report on the effect the previously described, modified assertive intervention had on inpatient usage after 36 months. It is important to be able to demonstrate sustained outcomes, since outcomes may tail off after the first 12 months. We compared readmissions and DIH of the same intervention group, with the same control group from our previous study. In this study, we were able to demonstrate that the positive outcomes we reported on in our 12-month follow-up study can be sustained over a 36 month period. The intervention group still had significantly less readmissions and DIH compared to the control group. Despite the success of ACT interventions locally, these highly specialized and focused interventions are expensive and possibly not justifiable in a low-income setting. Study 4: This study was conceptualized in an attempt to find a midway between a highly focused intervention “for few” and the less supportive standard care service which the majority of patients have access to. The intervention was a phone-based intervention, which aimed to support patients and families with frequent phone contacts and would facilitate the patients’ use of the existing standard care service. At 12 month follow-up, there was no difference in inpatient usage between the intervention and the control group. Use of illicit substances was high in both groups. Conclusion: Assertive interventions are effective in reducing inpatient care in our local setting, even when modified to allow for larger caseloads and less frequent visits. However, once home-visits and frequency of contacts are excluded from the model, programme efficacy is reduced significantly. These findings are important in the development of future community-based mental health services, as they will be able to suggest the best possible structure of prospective programmes for better patient results and more efficient and cost-effective programme management.AFRIKAANSE OPSOMMING : Die toename in aanvraag vir akute binnepasient beddens plaas druk op psigiatriese dienste in die Wes Kaap Provinsie van Suid-Afrika. Hoewel dit ooreenstem met internasionale tendense, poog hierdie projek om ‘n pro-aktiewe intervensie te vind wat effektief is in die vermindering van binnepasient gebruik en ook finansieel volhoubaar is in ‘n omgewing met beperkte hulpbronne. Die projek beoog ook om die gevolge van die deinstitusionaliserings proses aan te spreek. Hierdie sluit in, die toename in haweloosheid, die verskynsel van sogenaamde “draaideur” pasiente, onvoldoende ontslag beplanning en beperkte gemeenskapsgebaseerde hulpbronne. Draaideur pasiente dra betekenisvol by tot die druk op die aanvraag vir binnepasient beddens asook die koste geassosieer met akute binnepasient sorg. Intervensies wat heropnames in hoe frekwensie gebruikers (HFG) van geestesgesondheidsdienste verminder, mag binnepasient koste verminder en beskibaarheid van beddens verbeter. Pro-aktiewe Gemeenskaps Behandeling (PGB) verwys na intervensies wat focus op beperkte pasient ladings, gereelde kontakte, huisbesoeke en pro-aktiewe opvolg. Internasionale studies bewys dat PGB intervensies effektief mag wees in die vermindering van heropnames in HFGs in areas waar roetine dienste minder omvattend is. Studie 1: Hierdie was ‘n ewekansig-beheerde studie waarin ‘n groep lae frekwensie gebruikers (LFGs) van psigiatriese dienste vergelyk is met ‘n groep HFGs. In die studie is bepaal dat plaaslike HFGs dieselfde kenmerke het as HFGs wat in die internasionale literatuur beskryf word. Dit is insiggewend aangesien ons beoog om ‘n model aan te pas wat suksesvol was in ‘n internasionale populasie van HFGs. Net soos hul internasionale teenvoeters, was die plaaslike HFGs meer geneig om jong mans te wees, meer ernstig siek te wees en meer geneig tot onwettige substans misbruik. Studie 2: In hierdie studie het ons die effek ondersoek wat ‘n aangepaste, pro-aktiewe intervensie op heropnames, siekte graad en sosiale funksionering het, deur die intervensie groep met ‘n kontrole groep te vergelyk na 12 maande. Die intervensie was ‘n gemodifiseerde PGB waarin pasiente elke twee weke gesien is, pro-aktief opgevolg is, met die klem op tuis besoeke. Na 12 maande was die intervensie pasiente minder siek, het hulle beter sosiale funksionering rapporteer en het hulle minder heropnames en dae in die hospitaal (DIH) gehad. Studie 3: Hierdie studie was daarop gemik om vas te stel of die resultate wat verkry is in Studie 2, volgehou kan word oor ‘n periode van 36 maande. Dit is belangrik om volgehoue effek te kan demonstreer, aangesien positiewe uitkomste dikwels afneem na afloop van die eerste 12 maande. Na afloop van 36 maande was daar steeds aansienlik minder heropnames en DIH in die intervensie groep in vergelyking met die kontrole groep. Ten spyte van die sukses van plaaslike PGB intervensies, bly hierdie ‘n hoogs gespesialiseerde en gefokusde intervensie, wat relatief duur is en moontlik nie regverdigbaar in ‘n lae-hulpbron omgewing is nie. Studie 4: In hierdie studie het ons gepoog om ‘n middeweg te vind tussen ‘n hoogs gefokusde intervensie vir ‘n klein groep en die minder ondersteunende roetine sorgdiens waartoe die meerderheid van pasiente toegang het. Hierdie was ‘n telefoon-gebaseerde intervensie wat gepoog het om pasiente en families te ondersteun met gereelde foonoproepe, asook om die gebruik van die bestaande gemeenskaps-gebaseerde opvolgdienste te fasiliteer. Na afloop van 12 maande, was daar geen verskil in heropnames tussen die twee groepe nie. Onwettige substans misbruik was hoog in beide groepe. Gevolgtrekking: Pro-aktiewe intervensies is effektief in die vermindering van hospitalisasies in ons plaaslike omgewing, ongeag daarvan of die model aangepas word om groter pasientladings en minder gereelde besoeke te akkomodeer. Wanneer tuisbesoeke en gereelde kontakte egter heeltemal uitgesluit word uit die model, neem die effektiwiteit betekenisvol af. Hierdie bevindinge is belangrik in die ontwikkeling van gemeenskapsgebaseerde geestesgesondheidsdienste, aangesien dit kan help met die beplanning van meer koste-effektiewe, toekomstige programme en kan bydra tot beter uitkomste vir pasiente