538106 research-article2014

ANP0010.1177/0004867414538106Australian & New Zealand Journal of PsychiatryAllison et al.

Commentaries Australian & New Zealand Journal of Psychiatry 2014, Vol. 48(10) 952­–956

Commentaries

Acute versus sub-acute care beds: Should Australia invest in community beds at the expense of hospital beds? Stephen Allison1, Tarun Bastiampillai1 and Robert Goldney2 1Discipline

of Psychiatry, Flinders University, Adelaide, Australia 2Discipline of Psychiatry, University of Adelaide, Australia Corresponding author: Stephen Allison, Discipline of Psychiatry, Flinders University, Bedford Park, Adelaide, SA 5042, Australia. Email: [email protected] DOI: 10.1177/0004867414538106

Sub-acute care community units are a relatively new addition to Australia’s mental health system. A recent systematic review suggested that they might be able to provide cost-effective alternatives to hospital admissions (Thomas and Rickwood, 2013). On this basis, Commonwealth and State governments have begun to expand sub-acute care programmes with the aims of preventing unnecessary acute care admissions, shortening hospital lengths of stay and reducing readmission rates. However, questions remain about whether the introduction of these new sub-acute care units has in fact reduced the pressures on public hospitals. The outcomes of sub-acute care programmes in Brisbane and Adelaide shed further light on the ‘real-world’ effects of subacute care.

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A recent study by Siskind et  al. (2013) provides interesting results on the effectiveness of an established sub-acute care unit in reducing hospital demand. The study describes the outcomes of a crisis house in Brisbane that offered sub-acute care admissions as an alternative to hospitalisation (AtH) for people with severe and persistent mental illness. In the shortterm, Siskind et al. (2013) found that AtH patients spent fewer days in hospital during the index admissions, which provided cost savings for the regional mental health service. These results suggested that mental health planners might be able to open lowcost community houses to reduce the number of expensive hospital beds. However, the AtH study presented a more complex picture in the medium term. The AtH programme did not appear to reduce patient demand on hospitals during the following year. In fact, AtH patients were relatively high users of hospital services compared to selected controls. In the year after sub-acute care, AtH patients were significantly more likely to have emergency department (ED) presentations (60 vs 40%) and require hospital readmission (46 vs 26%). A newly released report on South Australia’s sub-acute care programme provides a further illustration of the ‘real-world’ effects of sub-acute care (Health Outcomes International, 2013). The most controversial aspect of the South Australian plan is the decommissioning of acute care hospital beds alongside the roll-out of subacute care community beds. Currently, South Australia appears to be the only State closing specialised psychiatric units within public acute

care hospitals. Generally speaking, acute care beds are increasing in Australian public hospitals in line with overall population growth. For example, Victoria has recently commissioned a significant increase in hospital beds over 2013–2014 in response to rising patient demand. During 2011–2012, Adelaide’s mix of mental health beds was changing as 23 acute care hospital beds were closed while 45 sub-acute care community beds were opened in newly built intermediate care centres (ICCs). This first phase of the ICC programme was funded at around AUD$7.2 million recurrent. As a consequence of these changes, South Australia sits well above the national average for community residential beds for people aged 18–65 (12.7 beds per 100,000 compared to 6.0 beds per 100,000), but significantly below the national average for non-veterans general hospital acute care adult beds (19.9 beds per 100,000 compared to 24.3 beds per 100,000). Additionally, South Australia has low numbers of nonacute care rehabilitation hospital beds (4.0 beds per 100,000 compared to 10.0 beds per 100,000) and very low rates of supported accommodation (Australian Institute of Health and Welfare, 2011; Department of Health and Ageing, 2010; Ernst & Young, 2013). In summary, South Australia has quite a different mix of beds compared to other States, including the lowest average number of Statefunded, non-veterans general hospital acute care adult beds in the nation[see]. It was hoped that Adelaide’s high number of ICC sub-acute care beds would assist in reducing psychiatric presentations to EDs, as well as

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ANZJP Correspondence compensate for the low numbers of acute care hospital beds. To date, there is very little evidence of this occurring and a recent Ernst & Young review found that ‘the mental health system in South Australia has experienced growing pressure within all emergency departments in respect to acute mental health patient demand’ (Ernst & Young, 2013: 1) during the period of ICC expansion and the closure of acute care beds. Based on the Brisbane and Adelaide studies, sub-acute care programmes do not appear to have impacted on hospital demand (Health Outcomes International, 2013). Preliminary data from the Adelaide sub-acute care programme indicated that ICC patients were slightly more likely (rather than less likely) to present to the ED and be admitted to an acute care hospital bed following sub-acute care admissions. This is consistent with the pattern of greater demand after AtH sub-acute care admissions in Brisbane (Siskind et  al., 2013). The reasons behind the higher demand are unclear, but short lengths of stay in these sub-acute care programmes may have meant that treatment was insufficient to change illness trajectories. The ICC evaluation concluded that ‘given the short length of stay in an ICC, it is not anticipated that acute mental health admissions would necessarily reduce’ (Health Outcomes International, 2013: 4). The low-risk profile of both AtH and ICC sub-acute care units may also limit their usefulness as an alternative to acute care hospitalisation. Patients in the Brisbane programme had lower levels of illness acuity than controls in the 12 months prior to an AtH admission. In the Adelaide programme, the majority of ICC patients were rated as either no-risk or low-risk for violence (97%) or suicide (90%) (Health Outcomes International, 2013: 18) and most of these patients would not have met the threshold for acute hospital care. The evaluation noted that the ICCs were neither designed nor staffed for the small proportion of

higher-risk patients who were admitted to reduce pressures in the EDs and acute care wards. Because of this low-risk admission profile, the ICCs operated to a large extent as an additional community option and in practice had only a very limited ability to reduce acute care hospital demand. In summary, despite the shortterm promise of the Brisbane AtH programme, the results imply that demand on hospitals remained relatively high in the medium term. In addition, the evidence to date suggests that the introduction of the Adelaide’s sub-acute care beds has neither reduced ED demand nor provided an alternative to the chronic shortage of acute care psychiatric inpatient beds. Hence, Australian mental health planners should be cautious about decommissioning newly built and staffed mainstream acute care psychiatric beds in public hospitals, which are a pillar of the National Mental Health Strategy, in favour of a largely untested model of sub-acute care community residential care. Australia is already operating from a low base of acute care psychiatric beds. Carr and Copolov (2011) have highlighted the major reductions in Australia’s psychiatric bed stock over recent decades. We have among the lowest numbers of psychiatric beds per capita in the developed world; much lower than the average given by the Organisation for Economic Co­­ operation and Development (OECD, 2013). Harris and colleagues have acknowledged that the ‘pressures on acute psychiatric inpatient units within all jurisdictions, resulting in high occupancy rates and lack of access to services to consumers in acute need, have raised doubts about whether current acute inpatient service levels are adequate’ (Harris et  al., 2012: 988). Furthermore, there is scepticism about the ability of community care to compensate for the relatively low numbers of acute care beds and reduce the pressures on EDs (Cunningham, 2012).

From a social justice perspective, it is imperative that we get the balance right and prevent acutely unwell psychiatric patients from languishing for longer periods in busy EDs than medical or surgical patients while awaiting an acute care hospital bed. The provision of acute and sub-acute care beds is a significant area of policy debate for psychiatry that needs careful scrutiny and evaluation across Australia and New Zealand. Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper. See Research by Siskind et al., 2013 47(7): 667–675.

References Australian Institute of Health and Welfare (2011) Specialised mental health beds. Available at: https://mhsa.aihw.gov.au/resources/facilities/ beds/ (accessed 17 May 2014). Carr VJ and Copolov D (2011) Out in the cold: Lack of hospital beds cuts off help for seriously mentally ill. Available at: http:// theconversation.com/out-in-the-cold-lack-ofhospital-beds-cuts-off-help-for-seriously-mentally-ill-2210 (accessed 17 May 2014). Cunningham PA (2012) The future of community-centred health services in Australia: An alternative view. Australian Health Review 36: 121–124. Department of Health and Ageing (2010) National mental health report 2010: Summary of 15 years of reform in Australia’s mental health services under the National Mental Health Strategy 1993–2008. Canberra: Commonwealth of Australia. Available at: http://health.gov.au/internet/main/publishing. nsf/Content/58B9C24B0D74E79ACA257BF0 001FEADF/$File/report10v3.pdf (accessed 17 May 2014). Ernst & Young (2013) Department for Health and Ageing, South Australia. Review of the South Australian stepped system of mental health care and capacity to respond to emergency demand. Adelaide: Government of South Australia. Available at: www.sahealth.sa.gov. au/wps/wcm/connect/3d07300040a491ea966 0bfe034676b7b/Review+of+Mental+Health-

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MHSA-OCP-20130809.pdf?MOD=AJPERES& CACHEID=3d07300040a491ea9660bfe03467 6b7b (accessed 17 May 2014). Harris MG, Buckingham WJ, Pirkis J, et al. (2012) Planning estimates for the provision of core mental health services in Queensland 2007 to 2017. Australian and New Zealand Journal of Psychiatry 46: 982–994. Health Outcomes International (2013) SA Health: Evaluation of the intermediate care services. Final report. Adelaide: Government of South

Australia. Available at: www.sahealth.sa.gov. au/wps/wcm/connect/b07eb98042ec81578c28 bc9d0fd82883/ICC+Final+eval+report.pdf?M OD=AJPERES&CACHEID=b07eb98042ec815 78c28bc9d0fd82883 (accessed 17 May 2014). Organisation for Economic Cooperation and Development (2013) OECD health statistics 2013: Frequently requested data. Available at: www.oecd.org/els/health-systems/oecdhealthdata2013-frequentlyrequesteddata.htm (accessed 21 May 2014).

Siskind D, Harris M, Kisely S, et  al. (2013) A retrospective quasi-experimental study of a community crisis house for patients with severe and persistent mental illness. Australian and New Zealand Journal of Psychiatry 47: 667–675. Thomas KA and Rickwood D (2013) Clinical and cost-effectiveness of acute and subacute residential mental health services: A systematic review. Psychiatric Services 64: 1140–1149.

Promoting positive attitudes of tobaccodependent mental health patients towards NRTsupported harm reduction and smoking cessation Renee Bittoun1, Melinda Barone2, Colin P Mendelsohn1, Emma L Elcombe1 and Nick Glozier3

consequently increasing their exposure to carbon monoxide and particulate matter (Fagerstrom, 2005). A relatively novel approach is a nicotine replacement therapy (NRT)supported harm-reduction strategy. This strategy provides patients with access to NRT while allowing smoking to continue unrestricted, thus lessening a patient’s initial anxiety associated with idea of “quitting smoking” while reducing their inhalation of toxins. This method has been shown to reduce tobacco-related toxin consumption and increase smoking cessation and sustained abstinence rates in healthy adults (Fagerstrom, 2005; Stead and Lancaster, 2007). It follows that this approach may engage and facilitate smoking cessation in patients with barriers to immediate cessation or sustained abstinence (Shiffman et  al., 2007), such as those with higher dependence, higher vulnerability to withdrawal effects, anxiety, depression, and distress. As such, NRT-supported harm reduction may be appropriate in mental health settings (Morris et  al., 2011); however, the acceptability of such an approach in mental health patients is unknown. The present study assessed the effects of simple education on attitudes to NRT-supported harm reduction in tobacco-dependent mental health outpatients. We hypothesized that informing mental health patients of this option would augment motivation to engage in this strategy. Our outpatient study was conducted at the Brain and Mind Research Institute, Sydney, Australia. Consenting participants completed a socio-demographic

assessment questionnaire followed by a two-part attitude assessment. In a single session, the views of participants with selfreported tobacco use were assessed prior to and immediately following reading the educational statement below: Recent research into smoking has proven that you can smoke and use nicotine replacement therapies (such as patches, gum, lozenge etc.) at the same time safely. In fact the use of nicotine replacement therapies while smoking may help you improve your overall health by reducing the harm that cigarettes do to you. The demographic data gathered included age, gender, mental health diagnosis, education level, and employment status. In addition, tobaccodependence levels were gauged via the two-item Heaviness of Smoking Questionnaire (Heatherton et  al., 1989), via self-reported average numbers of cigarettes consumed per day and time to the first cigarette smoked after waking. The attitude questionnaire targeted four primary barriers to the use of NRT-supported harm reduction, as indicated by previous research (Foulds et al., 2009). These comprised misconceptions regarding the health benefits, harm reduction effects, economic cost comparative to continued smoking in the absence of NRT, and safety of concomitant NRT and smoking. Post education, a single item assessed participants’ willingness to consider NRTsupported harm reduction. Ethics approval was granted by the University of Sydney Human Ethics Committee. Before commencing the study, each participant provided informed oral and written consent.

1Smoking

Research Unit, Brain Mind Research Unit, University of Sydney, Sydney, Australia 2Valeo Clinic, Sydney, Australia 3Department of Psychiatry and Brain Mind Research Institute, University of Sydney, Sydney, Australia Corresponding author: Renee Bittoun, Room 27m, Building M02F, 100 Mallett Street, University of Sydney, Camperdown, 2050 NSW, Australia. Email: [email protected] DOI: 10.1177/0004867414535673

Research has shown that smoking cessation is at least as beneficial to people with a mental illness as it is to people without, with cessation leading to reduced levels of anxiety, depression and stress (Taylor et al., 2014). Despite this, while over 85% of smokers with a mental illness have tried to quit at some time, the smoking rates for patients with a mental illness are still 2–3-times higher than that of the general population (Ragg and Ahmed, 2008). In the past, the only alternative to abrupt quitting was to advise smokers to reduce their tobacco intake, potentially leading to smokers altering their smoking topography (breathing more deeply and holding their breath longer) in an attempt to “get more” out of the cigarette but

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Acute versus sub-acute care beds: should Australia invest in community beds at the expense of hospital beds?

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