Am

J Psychiatry

136:10,

Continuity BY

October

1979

of Care

RICHARD

in the

PH.D.,

TESSLER,

Delivery JOHN

AND

of Mental

HAYES

The authors report on the help-seeking experiences of people referred to community settingsfor aftercare on dischargefrom a state mental hospital in western Massachusetts. They present results that bear on three questions relevant to public policy issues in the mental healthfield: 1) the proportion ofpatients who comply with referrals to aftercare agencies 2) the social and psychological characteristics of patients who comply with these referrals, and3) the impact of receiving aftercare on the probability of rehospitalization. ,

MASON,

delivery

of psychiatric

services.

That

continuity

of care

Services

M.A.

example,

who

studied

patients

referred

from

nc hospitals to a post-hospital social center in Cleveland, reported that 204 tients chose not to follow through on

and, to

furthermore, participate

that in

some

the

ofthe

aftercare

psychiat-

rehabilitation out of 312 patheir referrals

patients program

who

began

dropped

out

prematurely. of continuity

Additional evidence indicative of a lack of care in the delivery of mental health

services has (5), Gunderson ley and Kane

been

reported

and (8).

do not comply study many

DISCUSSION OF THE PROBLEM of continuity of care is common in the literature on primary medical care, but the problem is less often discussed in relation to the

Health

by

associates

The

with

Evans

and

(6), Kirk

exact

proportions

referrals

associates

(7), and Wool-

for aftercare

of people

who

varied

from

to study, but this is not surprising in view ways in which these studies differed.

A related

issue

revolves

around

the question

of the

of who

gets aftercare. Some patients may feel little need for aftercare on hospital discharge, either because their symptoms are no longer severe or because they have

also poses a challenge in the mental health area is suggested by recent trends in the treatment of the institutionalized mentally ill. For well over a decade mental health services in the United States have been ‘deinstitutionalizing. Hospital censuses have been substantially reduced, as has the average length of stay. The typical patient admitted to a state hospital today is treated on a short-term basis and then, on discharge, is referred to the community for some form of “aftercare” (1). Inasmuch as compliance with referrals to aftercare centers is voluntary, it is important to ask what actually becomes of the ex-mental hospital patient following discharge. Concern is widespread that many of these patients are being lost in the shuffle between the hospital and the community (2, 3). Recent data show that substantial proportions of ex-hospital patients do not comply with community referrals. Wolkon (4), for

alternative community.

Received

services was positively related to number of previous hospitalizations as well as length of stay during the most recent hospitalization. Diagnoses also distinguished people who used aftercare services from others: those diagnosed as schizophrenic or neurotic were most likely to receive aftercare, and those diagnosed as having a personality disorder were least likely to use community services. Much of the concern over the existence of continuity of care in the provision of aftercare services for the

‘

‘ ‘

March

6, 1978; accepted

Sept.

15, 1978.

Dr. Tessler is Associate Professor of Sociology, University of Massachusetts, Amherst, Mass. 01003. Mr. Mason is Research Associate, Boston University School of Medicine, Boston, Mass. Through June 1980 address reprint requests to Dr. Tessler at the Applied Biometrics Research Branch, Division of Biometry and Epidemiol#{243}y,

Rm.

18c-l8,

This

study

Allocation sachusetts.

National

Institute

56110 Fishers was

supported

from

the Graduate

Lane, in part

of Mental

Health,

Rockville,

Md.

by

a Biomedical

Research

Council,

Parklawn

Bldg.,

20857. Research

University

Grant

of Mas-

The authors would like to thank Stephen Armstrong, Paul Chapman, Seth Goldsmith, Mary Jackson, and Bill Jaskella for their comments on an earlier draft of this paper.

0002-953X/79/I

I/1297/05/$00.50

social Thus,

supports available discontinuity ofcare

to

them in the can be viewed

as less problematic to the degree to which those patients who do not comply with aftercare referrals are also those least in need of further care. Data pertinent to this question have been reported by Wolkon (4) and Kirk (7).

Wolkon cantly

tercare

(4) reported

related

that

to whether

marital

or not

program: single people people to get involved.

married pital stay were characteristic with the aftercare referral, ships were found between chiatric variables, including talizations, diagnosis, type the patient’s own perception

status

a patient

was began

signifian af-

were more likely than Longer lengths of hos-

of people who complied but no significant relationcompliance and other psynumber of previous hospiof hospital admission, and of his or her symptom-

atology. In contrast, in a study of 579 patients discharged from state mental hospitals in Kentucky, Kirk (7) reported that marital status was unrelated to use of aftercare services. In Kirk’s study, use of aftercare

ex-hospital of aftercare

© 1979 American

patient helps Psychiatric

rests on the assumption that patients stabilize themselves Association

receipt in the I297

CONTINUITY

community. services community?

OF

Am

CARE

Is it true, however, that use of aftercare ex-hospital patients to remain in the Studies pertinent to this issue have been

helps

carefully reviewed by Kirk (9), who concluded that there is evidence for all possible relationships between aftercare and rehospitalization. Some studies have indicated that use of aftercare services has no effect on the probability of rehospitalization, others have found that contact with aftercare services tends to prevent rehospitalization,

and

still

others

receipt of aftercare actually being rehospitalized. There is no simple way tradictory

results,

but

dency of studies on rehospitalization istics

of

the

that

one

have

increases

concluded

the

of

to

reconcile

possibility

lies

the impact the unique

who

aftercare

use

these

con-

in the

ten-

services.

use

of aftercare

The purpose of the literature on continuity institutionalization pliance with

charged

As

chusetts, teristics services.

munity

estimating for aftercare

referrals

a state

to facilitate

to the of de-

the extent of among patients

in western

Massacharacaftercare on corn-

we

hospital

comdis-

controlled

for

patient

character-

istics, thereby taking into account selection biases in fulfillment of aftercare plans that might otherwise confound proper interpretation of the results.

had

in three

been

and

Design

The people

study under

time. secutive

Participants sample

was prospective in character study were monitored over in the of patients

est units of Northampton Hampshire-Franklin and for

inclusion

in the

speak English, be between not have mental retardation and not have been admitted jurisdiction

of

the

court.

constituted to the

State Hospital Holyoke-Chicopee).

,

eligible

study admitted

study,

in that a period

the

a three

the of conlarg-

(Springfield, To be

patients

had

to

18 and 65 years of age, as their primary diagnosis, to the hospital under the Study

staff

approached

pa-

tients during the first week to 10 days of hospitalization and asked them to participate in the study. A total of 146 people agreed to participate and successfully completed a structured interview, the average duration of which was 75 minutes. These 146 people represented 68.5% of all of the people who were asked to participate

tients asked agreed but 1298

in the

study

to participate terminated

(N=2l3).

Fifty-five

ofthe

pa-

refused to do so: 12 patients the interview early. We ex-

length

3-4

October

1979

stay

for

the

all but 6 of these

by the

areas

end

of the

study.

communication with the the patient had been rethe patient actually cornfact that the patients lived

necessitated

services

to monitor

the

cooperation

in western

setts. In addition to monitoring ices during the period following

continued

of

weeks;

discharged

aftercare

Massachu-

use of aftercare hospital discharge,

hospital

of rehospitalization

records

within

servwe

to detect

a 90-day

period.

Measures

on the

three

sources

of patient

and

hospital

records,

clinics,

interview, it was

pos-

sible to measure a number of different variables. The key dependent variables-compliance with aftercare referrals and rehospitalization-were measured through questionnaires filled out by community clinic staff and through examination of hospital records. Measures of independent variables came from the interviews as well as the hospital records. For simplicity

of presentation these can be broken following groups: 1) sociodemographic source variables (age, sex, income, status,

education,

dence),

2) treatment

pitalizations,

birth

length

of current

hospital and

a variety

of symptom

and

community

tenure,

and

hospital

(hospital

scales

and

unit),

items

Research

scores

on

from

the

Instrument

devel-

and Barbara ofdelusions

a close friend, and in whose

,

hos-

3) clinical

drawn

disorders, sadness, suicidal ideation and 4) social integration

resilength

diagnosis,

,

having friends,

of

of last

Epidemiology

status, with

stability

of previous

by Bruce Dohrenwend these included measures

(marital teraction

into the four and social rerace, employment

(number

evaluation

cinations, thought ness-hopelessness physical health),

was

order,

down

history stay,

appraisal Psychiatric

Semple

modal

was

geographic

several

oped wend;

METHOD

The

On discharge we established community clinic to which ferred to determine whether plied with the referral. The

Drawing

giving special attention to the unique of the patients who actually used In assessing the impact of aftercare

tenure

mental

patients

community

re-

present study is to add of care under a policy

by

from

appears

1976.

of 146 patients

instances

Mannino and Shore ( 10) suggested, studies that report low rates of rehospitalization may actually be dealing with aftercare services that work with low-risk populations, whereas the converse may hold true in studies observing that hospitalization.

November

group

also

of aftercare character-

136:10,

plained the purpose of the study to all interviewees, and they all agreed to sign an informed consent form. Sample acquisition took place between January and

of

examined to ignore

people

that

chances

J Psychiatry

Dohrenand hallu-

guilt,

helpless-

and

perceived and

support

frequency care the

of inpatient

discharged).

The

scale

used

to measure

ness is a simple summated lowing four items (higher

moralization): I) In the have you had times when ifanything was worthwhile ly often,

sometimes,

helplessness-hopelessscale scores

consisting indicate

past 12 months, you couldn’t help anymore? (very

almost

never,

of the more

folde-

how often wondering often, fair-

never).

2) In the

past 12 months have you felt that nothing turns out for you the way you want it to? Would you say very often, fairly

often,

sometimes,

almost

never,

or never?

the past 12 months, have you felt completely (very often, fairly often, sometimes, almost never). 4) In the past 12 months, have you pletely hopeless about everything? Would very often, fairly often, sometimes, almost

3) In

helpless? never, felt cornyou say never, or

Am

J Psychiatry

TABLE Percents of Care

136:10,

October

/979

RICHARD

1 and

Nonparticipants

in Study

of Continuity

Characteristics Participants

(N=

Nonparticipants

Signifi-

(N=67)

cance”

146)

47.3

56.9

n.s.

46.5 15.1

3 1.3 22.7

p< .05 n.s.

Catholic

54.8

70.9”

p< .05

Schizophrenic

54.4

71.6

p