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