Review of Best Practices in Mental Health Reform

• Return to Table of Contents
• Summary of Section II
• I. Core Services and Supports: Summary of Evidence and Key Elements of Best Practice
• Assertive Community Treatment/Case Management
• Crisis Response/Emergency Services
• Housing/Community Supports
• Inpatient/Outpatient Care
• Consumer Self-Help and Consumer Initiatives
• Family Self Help
• Vocational/Educational Services

I. Core Services and Supports: Summary of Evidence and Key Elements of Best Practice

A balanced and effective service and support system is a central aim of mental health reform. It is meant to consist of programs that involve consumers and their families in the design and delivery of care. The promotion of independence to the fullest extent possible and true community integration are overall goals. Based upon the evidence from the literature such a balanced and effective service delivery system will include the following:

Assertive Community Treatment/Case Management

Research Evidence

A wide array of rigorous trials have accumulated evidence that:

• demonstrate that Assertive Community Treatment (ACT) programs are superior for improving clinical status and reducing hospitalization

Studies generally support that ACT:

• is a cost-effective alternative to hospitalization with standard aftercare for persons at risk for repeated hospitalization
• produces high rates of client and family satisfaction and no increased burden on families

A smaller body of controlled and uncontrolled studies show that:

• Rehabilitation and personal strengths models are effective in improving social and vocational functioning, and promoting residential stability and independence

Key Elements of Best Practice

ACT programs which include the following components:

• assertive outreach
• continuous, round the clock, time unlimited, individual support to people with serious mental illness
• services are predominantly provided in the community as opposed to office-based
• provision of flexible support specifically tailored to meet the needs of each individuals
• involvement of consumers and their families in all aspects of service delivery, including design, implementation, monitoring and evaluation

Programs are provided which serve special needs groups such as those with dual disorders.

Other clinical case management programs are provided to serve clients with less intensive needs.

Clinical case management program models include:

• Rehabilitation model which focuses on improving living skills, is individually tailored to client needs and provides continuous interpersonal support
• Personal Strengths model which focuses on client strengths and identifies or develops community resources and environments where clients can achieve success.

Crisis Response/Emergency Services

Research Evidence

Non-experimental and descriptive studies suggest that:

• crisis housing provides a viable alternative to hospitalization for persons with SMI
• diversion programs are effective
• crisis centres can serve persons with psychosocial problems

Key Elements of Best Practice

Services are established that resolve crises for persons with serious mental illness using minimally intrusive options.

Crisis programs are in place to divert people from inpatient hospitalization.

Evaluation/research protocols are incorporated into crisis programs.

Examples of crisis programs are:

• Telephone crisis services
• Mobile crisis units
• Crisis residential services - e.g. supervised apartments/houses, foster homes
• Psychiatric emergency/medical crisis services in hospitals

Housing/Community Supports

Research Evidence

Quasi-experimental and longitudinal studies show that:

• community residential programs can successfully substitute for long-term inpatient care
• supported housing can successfully serve a diverse population of persons with psychiatric disabilities but support networks need to be monitored
• consumer choice is associated with housing satisfaction, residential stability and emotional well-being

Cross-sectional studies show that:

• consumers prefer single occupancy, choice, and supports when requested

Controlled and non-controlled trials have demonstrated that:

• individuals with severe mental illness, including homeless people, can be housed when provided with assertive case management services

Key Elements of Best Practice

A range of different housing alternatives (e.g. supervised group homes or other residential settings) is provided but there is a shift of resources and emphasis on supported housing.

Supported housing incorporates the following critical elements:

• use of generic housing dispersed widely in the community
• provision of flexible individualized supports which vary in intensity
• consumer choice
• assistance in locating and maintaining housing
• no restrictions on length of time client can remain in the residence
• case management services are not tied to particular residential settings but are available to the client regardless of whether the client moves or is hospitalized

Community residential housing is provided as a substitute for long-term inpatient care.

Housing needs of the homeless mentally ill which include an assertive outreach component are addressed.

Inpatient/Outpatient Care

Research Evidence

Well designed follow-up studies show that:

• Discharge of long-stay patients is associated with improved social functioning over time
• Individuals and families prefer community care to hospitalization
• Clinical and social outcomes are at least as good for discharged patients receiving community care as for matched counterparts remaining in hospital

Numerous controlled trials show that:

• Day hospitalization is less costly than inpatient care with comparable outcomes
• Day hospitalization offers more intensive treatment in a less restrictive and more home-like environment
• Shorter length of stay is generally not associated with increased readmission and achieves similar outcomes to longer stay admissions
• Home-based treatment is an effective alternative to admission for many patients

Preliminary descriptive studies show that:

• Integrating mental health professionals in primary care settings can enhance continuity of care; increase accessibility to mental health services; lead to more efficient use of mental health services; provide new opportunities for continuing education for physicians; and improves communication between mental health services and family practitioners.

Key Elements of Best Practice

• Long-stay patients in Provincial Psychiatric Hospitals are moved into the community with carefully planned transitions to alternative care models.
• Inpatient stays are kept as short as is possible without harmful effects on patient outcomes.
• Partial hospitalization programs are available as an alternative for inpatient admission. Day treatment is an option for those with non-psychotic diagnosis.
• Home treatment programs (that are either assertive community treatment teams or adjuncts to intensive case management) are available as an alternative for inpatient admission.
• New service delivery models that link family physicians with mental health specialists are in place.

Consumer Self-Help and Consumer Initiatives

Research Evidence

While there is variability in the quality of studies conducted to evaluate self-help and consumer initiatives, there is consistency in findings.

• Participation in self-help is associated with
• reduced hospitalization
• reduced other service use
• increased knowledge, information and coping skills
• increased self-esteem, confidence, sense of well-being and of being in control
• stronger social networks and support
• Compared with professionally led groups, self-help groups emphasize experiential knowledge and social support, and tend to be more spontaneous, unstructured and unconstrained by time.

Key Elements of Best Practice

There are growing numbers of funded organizations that utilise non-service models to engage in:

• mutual support
• advocacy
• cultural activities
• knowledge development and skills training
• public education
• educating professionals
• economic development

Evaluation of the effectiveness of these initiatives that uses appropriate, alternative methods is supported.

The general public and mental health professionals are educated about the value of self-help.

Steps are taken to attract and train strong leaders for self-help groups.

Family Self Help

Research Evidence

Existing research on family self-help is limited in quantity and quality, with single group, cross-sectional study designs frequently used. Study findings associate participation in support groups with:

• increased levels of information among participants
• improved coping skills
• reduced caregiver burden
• improved identity as caregiver
• improved relationship with and ability to support ill relative
• improved emotional support

Key Elements of Best Practice

• Funding is provided to family self help groups (as individual or joint consumer-family initiatives) and they are used as a resource in the planning and evaluation of care delivery.
• Evaluation of the effectiveness of these groups that uses appropriate, alternative methods is encouraged and supported.

Vocational/Educational Services

Research Evidence

There are a number of fairly rigorous studies which demonstrate that:

• People with serious psychiatric illness have the capacity to work
• Employment programs should be encouraged for even the most disabled individuals
• Supported employment is more effective than other employment models
• Supported education enables clients to return to school on a full-time basis

Key Elements of Best Practice

There is a shift from traditional methods of providing vocational services to supported employment which includes:

• continuous, time-unlimited individual support
• attention to client preferences
• a place-train philosophy with on-site job specific skills training

Supported education and social recreational programs are viewed as promising approaches in need of further evaluation.