2004 - Day Hospital Care

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Dayhospitat care JaneBriscoe StefanPriebe

History and context of psychiatric day hospitals Over the last 50 years all Westernindustrialized nations have seen far-reaching reforms of mental health care with the closure and 'downsizing' of former asylums and the establishmentof services in the community (Fakhoury and Priebe, 2002) [see also pages 1-4 and 5-7J. For example,in England, psychiatric in-patient beds have been reduced by over two-thirds since the mid-1950s.At the sametime, with referralsto acute in-patient care continuing to rise, admissionshave more than doubled (SainsburyCentrefor Mental Health, 1998). Thus, non-residential alternatives to tertiarv level mental health care have been sought. Within this context of deinstitutionalization there has been a growth in the use of psychiatric day hospitals across Europe and North America as part of a comprehensive system of community care. In the UK, health policies since the early 1960shave recommended the use of day hospitals as an alternative to acute in-patient care and continue to stress the principle that patients are entitled to receive appropriate treatment and support in the least restrictive environment possible. Defining day hospitals Although day hospitals have a long history beginning in Russia in the 1920s,it remains unclear what servicesare grouped under this umbrella term, which may be used to describe any 'multidisciplinary day-carefacilities offering comprehensivepsychiatric care' fMarshall et 0"1.,2001J.There is great diversity in the uses and aims of day hospitals,with some functioning as an alternative to acute in-patient care, some for the rehabilitation and support of the chronically ill, and others for the treatment of neurotic and personalitv disorders.

JaneBriscoeis a researchassistontat the LJnitfor Socialand Community Psychiatryat Bort'sand TheLondonSchoolof Medicine,QueenMary, Universityof London,London,UK.Sheobtaineda bachelor'sdegree in psychologyond sociologyfrom the Universityof Bath.Herresearch interestsincludeocutementalhealth careand the provisionof day hospitalservicesacrossEurope. StefonPriebeis Professorof Socialand CommunityPsychiatryat Bort's and TheLondonSchoolof Medicine,QueenMary, Universityof London, London,UK,and on HonoraryConsultantPsychiatristin EastLondon.

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Types of day hospital Various terms are employed to distinguish between day hospital models, but there is no clear and consistentuse of terminology to differentiate day hospitals offering such varied services.To complicate matters further, many day hospitals that began as crisis services no longer have that focus, while sometimes retaining the name, and have either disappearedor gradually evolved into psychotherapeuticout-patient units. For example, Creed ef al.'s (1989) important contribution to the evidencebase supporting the use of psychiatric day hospitals as an alternative to in-patient care is based on the evaluation of an acute day hospital in Manchester that transformed into the base and drop-in centre for a 'Home Options' service soon after the researchwas completed. In a systematicreview of day-careeffectiveness,Marshall et al. (2001.)distinguished four categoriesof day hospital: . acute day hospitals (aim: alternative to acute in-patient admission) o transitional day hospitals {aim: shortening admission) o day-carecentres (aim: rehabilitation or maintenance) . day treatment programmes (aim: enhancing out-patient treatment). To allow some consistencyand clarity, these labels are used here; however, this contribution also discusseshow the day hospital types are in practice mutually exclusive, and critically appraises the use of such theoretical distinctions. Day hospital as an alternativeto in-patient care This type of day service focuseson acute treatment for patients in crisis,and has emergedas an alternativeto acute in-patient admis'diagnostic sion, providing and treatment servicesfor people who would otherwise be treated on traditional psychiatric in-patient units' [Rosie,l9B7). However, there may be some variation in the content of service provision and the service name (e.g. crisis day service, acute day hospital) within this subgroup. The researchinterest in day hospitais as an alternative to inpatient care has reflectedand sustainedpolicy interestin this area. In a recent Health TechnologyAssessment,Marshall et oL. (2001) identified nine randomized controlled trials comparing acute dayhospital and in-patient psychiatrictreatment.The existing research suggeststhat between 1B% and 39o/oof all psychiatric in-patient admissionscould be diverted to acute day hospitals.Marshall et al. concluded that patients randomized to day hospital or in-patient treatment showed similar improvementsin social functioning, and there was no significant difference in readmission rates between the two groups.However,day hospital patients showed more rapid improvement on measuresof psychopathologyand were more satisfied with their treatment than in-patient controls. In addition to high user satisfactionwith day hospital care,which is important in terms of later engagementand the therapeuticalliance,researchalso suggeststhat families are more satisfiedwith this model of care. Despite the abundance of researchon acute day hospitals, and a continued emphasis on the need to incorporate day hospitals in service provision, this model has not been wideiy adopted (Harrison et al., 2003), and has recently been described as 'definitely not in fashion' (Marshall, 2003). In comparison, more radical approaches to community care, such as assertive outreach (see pages l4-17) and home treatment fsee pages 22-5], have been taken up more readily by service providers.

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MOVINGOUTOFTHEASYLUM

to place' Friern patients were identified and followed up separately, togetherwith eight patientsin other hospitaisfrom the three catchment area services relating to Friern [Treiman and Leff, 2002). Follow-up data have not been reported on a further residual group of 57 Friern patients who were transferredto other hospitals.TAPS also studied the impact of hospital closure on local acute mental health servicesand psychogeriatricpatients. Outcomesof the study It is impossible to do full justice to the richness of the TAPSstudy in a brief review. The S-year outcomes for the 670 patients dischargedto community settings - largely staffed houses - showed no overall change in symptoms and behavioural disturbance,but significant gains in social and domestic skills, an enrichment of social networks and an objectiveimprovement in living conditions (Leff and Tfeiman, 2000). Patients,although often reluctant to be discharged,preferred being out of hospital. Nineteen per cent of patients died during the follow-up period, all of natural causesand at a rate consistentwith the elevatedstandardizedmortaiity ratio of people with schizophrenia.Very few resettledpatients were lost to follow-up and few moved into any form of independent living. Readmissionrates were relatively low (38% over 5 years), but a third of readmitted patients became long-stayonce again and 10% were in hospital at the time of follow-up fTreiman et aI., 1999). This demand does not appear to have been anticipated within the closure programme. 'difficult The to place' patients, who had been considered unsuitable for transfer to community facilities, moved into a variety of specialist,nurse-basedserviceswithin the three catchment area services (Tfeiman and Leff, 2002). Although there was no evidenceof improvement in mental stateover 5 years,a significant improvement in functional abilities was noted, together with a very marked reduction in severe behavioural problems, particularly physical aggression.As a result of a decreasein problematical behaviours,40 % of the survivors of the cohort were able to move into less-supportedaccommodation. The least satisfactoryaspectof the closure processappearedto be its impact on patients using tire acute wards of the three local services, all based in busy district general hospitals (Leff et al., 2000). Following the closure, these wards, in common with all acute mental health services in London, experienced very considerablepressures. UK and international findings The broad findings of the TAPS study have been replicated in both the UK and the international literature, which includes studies from the USA, Australia, Italy, Germany, Canada and the Netherlands.The vast majority of long-staypatients require highly supportedsettingson discharge.A small but significantproportion of patients cannot be managed outside hospital, requiring some form of continuing care. People moving out of hospital tend to report satisfaction with their new living circumstances and to show an improvement in functional skills and overt behavioural disturbance but not symptoms. The published evidence suggeststhat both'elderly graduates' (with a functional mental illness) and psychogeriatric patients fwith dementia) can be relocated to environments with better_ quality care without an increase in mortality. However, anecdotally, poorly managed closure programmes can be associatedwith

significant numbers of patient deaths becauseof poor preparation of patients and staff and inadequatesubsequentattention to physical and mental health care.

The new long stay Even when the mental hospital has closed and alternative community serviceshave become well developed,people continue to become long-stay.Thesepatients are clinically very heterogeneous (Holloway et aI., 7999): some have severe functional psychoses that are treatment resistantor have functional deficits that respond well to care within a rehabilitation service; others present a range of challenging behaviours related to comorbidity (e.g. substance misuse, personality disorder, autistic spectrum disorder), neuropsychiatric disorder or offending behaviour. A thoughtful closure programme should both provide for existing 'difficult to place' patients and seek to ensure that the needs of the newly accumulating long-stay patients are catered for in the service system that replacesthe traditional mental hospital. a

REFEREf{CES DavidgeM, EtiasS,JayesB, WoodK,Yatesl. Surveyof EnglishMental I llnessHospitals,March1993. Birmingham:Inter-Authority 1993. Comparisons andConsultancy, University of Birmingham, K.Thenewlong-stayin an HollowayF,WykesT,PetchE,Lewis-Cole 7999; 45:. innercityservice:a tale of two cohorts.lntJ SocPsychiatry 9)-703. LeffJ.Whyis carein the communityperceivedas a failure?BrJ Psychiatry 2O072179:387-3. patientsdischarged from psychiatric Leffl,TreimanN. Long-stay hospitals. SociaIandclinicaloutcomes afterfiveyearsin the iatry 20OO;t7 4: 277-23. community.TAPSProject46. BrJ Psych LeffJ,Treiman N, KnappM, HallamA.TheTAPS Project. A reporton 13 yearsof research,1985-1998. PsychiatrBull 2O0O;24l. 765-8. F.Inpatient In:Thornicroft G, Szmukter G,Hotloway treatment. SzmuklerG, eds Textbookof CommunityPsychiatry.Oxford:Oxford Press,2001. University Treiman inpatients considered N, Leffl.Long-term outcome of long-stay unsuitableto live in the community. TAPSProject44. BrJ Psychiotry 20O2t7871428-32. patients Treiman N,LeffL GloverG.Outcome of longstaypsychiatric resettledin the community:prospective cohortstudy.BMI 7999t 379273-76.

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However, the acute day hospital may yet make a comeback as the evidence base for its efficacy is now more establishedand it has become apparentthat such units can offer a much less labourintensive (and thus cheaper) service than home treatment or inpatient care,whereby'comparatively small numbers of nursescan maintain a high level of input to substantial numbers of patients in a safe environment for one-to-onetreatment' [Marshall, 2003). Also, unlike home treatment, day hospitals can provide sociotherapeutic group-basedactivities in which patients suppofi one another. Day hospitals can satisfy the common expectations of users and carersthat acute mental disorderswarrant intervention in an institution, while also maintaining patients in - rather than removing them from - their social context. Yet the function of a day hospital for acute treatment is not to replace conventional in-patient care or home treatment, but to be one therapeutic option among others. Which of these options is the most appropriate in a given situation may depend on patient preferenceand previous experience,as weli as individual needs that can change over time. There is littie literature on how services change over time. However, day hospitals appear to require a degree of organizational rigidity to maintain the focus on acute treatment; such key elements are summarized in Figure 1. The example is based on the operational policy of the day hospital in the East London borough of Newham, which has worked successfullyas an acute service since 1999. Day hospitals to shorten in-patient admission Tiansitional day hospitals have been developed to offer timelimited care to patients who have just been discharged from in-patient care.Such day hospitals aim to changethe pattern ofhospital care

Suggestedprinciplesfor a dayhospitatfor acute treatment . . . .

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All referredpatientsshouldrealtyneedcrisisintervention with no waitinglist A definednumberof places, Runby a multidisciplinary team remainwithCMHTs, RMOresponsibility andcarecoordination between dayhospita[andcommunity so goodcommunication teamsis essentiaI Patients required to attendMondayto Fridayfrommorningto at theweekends with optionaI attendance evening programme but individuat Treatment basedon groupactivities, (biological, psychologicaI andsocial)shouldalso interventions be madeavailable fromthoseusedby in-patients Facilities shouldbe separate lt maybe necessary to operatesomeexclusioncriteriabased (e.g.patientswith primarydrugdependency); on diagnosis however,it is beneficialto havea patientgroupwith a rangeof problems asthis canbe positivefor the programme atmosohere

mental health team responsible medicalofficer; CMHT, community RMO, (Based 2002) onPriebe, 1

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for people with severemental health problems, as they can allow in-patient admissionsto be shortened. However, there is a lack of quality research on short-stay admissions. In a recent Cochrane review (Johnstone and Zolese, 2003), only one randomized controlled trial in this area was identified, which compared standard in-patient admission fdischargeat carers'discretion) with planned dischargeafter lessthan B days to community day-care.Thus there is a need for further researchinto the efficacv of the transitional day-hospital model. Day-hospitaladmission after fuilure of out-patient care Using Marshall et aI|s (2001)definition, there are two day hospital models that have been developedto offer more intensive input for patients who have failed to respond to out-patient care. Day treatment progrommes typically offer treatment to patients with non-psychotic disorders (usually patients with affective or personality disorders). Day-care centres offer structured support to patients with lonSterm severemental disorders (mainly schizophrenial who would otherwise be treated in out-patient clinics. Marshall et cl. identified only two randomized controlled trials comparing day treatment programmes with conventional outpatient care for non-psychotic patients who were refractory to out-patienttreatment.No usableoutcome data were found on quality of life, burden on carers,readmission rates or costs. One triai reported significantly higher user satisfactionin the day-hospital group, and the other reported significantly lower user satisfaction. There was evidence from one trial suggestingthat day treatment programmeswere superior to continuing out-patient care in terms of improving psychiatric symptoms. There was no evidence that day treatment programmes were better or worse than out-patient care on any other clinical or social outcome variable, or on costs. Nor were the reviews able to judge the proportion of patients for whom day hospital treatment might be appropriate or effective owing to differencesin intake criteria with regards to treatment resistance. The evidenceto support the use of day-carecentresis similarly patchy. Marshall er al. concluded that there is no evidence that day-carecentres are any better or worse than out-patient care on any clinical or social outcome variable, although there is some evidence to suggestthat the cost of day-carecentres is greater. The lack of researchinto either of these day hospital models has resulted in a lack of clarity concerning typical or suggested programme content and provides no basis for the use of these models in mental health system that encouragesevidence-based practice.

Day hospital provision: a national picture There is empirical evidence to support the efficacy of specific day -hospital models, but a lack of researchon what English day hospitals do in practice.A recent national survey of day hospitals conflrmed that there is great heterogeneityin English day-hospital service provision (Briscoe et aI., 2004). Day hospital managers were asked to rate the relative importance of various aims and functions for their service (Figure 2). A cluster analysis did not reveal strikingly different day hospital profiles with respectto their aims and functions. Three groups were identified: . the first had less emphasison chronic and social rehabilitation

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positive evidencefor the flexibility of day hospital models to adjust to different local needs. Yet one could also draw the following conclusions: o day hospitais have not found a clearly defined role within the spectrum of distinct servicesthat modern community mental health care provides . the attractive label 'day hospital' is used to justify a range of selVtces o it is difficult to sustain the focus on acute treatment, so that day hospitals often drift into providing a range of other functions. There is a distinct lack of support for the use of other, particularly multifunctional, day hospital models, which is at odds with the principles of evidence-basedpractice. There is a strong case for the continued need for day hospitals for acute treatment to provide a less restrictive and more cost-effectivealternative to in-patient care. This research evidence is coupled with renewed policy interest, so day hospitals for acute treatment may continue to function as an integral and essentialpart of community mental health care in the UK. a

Survey resultsof aimsandfunctions of dayhospitals in England Service to shorten in-patient treatment Alternative to in-patient care o G

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Psychotherapy REFEREI{CES ANDFURTHER READING Briscoe McCabe R, Priebe S, Katlert T.A nationalsurveyof psychiatric J, day hospitals.PsychiatrBullR CollPsychiatr2004;28276O-3. CreedF,BlackD,AnthonyP.Dayhospitalandcommunity treatment for acutepsychiatric illness:a criticaIappraisal.BrI Psychiatry7989; 154:300-10. Fakhoury W,PriebeS.Theprocess of deinstitutionalisation: an internationaI overview.CurrOpinPsychiatry 2002; t5:787-92. Harrison J,MarshalS,MarshallP,Marshall l, Creed,F.Dayhospitalvs. hometreatment: a comparison of illnessseverity andcosts.Soc Psychi atry Psychi atr Epi demi oI 20O3; 38l.547- 6. for peoplewithsevere Johnstone B ZoleseG.Lengthof hospitalisation mentali[[ness.Cochrane Review.In: TheCochrone Librarv.lssue4. Chichester: Witey,2003. MarshallM.Acutepsychiatric dayhospitals. BMI2003;327:776-77. MarshallM, CrowtherR,Almaraz-Serrano A et al. Systematic reviewsof the effectiveness of daycarefor peoplewithseverementaIdisorders: (1)AcutedayhospitaI (2)Vocational versusadmission; rehabititation; (3) Dayhospitatversusoutpatientcare.HealthTechnology Assessment 20O7;5: 27. PriebeS. Makingcrisisdayservices happenin practice. MentalHealth Times200227:72-73. Rosie| 5. Partiathospitalization: a reviewof recentliterature.Hosp CommunityPsychiotry 7987; 38: 7297-9. SainsburyCentrefor MentaIHealth.AcuteProblems: A Surveyof the Wards.London:SainsburyCentre Qualityof Careof AcutePsychiatric for MentalHealth,1998.

Rehabilitation for chronicdisorders SociaIrehabilitation or support

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o the second had less emphasis on crisis intervention and addition to out-patient treatment o the third was apparently multi-functional. There was no evidence of day hospitals solely providing an alternative to in-patient care; nevertheless,this policy focus appears to be reflectedin the survey results, as providing an alternative to in-patient care was the most consistently highly rated aim across all three groups. Howeveq the majority of respondentsprioritized multiple roles, with many day hospitals aiming to provide acute and chronic care concurrently, suggestingthat these roles are not mutually exclusive. Most day hospital managersrated multiple aims and functions as being of great or greatestimportance. These findings not only have implications for the use of terminology to describe dayhospital care, but highlight the need for generalizable research to support such practice, for adequate service descriptions to be included in research publications, and for service planners to respond to researchevidence.

Conclusion The term'day hospital' covers a heterogeneousgroup of mental health service structures, reflecting the multitude of aims and functions even within a single institution. This may be seen as

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