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Medline searches returned titles in total. Inclusion criteria were quality and relevance to other specialties. Policy material was included to illustrate the socio-political context of the development of community services.
Community care was consistently associated with greater patient satisfaction and quality of life across specialties. It was not a cheaper alternative to hospital care. Disadvantages included the exodus of experienced inpatient staff to community settings and the development of alternative institutions in the non-statutory sector. Those planning community-based care for physical health problems should learn from the experience of mental health services.
In this review, the process of deinstitutionalization of psychiatric services to community-based care over the last 50 years is used as an example from which other specialties could draw as they attempt to respond to current directives on the provision of increased community care for longer term physical illnesses. Searches of the Department of Health DH and Royal College of Psychiatrists' websites were carried out using the search term community care in each website's own search engine to identify relevant policy and guidance documents.
In order to provide an overview of the historical perspective of the development of community care in relation to psychiatry, hand searches of historical accounts of the asylums and their closure were carried out at the libraries of University College London Hampstead Campus and the Institute of Psychiatry. The Medline search for community care and mental health identified titles.
When mental health was substituted for long-term conditions, no titles were returned. Research papers were included on the basis of the quality of the paper or research and the relevance of the content for a broad audience.
Policy, legislation and guidance documents were engaging with involuntary service users a literature review and case study to illustrate the social and political context supporting the development of community care in the UK.
International policies were not included. Although there are a number of books and records detailing the history of the asylums, the historical materials included in this article were selected for their inclusion of relevant information about the development of community services prior to the closure of the asylums. The origins of psychiatric services in England date back to when a monastic priory was founded in the city of London on the site where Liverpool Street station now stands. This priory provided shelter for the sick and infirm and from onwards was referred to as a hospital, The Bethlem Hospital the name being derived from Bethlehem.
InKing Henry IV ordered a Royal Commission to investigate allegations of scandals, malpractice and embezzlement of funds at the Bethlem Hospital. The report of the Royal Commission provides the earliest evidence that the Bethlem Hospital was treating men suffering from insanity as well as from physical illnesses.
Inthe city of London commissioned a new building for the Bethlem Hospital to be built at Moorfields. This was the first hospital for the insane in the UK. Most asylums were built on the outskirts of major cities, engaging with involuntary service users a literature review and case study, in order to provide a rural retreat for patients. Most operated as self-sufficient communities with their own water supplies, farms, laundries and factories.
They were therefore isolated from the local community and psychiatrists working with them were isolated from their colleagues in other medical specialties. The Lunacy Act of set the parameters for admission, engaging with involuntary service users a literature review and case study, providing a legal system in which a patient had to be certified as insane in order to be admitted to the asylum.
The parish doctor declared patients insane and they were then placed on a compulsory reception order by a local magistrate and taken to the asylum. These differences in admission criteria contributed to an exponential rise in the asylum population. Colney Hatch Asylum, the largest in Europe, was originally built to accommodate patients but was enlarged within 10 years to take and in when it was renamed Friern Hospitalthere were patients.
The rising population was due to a number of factors including the admission of many severely disabled patients who could never be discharged and the expanding Middlesex population. There were also a large number of poorly understood and untreatable conditions presenting with psychiatric symptoms such as metabolic disorders, lead poisoning, syphilis and intracranial tumours. The establishment of the National Health Service inthe introduction of phenothiazine drugs in the s and the social and political climate around this time were all factors that influenced the gradual closure of the large Victorian institutions.
This led to the increasing awareness that to keep patients in hospital when they had recovered from the acute stage of their illness was an infringement of their human rights. The Mental Health Act was the first mental health legislation to clarify the reasons why an individual might need to be admitted to engaging with involuntary service users a literature review and case study and treated against their will, and the distinction between voluntary and involuntary treatments became clearer.
The work of Goffman 6 and Wing and Brown 7 on institutionalization of psychiatric patients and the poor standards of care and quality of life fuelled a political and social movement to close down the Victorian asylums.
There followed a dramatic change in the location of psychiatric service provision. The model adopted by the district general hospitals for the organization of psychiatric services was the same as for other hospital disciplines, namely, inpatient and outpatient facilities within the hospital building.
Outpatient clinics, therefore, became an integral part of psychiatric service provision and moved from having a triage function to becoming a resource for both assessment and follow-up. Alongside these developments, there was a shift towards the provision of other community-based services for people with mental illnesses, such as supported housing, day services and community-based mental health nurses and social workers.
Reported inadequacies in community service provision for those individuals who had previously lived in asylums have provoked a great deal of debate over the last 40—50 years. However, the tenor of this dialogue has altered. Events in the s turned societal attention from charitable concern for this group's welfare to an increasing fear of them.
The high profile case of Christopher Clunis, a man with a diagnosis of schizophrenia, who murdered Jonathan Zito in an unprovoked attack at Finsbury Park station in London, 18 highlighted the potential for community patients living a transitory lifestyle to lose contact with mental health services. The implementation of the Care Programme Approach CPA1920 which is still a fundamental framework within which mental health services operate, attempted to improve continuity of care for people with mental health problems.
All patients considered appropriate for the CPA have an identified professional who co-ordinates their community care package and who arranges regular reviews of their care with other professionals including their consultant psychiatrist.
Handover of this responsibility has to take place through a formal process if the patient moves to another geographical area to minimize the chances of them becoming disengaged from services. In addition, the National Service Framework for Mental Health 21 detailed the development of a number of new community mental health services that were designed to interface with existing community mental health teams but to focus on certain groups.
Two of the three new models, early intervention services and crisis resolution teams, have both been shown to reduce the likelihood of admission when compared with community mental health team care and to lead to improved patient satisfaction with services. It has been suggested that the reason for the lack of efficacy of assertive outreach in the UK may be due to replication of certain critical components of the model by the services with which it has been compared community mental health teamsspecifically integration of health and social care management and greater use of home visiting than the comparison services in the USA.
However, even in the UK, it does appear to be more successful at engaging this group than community mental health teams and patient satisfaction is also greater. One unforeseen and negative consequence of the National Service Framework's investment in community care has been the exodus of experienced staff from inpatient to community settings. In addition, mental health wards have become increasingly difficult places to work and, for patients, difficult places to recover from engaging with involuntary service users a literature review and case study illness as they now concentrate on those who are most unwell and cannot be treated in the community, engaging with involuntary service users a literature review and case study.
The poor conditions exacerbate staff retention problems leading to disproportionate numbers of inexperienced or temporary staff. Some service developments from the National Service Framework may have been, at least in part, a response to public concerns about the risk that mental health service users living in the community pose to others. However, evidence from a large study in Victoria, Australia showed that in the 25 years since deinstitutionalization, the proportion of people with a mental health problem charged with an offence rose at the same rate as a control group drawn from the general population.
However, it is well established that the identification of mental health problems in people presenting to primary care services is difficult and few are referred to secondary mental health services. With the closure of the asylums came an expansion in provision of specialized housing for people with mental health problems by health and social services, voluntary organizations and housing associations.
Legislation such as the National Health Service and Community Care Act as well as the Supporting People initiative 34 has facilitated engaging with involuntary service users a literature review and case study agencies to develop and provide specialized housing. These include independent tenancies with community workers providing outreach support, supported tenancies with staff on site and staffed hostels, group homes, residential care homes and nursing homes.
There engaging with involuntary service users a literature review and case study been no trials investigating the efficacy of different types of specialized housing to date, which reflects the inherent feasibility issues in carrying out this type of research, 35 but certain models appear to be developing secondary to patient preferences, with increasing investment in supported flats rather than group settings because the majority of services users prefer their own independent living space.
Although this emphasis on the promotion of independence is encouraging, there remains a group of patients whose needs are such that they continue to require inpatient care. This group, most of whom are detained under the Mental Health Act, has arisen since the closure of the asylums. As inpatient bed use is the most expensive component of health care, community alternatives can appear attractive and potentially cheaper.
However, Macpherson et al. This concluded that appropriate community care is not a cheaper alternative to hospital care and that the costs associated with caring for those with high levels of need in the community may be greater than hospital care.
In line with this, McCrone et al, engaging with involuntary service users a literature review and case study. A study that compared inpatient mental health care in two areas where deinstitutionalization was well established Verona, Italy and Victoria, Australia and one area where most care was still hospital-based Groningen, The Netherlands found that the length of stay was shorter where community services were well developed.
There was no clear explanation for this, which suggests that socio-cultural factors and admission thresholds play an important part in how minimal inpatient service use can become. The highest levels of formal care were received by participants in the UK and the lowest levels were in Italy.
In addition, it has been found that a higher proportion of patients in Italy live with relatives than in the USA, 47 which supports the importance of the role of socio-cultural factors in determining the amount and type of community care delivered.
The degree to which society is willing to accept people with mental health problems has an obvious impact on their quality of life and the success of community-based care. Recent governmental support for the promotion of more socially inclusive practices for the mentally ill has come from the Social Exclusion Unit of the Office of the Deputy Prime Minister's report on mental health.
It also includes public campaigns to reduce stigma and discrimination against people with mental health problems and the promotion of existing legislation around equality. This agenda has been strongly influenced by the success of the civil rights movement and organizations such as the Disability Rights Commission in their campaigns to gain equality in many aspects of life for people with physical disabilities.
It might, therefore, be expected that society will be more familiar with these issues and supportive of community care for people with physical health needs than has been the case for people with mental health problems.
Together with National Service Frameworks for Coronary Heart Disease, Diabetes, Renal Services, Long Term Neurological Conditions and Mental Health, there is a clear governmental steer to increase home-based services to people whose health problems place them at risk of recurrent hospital admissions. These initiatives are driven by engaging with involuntary service users a literature review and case study desire to improve integration between health and social care provision for people with multiple and complex health needs, with the aim of improving the patient experience and reducing the risk of relapse and hospital admission.
In addition, community matrons will support these new ways of working. These are engaging with involuntary service users a literature review and case study skilled community practitioners whose role will include co-ordination of health and social care services for people with complex physical health needs as well as carrying out investigations and administering treatments.
It remains to be seen whether these approaches will reduce engaging with involuntary service users a literature review and case study. A systematic review of home care programmes for patients with cancer found that quality of life and satisfaction with services were greater for those treated at home, but there were equivocal findings regarding the impact of the programmes on inpatient bed use.
The evidence from this review suggests that a number of areas should be given attention when services shift from hospital-based to community-based models of care. Perhaps, the most important message is that community services cannot completely replace hospital care.
Some patients, particularly those with higher levels of need, may remain supported at home for longer with the input of more intensive forms of home treatment but still require admissions from time to time.
Among mental health service users, being unemployed or single increases the chance of inpatient bed use 2-fold and those with more severe and complex problems such as psychosis and personality disorders are more likely to require admissions.
In fact, Thornicroft and Tansella's review 55 of community mental health service provision clarifies that a balanced service includes inpatient beds, although the number of beds inversely reflects the quantity and quality of community resources available. They conclude that to enable a balanced system to work, resources from reductions in inpatient services should be invested into community services.
In other words, community services are not cheaper alternatives to hospital-based services, but should be seen as part of a whole system.
Therefore, the focus on inpatient bed use as a measure of efficacy needs to be considered in the context of its integral role within this system, accepting that it is the most expensive element of care, engaging with involuntary service users a literature review and case study. The evidence presented highlights some benefits of community-based care, which are consistent across specialties such as greater patient satisfaction and quality of life.
However, for those people with high levels of need, the experience from mental health services suggests that awareness of the potential for inpatient beds to be gradually replaced by other forms of institutional care in the non-statutory sector is needed.
A further problem is that new community services may draw staff away from inpatient settings which become increasingly focused on the most severely unwell, which, in turn, makes the ward environment an increasingly difficult place to work, leading to further staff retention issues and poorer quality of care for those who require hospital admission. This article has attempted to review the major research, legislation and policy relating to 50 years of community mental health care and to draw out themes relevant to service planners and providers responding to the current political and social drives to expand community care for other specialties.
Currently, there is a need for further research in this field, particularly for randomized controlled trials of different models of community care for people with long-term physical health needs. Since the era of community care has arrived, the experience and evidence base of mental health services should inform other specialties.
With this in mind and to conclude, engaging with involuntary service users a literature review and case study, a study that investigated the characteristics of good community care for people with severe mental illnesses from the perspectives of clients, families, professionals, policy makers and other citizens in five European countries found that the most important characteristic was a trusting and stimulating relationship between clients and professionals.
Good care was defined as effective treatment tailored to individual needs and accessibility of services was also highly rated. Google Scholar. Google Preview.
Combating loneliness and social isolation for the older adults
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Jan 23, · Among mental health service users, being unemployed or single increases the chance of inpatient bed use 2-fold and those with more severe and complex problems such as psychosis and personality disorders are more likely to require admissions. 54 It may be the case that people with other forms of long-term health needs who are socially isolated Sep 02, · This literature review presents the data supporting future studies of the effects of natural settings for the long term care and rehabilitation of the elderly having the medical and mental health problems frequently occurring with aging. in a natural setting, engaging the involuntary attention may spare voluntary attention fatigue, allowing This course also provides a graduate foundation for conducting business research. Topic coverage includes: research methodology, literature review, hypothesis generation, data collection and summary techniques. Additional coverage includes study of qualitative and quantitative data as well as reviewing conceptual versus empirical research studies
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