Cost-effectiveness of intensive psychiatric community care for high users of inpatient services.

BACKGROUND: This 2-year experimental study evaluated the effectiveness and cost of 10 intensive psychiatric community care (IPCC) programs at Department of Veterans Affairs medical centers in the northeastern United States. METHODS: High users of inpatient services were randomly assigned to either IPCC or standard Department of Veterans Affairs care at 6 general medical and surgical hospitals (n=271 vs 257) and 4 neuropsychiatric hospitals (n=183 vs 162). Patient interviews every 6 months and national computerized data were used to assess clinical outcomes, health service use, health care costs, and non-health care costs. RESULTS: There was only 1 significant clinical difference between groups across follow-up periods: IPCC patients at general medical and surgical sites had higher community living skills. However, at the final interview, IPCC patients at general medical and surgical sites showed significantly lower symptoms, higher functioning, and greater satisfaction with services. Treatment with IPCC significantly reduced hospital use only at neuropsychiatric sites (320 vs 513 days, P<.001). Total societal costs, including the cost of IPCC, were lower for IPCC at neuropsychiatric sites ($82,454 vs $116,651, P<.001), but greater at general medical and surgical sites ($51,537 vs $46,491, P<.01). When 2 sites that incompletely implemented the model were dropped from the analysis, costs at general medical and surgical sites were $38 lower for IPCC (P=.26). CONCLUSIONS: At acute care hospitals, IPCC treatment is associated with greater long-term clinical improvement and, when fully implemented, is cost-neutral. At long-stay hospitals treating older, less-functional patients, it is not associated with clinical or functional improvement but generates substantial cost savings. Intensive psychiatric community care thus has beneficial, but somewhat different, outcome profiles at different types of hospitals.

Therapeutic alliance and outcome in a VA intensive case management program.

A total of 143 clients and their case managers in a Veterans Affairs (VA) intensive case management program modeled on the Program for Assertive Community Treatment rated their therapeutic alliance after two years in the program. Strong case-manager-rated alliance was associated with reduced symptom severity and improved global functioning as rated by independent assessors; it was also associated with higher client ratings of community living skills and more positive outcome as perceived by both clients and case managers. Strong client-rated alliance was associated only with more positive client-perceived outcome. Alliance ratings were not associated with use of inpatient psychiatric hospitalization. The case manager-client alliance appears to be a significant component of therapeutic effectiveness.

Therapeutic limit setting in an assertive community treatment program.

OBJECTIVE: The study examined the use of therapeutic limit-setting activities by members of assertive community treatment teams with clients who had serious mental illness. METHODS: Case managers from 40 Veterans Affairs intensive psychiatric community care teams reported their use of 25 limit-setting activities with 1,564 veterans during the first six months of treatment. The 25-item measurement scale was factor analyzed, and a standard multiple regression procedure was used to regress scale scores on clients' characteristics, the frequency of case managers' contact with service providers and others, and clients' and case managers' perceptions about the therapeutic alliance. RESULTS: Case managers relied most frequently on informal verbal approaches to limit setting and relied least on formal legal restrictions. Factor analysis of the instrument, the Therapeutic Limit Setting (TLS) scale, reduced the number of items to 20 and resulted in a five-factor solution. The limit-setting factors were verbal guidance, money management, contingent withholding of services or support, enforced hospitalization, and invocation of external authorities. The TLS and its subscales were characterized by high internal consistency, modest intercorrelation, and unique relationships with variables related to clients' characteristics, the treatment process, and the therapeutic alliance. Case managers were more likely to set limits with clients who had more extensive hospitalization histories, a representative payee, recent alcohol or drug use, more arrests, and more severe symptoms. CONCLUSIONS: Case managers used a range of limit-setting strategies in assertive community treatment. Limit setting is a frequent and potentially important aspect of assertive community treatment that may be useful for comparing levels of assertiveness in assertive community treatment teams and other community-based rehabilitation services.

Flexible work schedules and family time allocation: Assessment of a system change on individual behavior using self-report logs.

This study assessed the effects of a flexible work schedule ("flextime") on time allocated to children and spouse by federal workers. Direct behavioral observations of family, home, and work functions were precluded because of the cost involved in observing many people for long periods of time. In order to obtain detailed individual data, participants completed hour-by-hour activity logs a mean of twice per week for 35 weeks. Participants received prior training on log completion, initial feedback on the detail of their log entries, and were prompted to complete the forms. Four different procedures assessing reliability indicated a corroboration rate of 80% with other sources. Log data were reliably reduced to nine categories such as "PM time with children" and 37 subcategories such as "time at dinner." The log data were presented in time-series form and the use of a quasi-experimental design showed that participants who altered their work schedule were able to spend more PM time with their families. The log data demonstrated that the capacity exists to assess closely the effects of large-scale changes at a micro-behavioral level, but other methods are needed to make complex self-reporting systems less expensive and more capable of immediate monitoring of the intervention's effects.

Effects of self-monitoring and feedback on residential electricity consumption.

Prior research has indicated that frequent feedback could reduce residential electricity consumption by 10% to 15%. However, because feedback was primarily given in written form, this procedure might not be practical. The present study evaluated a potentially more practical feedback procedure during peak-use periods with high electricity consuming households. The study was conducted during the winter in an upper-middle class neighborhood of almost identical, all-electric townhouses (N = 71) that averaged about 170 KWH per day per household for a monthly bill of over $200. Twelve households received daily written feedback. Sixteen households (self-monitoring) were taught to read their outdoor electricity meter and to record KWH used every day. A comparison group was composed of 14 households that had volunteered to participate and 29 others that had only given permission to have their meters read. During a 1-month period that the procedures were in effect, the feedback group reduced consumption by 13% and the self-monitoring group by about 7%. These reductions, relative to the comparison group, were maintained during an early spring 1-month follow-up period and, to a lesser extent, during a 6-week warm spring period. Self-monitoring participants were highly reliable and persistent meter readers. Reductions in electricity use were reported by households to be largely attributable to lowering of the heat thermostat, and large monetary and KWH savings were found. Techniques to make self-monitoring cost-effective important components of the self-monitoring procedure, methods to apply self-monitoring more broadly, and plans to combine behavioral procedures with physical technology are discussed.

Issues in multivariate assessment of a large-scale behavioral program.

Several social and research issues directly affected the development and implementation of multivariate assessment in a large community-based applied research program. Examples are drawn from experiences of the Preparation through Responsive Educational Programs Project for disruptive and skill deficient adolescents in suburban, rural, and urban junior high school settings, focusing on the assessment of academic and social skill development and long-term skill maintenance. The social context altered both project treatment and follow-up plans, requiring assessment of potentially unintended effects and decreasing consistency across sites. Future community acceptance of such programs may depend on the investigators' adaptation to diverse community pressures for program conduct and assessment and the measurement of phenomena that are not always directly observable.