Predictors of health services utilization among persons with psychiatric disabilities engaged in supported independent housing.

OBJECTIVE: Persons with psychiatric disabilities are at greater risk for medical comorbidity, and prior research suggests these persons may underutilize health services. In response, this study examined the impact of engagement in psychiatric rehabilitation services, including case management, on utilization of general health services among persons with psychiatric disabilities engaged in supported housing, while controlling for demographic and clinical characteristics. METHODS: Poisson regression analyses were used to examine the impact of socio-demographic, clinical, and service characteristics on reported utilization of general health services in the past year. RESULTS: Findings indicated supported housing residents receiving case management coupled with weekly contact with residential support services visited a general health practitioner more frequently than those with less support services. CONCLUSIONS AND IMPLICATIONS: Study results suggest psychiatric rehabilitation services provided to persons in the context of safe and affordable housing may represent an important mechanism for enabling persons with psychiatric disorders to access needed medical care.

Impact of psychotic disorders on discharge dispositions of adults 65 or older after a general medical inpatient stay.

OBJECTIVE: This study examined the extent to which a psychotic disorder, as well as demographic and clinical characteristics, predicted the discharge disposition of adults aged 65 or older after a hospital stay for a general medical illness. METHODS: Data from a nationally representative sample of hospital discharges among persons 65 years of age or older (N=2,334,130) were drawn from the 2007 Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project. A series of multivariate logistic regression models were constructed to examine the impact of psychotic disorders and demographic and clinical characteristics on four discharge dispositions--routine discharge, home care, nursing facility, or in-hospital mortality--among patients with or without a psychotic disorder. RESULTS: Patients with a psychotic disorder (N=23,751) were significantly more likely than those without a psychotic disorder (N=2,310,379) to be discharged to home care (OR=1.60) or to a nursing facility (OR=4.49) or to die in the hospital (OR=1.95). Patients with a psychotic disorder were more likely than patients without a psychotic disorder to be discharged to a nursing facility if they were also male (OR=4.96), between 65 and 74 years old (OR=6.05), or admitted from another inpatient facility (OR=6.14) or if their illness was of mild or moderate severity (OR=4.87). CONCLUSIONS: The significantly increased likelihood for referral to skilled home care and nursing facilities after hospital discharge among psychotic patients highlights the need for viable and dynamic community-based care options for maintaining the health and well-being of older adults with a psychotic disorder after an acute care event.

Toward understanding errors in inpatient psychiatry: a qualitative inquiry.

While prior research has identified the impact, nature, and causes of medical error in general medical settings, little is known about errors in inpatient psychiatry. Understanding the broad range of errors that occur in inpatient psychiatry is a critical step toward improving systems of care for a vulnerable patient population. An explorative qualitative analysis of key informant interviews identified a preliminary typology of errors and the contextual factors that precipitate them in inpatient psychiatry. The types of errors and their contextual factors fall broadly within the rubric of categories identified in medicine and surgery. However, many of the specific errors and contextual factors manifest themselves differently and are shaped by the uniqueness of the inpatient psychiatric setting and patient population. Interventions geared toward improving systems of care for psychiatric patients should draw on best practices for safety in medicine and surgery, but also be complemented with new strategies specifically tailored to the inpatient psychiatric setting.

A place called LIFE: exploring the advance care planning of African-American PACE enrollees.

The goals of this exploratory study were (a) to describe, among African-American PACE (Program of All-Inclusive Care for the Elderly) enrollees, verbalized preferences for end-of-life care as compared to preferences for care as documented in their medical record and (b) to explore the personal values that inform end-of-life decision making among these frail elders. Medical record review and semi-structured interviews generated descriptive and qualitative data for 18 African-American enrollees in a PACE program located in a large eastern city of the United States. Review of verbalized and documented preferences for end-of-life care among participants indicated that most preferred life-sustaining treatments. In addition, findings suggest that these PACE enrollees had limited information or understanding of the interventions and terminology associated with advance directives. Content analysis of interviews indicated that end-of-life decision making was influenced by the desire to maintain usual activities of daily living; to avoid burdening caregivers; and to remain in control of personal health care. Furthermore, these African-American elders relied on faith in God as central to medical decision making, believing ultimately that God controls the end of life. This research may enhance the ability of social workers, in collaboration with other members of PACE or similar interdisciplinary teams, to understand the values and attitudes associated with the preferences of older African Americans for care at the end of life. These findings suggest future research is needed to ensure advance care planning acknowledges and responds to the values and preferences of African-American PACE enrollees for the end of life.