A predictive model to allocate frequent service users of community-based mental health services to different packages of care.

AIM: To develop predictive models to allocate patients into frequent and low service users groups within the Italian Community-based Mental Health Services (CMHSs). To allocate frequent users to different packages of care, identifying the costs of these packages. METHODS: Socio-demographic and clinical data and GAF scores at baseline were collected for 1250 users attending five CMHSs. All psychiatric contacts made by these patients during six months were recorded. A logistic regression identified frequent service users predictive variables. Multinomial logistic regression identified variables able to predict the most appropriate package of care. A cost function was utilised to estimate costs. RESULTS: Frequent service users were 49%, using nearly 90% of all contacts. The model classified correctly 80% of users in the frequent and low users groups. Three packages of care were identified: Basic Community Treatment (4,133 Euro per six months); Intensive Community Treatment (6,180 Euro) and Rehabilitative Community Treatment (11,984 Euro) for 83%, 6% and 11% of frequent service users respectively. The model was found to be accurate for 85% of users. CONCLUSION: It is possible to develop predictive models to identify frequent service users and to assign them to pre-defined packages of care, and to use these models to inform the funding of psychiatric care.

[Care across all phases of schizophrenia and initiation of treatment: discrepancy between routine practice and evidence. The SIEP-DIRECT'S Project]. / Elementi comuni dell'assistenza in ciascuna delle fasi della schizofrenia e specificità nell'esordio: discrepanze fra pratiche di routine ed evidenze. Il progetto SIEP-DIRECT'S.

AIMS: To evaluate the quality of psychiatric care in Italian community-based services and the discrepancy between real practices and NICE recommendations for the treatment of schizophrenia concerning the elements common to all phases of care and the first episode of psychosis. METHODS: Data concerning 14 indicators on common aspects of care in all phases and 11 indicators concerning psychosis onset, drawn from NICE Recommendations, were collected in 19 Departments of Mental Health. RESULTS: An optimistic attitude seems to prevail in the staff in all phases of care, while remarkable discrepancies between service practice and recommendations have been found in relation to systematic assessment, availability of informative leaflets and support to relatives. Concerning the treatment of first episode, a lack of specific services and differentiated activities, and paucity of practices based on specific guidelines has been detected. However, Italian community based services proved to have a good capacity to provide help quickly to those seeking help for a psychotic onset, to maintain regular contact with them in the subsequent year, and provide pharmacological treatment reasonably in line with the scientific evidence. Instead, little specific support is provided to the relatives. CONCLUSIONS: The results show critical points concerning capacity of assessment and treatment standardization, in all aspects of care and specifically in the treatment for the first episode. Differentiation of activities specifically dedicated to the patients at their first episode should be promoted as well as strategies to support relatives in a more specific way.

[Promoting recovery of schizophrenic patients: discrepancy between routine practice and evidence. The SIEP-DIRECT'S Project]. / Promuovere il recupero dei pazienti con schizofrenia: discrepanze fra pratiche di routine ed evidenze. Il Progetto SIEP-DIRECT'S.

AIMS: The aim of this work is to present the main discrepancies, as evidenced by the SIEP-DIRECT'S Project, between the evidence-based NICE guidelines for schizophrenia and the usual practices of the Italian mental health services in order to promote the recovery of patients with schizophrenia. METHODS: Starting from the main NICE recommendations on recovery promotion, 41 indicators were developed. These were experimented in 19 participating Italian Mental Health Departments (MHD) or Psychiatric Services through self-evaluation of the activities carried out to promote patient recovery with the aim of assessing the level of adherence to the recommendations. The data required by most of the indicators were obtained from the psychiatric informative system or from the Direction of the MHD. Moreover, specific research was carried out on the clinical records and on representative patient samples. Furthermore, for 14 indicators, there was requested an assessment by the part of "multidisciplinary" or "specialistic" focus groups who then attributed a score according to a defined "ad hoc" scale. RESULTS: According to the data obtained, although the mental health services seem to care about the physical condition of their patients, they do not routinely examine principle parameters such as blood pressure, glycaemia etc., and collaboration with general practitioners is often complex or not uniformly practiced. Most psychiatrists and psychologists possess the basic communication skills but not enough competences in cognitive-behavioural treatments; such treatments, and every other form of structured individual psychotherapy, are seldom carried out and seem to have become marginal activities within the Services. Also family psycho-educational interventions are under-used. The Services are very active in the care of multi-problem schizophrenia patients, who make up a large percentage (almost a quarter, on average) of the patients in their care. These patients are offered specific and integrated treatment plans with the involvement of other health services and social agencies operating in the territory. The strategies adopted by the services for the pharmacological treatment in the prevention of relapses and for patients with frequent crises or with treatment-resistant schizophrenia are all in line with the NICE recommendations. Finally, the Services promote activities of vocational training and supported employment, but the outcomes of these are often unsatisfactory. CONCLUSIONS: The results of the study show a picture of the Italian mental health services with bright yet also dark areas as regards recovery promotion activities. The Services seem to guarantee adequate pharmacological evidence-based treatments, an integrated assistance and good management of multi-problem patients. They have difficulty, however, with respect to the monitoring of the physical health of the patients, psychotherapeutic activities, including those for families, and the promotion of supported employment. Moreover, they still show problems regarding the structuring and formalizing of care processes. To improve this situation, they should make greater use of professional guidelines, protocols and written procedures.

[Proposal for a new funding system for mental health departments. Results from an evaluative multicentre Italian study (I-psycost)]. / Proposta per un nuovo sistema di finanziamento dei dipartimenti di salute mentale. Risultati di uno studio valutativo multicentrico nazionale (I-psycost study).

AIMS: To obtain a new, well-balanced mental health funding system, through the creation of (i) a list of psychiatric interventions provided by Italian Community-based Psychiatric Services (CPS), and associated costs; (ii) a new prospective funding system for patients with a high use of resources, based on packages of care. METHODS: Five Italian Community-based Psychiatric Services collected data from 1250 patients during October 2002. Socio-demographical and clinical characteristics and GAF scores were collected at baseline. All psychiatric contacts during the following six months were registered and categorised into 24 service contact types. Using elasticity equation and contact characteristics, we estimate the costs of care. Cluster analysis techniques identified packages of care. Logistic regression defined predictive variables of high use patients. Multinomial Logistic Model assigned each patient to a package of care. RESULTS: The sample's socio-demographic characteristics are similar, but variations exist between the different CPS. Patients were then divided into two groups, and the group with the highest use of resources was divided into three smaller groups, based on number and type of services provided. CONCLUSIONS: Our findings show how is possible to develop a cost predictive model to assign patients with a high use of resources to a group that can provide the right level of care. For these patients it might be possible to apply a prospective per-capita funding system based on packages of care.