Community integration of former state hospital patients: outcomes of a policy shift in Vermont.

OBJECTIVE: The study examined the level of community integration achieved by patients discharged from the state hospital into the community in compliance with a regionalization policy in Vermont that sought to reduce the need for central hospitalization through expansion of community capacity. METHODS: The population in residence at the state hospital on August 30, 1989, was tracked longitudinally as patients were discharged into one of Vermont's ten catchment areas. Structured interviews about the current status of the discharged individuals were conducted four years later with case managers, nursing home personnel, and community care home operators. Service utilization and hospitalization data were obtained from the Vermont Department of Mental Health database. RESULTS: Of 122 patients in residence at the state hospital on the given date, 58 were discharged into the community, of whom 46 consented to participate in the study. At follow-up, about half lived in structured residential settings. Of the 46 followed, 87 percent were rehospitalized during the study period for periods ranging from three months to one year. Although participants had adequate levels of support both from within and outside the mental health system, their integration into the community was low in terms of their use of community resources, stigma-related problems, and difficulties gaining access to services. CONCLUSIONS: The regionalization policy accomplished some of its goals, especially those related to downsizing the state hospital, placing clients in community residential settings, and enhancing the range of community services. The more pervasive and insidious problems of community integration faced by consumers were not effectively mitigated by the policy.

A qualitative approach to assessing the effects of system change on consumers, families, and providers.

OBJECTIVE: In 1988 Vermont implemented a policy designed to reduce the state hospital census and expand community-based services. This qualitative study assessed perceptions of the policy's impact among mental health consumers, family members, and providers. METHODS: Eleven focus groups were convened, which included 94 participants from across the state. Separate groups were held for consumers, family members, and providers. Trained facilitators guided discussion of the policy's effect on quality of life, housing and vocational status, community integration, and social networks. Audiotapes of the discussion were transcribed, and content was analyzed. RESULTS: Several universal themes were noted. All participants reported that stigma was still a substantial barrier to integration and that community education to reduce stigma had not been effective. Tension between families and providers was a problem; family members felt that although providers depended on their supporting the consumer, they were not included in treatment planning. All participants noted that urban areas were better served by the policy's service packages. A lack of coordination of community services was reported to be a continuing problem across the state. In contrast to findings of previous studies, consumers in this study preferred not to live alone, which led to feelings of isolation. CONCLUSIONS: Service delivery in rural areas and system coordination throughout the state must be improved. Families' conflicting feelings of burden and isolation must be addressed. Further research should determine more clearly the range of housing preferences among consumers.