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Home-Based Versus Hospital-Based Care for People with Serious Mental Illness

Published online by Cambridge University Press:  02 January 2018

I. M. Marks ,
J. Connolly ,
M. Muijen ,
B. Audini ,
G. McNamee  and
R. E. Lawrence
I. M. Marks*
Affiliation:
Institute of Psychiatry and Bethlem-Maudsley Hospital
J. Connolly
Affiliation:
Bethlem-Maudsley Hospital
M. Muijen
Affiliation:
Sainsbury Centre for Mental Health, London SE1
B. Audini
Affiliation:
Royal College of Psychiatrists Research Unit
G. McNamee
Affiliation:
West Lambeth Community Care Trust, London SW9
R. E. Lawrence
Affiliation:
West Lambeth Community Care Trust, London SW9
*
Professor I. M. Marks, Institute of Psychiatry, De Crespigny Park, Denmark Hill, London SE5 8AF
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Abstract

Background.

A controlled study tested whether the superior outcome of community care for serious mental illness (SMI) in Madison and in Sydney would also be found in inner London.

Method.

Patients from an inner London catchment area who faced emergency admission for SMI (many were violent or suicidal) were randomised to 20 months or more of either home-based care (Daily Living Programme, DLP; n = 92), or standard in-patient and later out-patient care (controls, n = 97). Most DLP patients had brief in-patient stays at some time. Measures included number and duration of in-patient admissions, independent ratings of clinical and social function, and patients' and relatives' satisfaction.

Results.

Outcome was superior with home-based care. Until month 20, DLP care improved symptoms and social adjustment slightly more, and enhanced patients' and relatives' satisfaction. From 3 to 18 months DLP care greatly reduced the number of in-patient bed days as long as the DLP team was responsible for any in-patient phase its patients had. Cost was less. DLP care did not reduce the number of admissions, nor of deaths from self-harm (3 DLP, 2 control). One DLP patient killed a child. Even at 20 months many DLP and control patients still had severe symptoms, poor social adjustment, no job, and need for assertive follow-up and heavy staff input. (Beyond 20 months most gains were lost apart from satisfaction.)

Conclusions.

It is unclear how much the gain until 20 months from home-based care was due to its site of care, its being problem-centred, its teaching of daily living skills, its assertive follow-up, the home care team's keeping responsibility for any in-patient phase, its coordination of total care (case management), or to other care components. Home-based care is hard to organise and vulnerable to many factors, and needs careful training and clinical audit if gains are to be sustained.

Type
Papers
Information
The British Journal of Psychiatry , Volume 165 , Issue 2 , August 1994 , pp. 179 - 194
Copyright
Copyright © Royal College of Psychiatrists, 1994 

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