Professional literature in the past five years regarding the care and treatment of deinstitutionalized chronic mentally ill (CMI) persons has presented growing concerns that services for some CMI persons are inadequate or nonexistent. A number of previous authors have suggested that there may be a consistent, as opposed to a random, bias in the traditional mental health service delivery system whose services are contingent upon client characteristics that, in the very least, assume foresight, independence, initiative, and consistency. Lacking these qualities, clients may not seek services to which they are entitled or they may be frustrated in maintaining those services. This study provides a description of a CMI population (n = 142) that received outreach services from a small county psychiatric hospital. These clients were selected because they were evaluated as severely disturbed, potentially impulsive, and had a history of not following through with traditional mental health services, i.e., they did not make or keep prescribed appointments for therapy or education. This group served as a model against which to compare characteristics of the traditionally engaged clients. Previous authors as well as this study found that the dropout populations were younger, less compliant with prescribed anti-psychotic medication, engaged in more alcohol and drug use, were more likely to live independently and to be rehospitalized with greater frequency. Increased hospitalization also correlated with less functional independent living skills. In other reported research several variables were found to discriminate the younger CMI. This study could only confirm an increase in substance abuse although several confounding factors are discussed. Finally, the outreach program itself was examined, some services were quantified, and some were related to specific client characteristics. For instance, 40 percent of this CMI population was primarily reliant on their outreach worker for all transportation beyond walkable distances; and those clients receiving the most number of outpatient visits were those rated most rejecting of services and those with the poorest independent living skills. The treatment population was found to have reduced their total number of admissions and days hospitalized during the two-year period of investigation.

Two related program evaluations of the mental health system in Puerto Rico are conducted. Initially, research is carried out in two state psychiatric hospitals involving an organizational analysis of relevant systems variables as they impinge upon effective institutional functioning. In this scheme hospital effectiveness is predicted by success in achieving formally prescribed goals and in the adequacy of resource utilization. The basic assumption is that the psychiatric hospital reflects the patterning of reciprocal and interdependent behaviors of individuals which form a larger all-important pattern. The hospitals are studied by means of a questionnaire administered to staff to ascertain perceptions of the work environment, communication and coordination processes, overall hospital organization, and the treatment environment. The results of organizational functioning are presented in a profile analysis plotting institutional means over ten functional dimensions. Individual component variables are converted into standard scores and broken down by staff sub-groups. Each institution and staff sub-group differs uniquely across the dimensions. Overall the results point to excessive staff frustration and disillusionment with the organization's functions, and a treatment environment limited in patient autonomy, socio-emotional interaction, and therapeutic content. The complementary study of first releases from these hospitals examines background and performance characteristics of a sample of patients in an effort to distinguish those who complied with aftercare referrals from those who did not, and those who were readmitted from those still in the community one year after release. Bivariate analysis of the relationship between each of the two dependent variables and the several demographic and treatment variables at each hospital reveals that the strongest differentiation of compliers from non-compliers is having been active in pre-hospital outpatient care, while the extent of use of aftercare was the strongest predictor of remaining in the community. Implications for policy and for further research in mental health service delivery are discussed.

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The impact of the introduction of hospital medical day care programs on inpatient use was studied, to see if there was a reduction in average lengths of stay, cases or patient days, for those diagnostic categories in the programs. The provincial government funded these programs to create an alternative to hospitalization. Studies on the issue of whether or not day care is an alternative or substitutes for inpatient use were examined. Interest in ambulatory care is growing because of the increasing age of the population, increasing duration of chronic illness and increasing costs of hospital services. Three programs at Lions Gate Hospital in North Vancouver, B.C. were chosen: Chronic Obstructive Lung Disease (CO.L.D.) program, Diabetic Day Care,and the Neuro (Neurology) program. The population for study were divided into four groups: those from North and West Vancouver who used Lions Gate Hospital, patients from the rest of the Greater Vancouver Regional District (G.V.R.D.) who used other G.V.R.D. hospitals, arid to allow for 'spill-out' cases, those from North and West Vancouver who used other hospitals in the province and those from the rest of the G.V.R.D. who used Lions Gate Hospital. The methodology involved the use of a multiple time series design which would allow some comparison before and after the introduction of the CO.L.D. program, as well as comparison between the North Shore and the rest of the G.V.R.D. A regression analysis, using a dummy variable for the CO.L.D. program, on average length, of stay, cases and patient days showed no statistically significant results. The data collection period, 1970 to 1979/80, does not provide conclusive answers for Diabetic Day Care, introduced at Lions Gate Hospital in 1966 and in some of the hospitals of the rest of the G.V.R.D. in 1972, or for the Neuro program, introduced at Lions Gate Hospital in 1979. However, population and age adjusted cases and patient days for all three programs are consistently higher in the rest of the G.V.R.D. when compared with North and West Vancouver and deserve further investigation. The implications from this study, that there is no impact from medical day care, programs on rates of inpatient use, is consistent with similar studies on Diabetic Day Care and Day Care Surgery. The health care system does not seem to be able to respond to innovations of this type and they are additions to existing services. / Medicine, Faculty of / Population and Public Health (SPPH), School of / Graduate

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published_or_final_version / Medical Sciences / Master / Master of Medical Sciences

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