This cohort study investigated outcomes and costs for users of inpatient mental health rehabilitation units that were assessed as being above median quality during our previous national survey [9]. By including better performing units we aimed to identify the aspects of good quality care that were most likely to be associated with supporting patients to improve in their social function and achieve successful community discharge, the main aim of rehabilitation services [24].
Main findings
Over half the patients achieved a successful community discharge within the 12 month follow-up period and there were small improvements in the ratings of social function. The multivariable regression models did not appear to identify any associations between the seven QuIRC domains assessing the quality of care provided in the units and better clinical outcomes for patients (social function or length of admission in the rehabiliation unit). However, a number of potential factors that were associated with successful discharge were identified, (albeit with relatively small odds ratios). This analysis was repeated including patients who were considered by staff to be ready for discharge but who were awaiting a suitable community placement, in order to avoid bias due to lack of availability of appropriate local supported accommodation. Both analyses found that the degree to which patients were engaged in activities at recruitment was positively associated with successful discharge/readiness for discharge but those who had been in hospital longer were less likely to achieve this positive outcome. In the first model, patients’ social skills at recruitment (the communication sub-scale of the Life Skills Profile) were also found to be positively associated with successful discharge, as was the degree to which the rehabiliation unit operated with a “recovery” orientation.
Although the negative association between fire setting and discharge/readiness for discharge is not surprising, less easy to explain is the negative association between receiving CBT and successful discharge. These findings are discussed further below.
The cost analysis showed that there was a decrease in costs of care over the 12 months of the cohort study, though the cost of contacts with support workers remained more or less stable and the costs of contacts with care co-ordinators increased. The majority of staff in supported accommodation that most service users moved on to were support workers, explaining the stability of costs associated with this staff group. Quality of care was not associated with costs of care when adjusted for service user age, gender and social functioning. Less severe symptoms and higher functioning (higher scores on the Global Assessment of Functioning) were associated with lower costs of care, presumably because service users who were less unwell had less need of staff support. This is something that has been demonstrated previously [25]. Service users with a history of fire setting were less likely to be discharged in our sample. Therefore, there was a trend towards higher costs at follow-up among those with problems on the Special Problems Rating Subscale that included this behaviour.
Clincal implications
Our results are important in helping to inform the practice and interventions that are most likely to help people with complex mental health needs progress in their rehabilitation. The finding that patients’ activity at recruitment into the study was associated with successful discharge/readiness for discharge at 12 months supports our decision to develop and test a staff training intervention aimed at promoting patient activity during other phases of the REAL study [26]. The association with social skills and successful discharge is also of interest. The evidence for the effectiveness of social skills training for people with schizophrenia has not been considered adequate for NICE [27] to recommend routinely offering it to people with schizophrenia. However, a meta-analysis of 22 trials of social skills training [28] found it to be associated with improvements in psychosocial functioning and negative symptoms, though problems with heterogeneity of methods and reporting of results limited the robustness of the findings [29]. Nevertheless, the Scottish Intercollegiate Guidelines Network guidance on the management of schizophrenia [30] states “social skills training may be considered for individuals diagnosed with schizophrenia who have persisting problems related to social skills.” Further studies are required to investigate the potential benefit of specific social skills training for people with complex mental health problems who are referred to rehabilitation services.
Our finding of a positive association between successful discharge and recovery orientated practice is of particular interest. Recovery orientated practice in mental health services is strongly encouraged by policy makers [31]. It incorporates a focus on therapeutic optimism and collaborative working with patients to agree together the goals of treatment and support, rather than the more traditional approach of a professional led treatment plan with the patient as passive recipient [32, 33]. Mental health rehabilitation services were early adopters of the recovery approach [34] and current commissioning guidance describes them as operating with this style and values [24]. One specific aspect of recovery orientated practice, namely the employment of ex-patients as members of the inpatient staff team occurred in 38 % of units (and one third of units across England in our national survey). The Recovery Based Practice domain of the QuIRC also includes many other aspects of care, including assessment of the degree to which collaborative care planning practices are employed and the therapeutic optimisim of the staff. We believe that our results may provide the first empirical evidence of the possible benefits of recovery orientated practice for people with complex psychosis.
We also identified factors associated with less chance of successful discharge/readiness for discharge. The greater the percentage of patients in the unit who had received CBT in the year before recruitment into the study, the less likely successful discharge was. Whilst this could be interpreted as suggesting a negative effect of CBT, there is strong evidence of its effectiveness in people with psychosis and it is recommended for treatment of this group [27]. A more likely explanation is that patients with the most complex needs, who are hardest to treat, are more likely to receive CBT as part of the range of interventions aimed at improving symptoms and functioning. This explanation concurs with the finding that patients who had been in hospital longer were less likely to achieve successful discharge/readiness for discharge. In other words, those with the most complex and treatment resistant symptoms tend to remain in hospital longer and are, perhaps, more likely to be offered more interventions over time. A possible alternative explanation is that patients who engaged with CBT developed greater insight into their mental health problems but required longer inpatient treatment as a consequence. However, we did not assess insight in this study and must stress that this possible association is purely hypothetical.
A history of fire setting was also associated with less chance of successful discharge/readiness for discharge and greater costs of care, although only 7 % of the cohort had such a history. Challenging and dangerous behaviours have previously been noted to make individuals difficult to discharge from hospital [5, 8]. Arson is an especially challenging behaviour and many supported accommodation providers are, understandably, reluctant to offer placements to people with this kind of serious risk history. Conversely, we found that a history of self-harm (which had occurred for 41 % of the cohort) was associated with a greater chance of successful discharge/readiness for discharge. This seems a rather paradoxical finding. Perhaps those who self-harm have less severe negative symptoms and are more motivated to act (albeit in a detrimental manner) than those with more severe negative symptoms whose level of function is so poor that it impedes community discharge. Self-harm may also indicate the presence of mood symptoms [35] which are generally associated with a better prognosis than negative symptoms alone. It should also be borne in mind that this factor included self-harm at any point in the person’s history, and these acts may have been many years earlier.
The fact that 14 % (1 in 7) of patients whom staff considered ready for discharge could not leave the unit because no suitable community accommodation was available is concerning. This represents an inefficient use of resources and needs to be addressed urgently to ensure that patients are supported in the least restrictive environment appropriate to their needs. More investment in community based supported accommodation is therefore required. This should include specialist accommodation for the small percentage of service users whose challenging behaviours such as a history of fire setting, impede move-on.
Strengths and limitations
Our study was only able to report associations between service and service user characteristics and outcomes. Since mental health rehabiliation services have been in place across England for many years, randomisation was not possible and there are no suitable comparison services that could be used for a case control design. The only feasible approach to evaluation therefore, was an observational study. Whilst our analyses were exploratory, we can have some confidence in our findings. We recruited a large sample from across most of the better performing inpatient mental health rehabilitation units in England. Our follow-up rate was excellent, with primary outcome data on successful discharge collected on over 90 % of our cohort. This is also a “hard” dichotomous outcome which does not rely on subjective opinion. Our decision to use staff rated outcomes also minimised the amount of missing data on patients’ social functioning at 12 month follow-up. However, inclusion of patient rated outcomes, such as quality of life and satisfaction with treatment and support, would have allowed us to report on a more comprehensive range of perspectives on the concept of “meaningful” clinical outcome.
Nevertheless, our results appear to support the therapeutic optimism that is enouraged in mental health rehabilitation services. The majority of patients in our study were successfully discharged to the community within our 12 month follow-up period (without readmission or community placement breakdown), despite the severity and complexity of their mental health problems that had led to their referral to these specialist services. Mental health rehabilitation services are therefore succeeding with an especially complex group and reducing the costs of care through their input. We found that successful discharge was associated with units operating an approach that incorporated a recovery orientation. Higher levels of patient activity and social skills were also associated with a greater chance of successful discharge. Patients with more complex needs and challenging behaviours (specifically, fire setting) were less likely to achieve successful discharge. Our findings suggest that further research is needed to identify effective interventions that enhance recovery orientated practice, patient activities and social skills in these settings.
Whilst our study was carried out in better performing services in England, the results have obvious relevance for lower quality units, not just in the UK, but in other countries where the quality of care may differ.