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A Retrospective Quasi-Experimental Study of a Transitional Housing Program for Patients with Severe and Persistent Mental Illness

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A Retrospective Quasi-Experimental Study of a Transitional Housing Program for Patients with Severe and Persistent Mental Illness
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  A Retrospective Quasi-Experimental Study of a Transitional Housing Program for Patients with Severe and Persistent Mental Illness  Authors : Dan Siskind * , Lecturer  1 , Senior Lecturer  2 , and Consultant Psychiatrist 3 Meredith Harris, Principal Researcher  1 , Steve Kisely, Professor  1,2,3,4,5  Victor Siskind, Adjunct Professor  6  James Brogan, Research Assistant 1,3  Jane Pirkis,   Professor  7 , David Crompton, Associate Professor  2 , and Executive Director  3  Harvey Whiteford, Kratzmann Professor  1   1 School of Population Health, The University of Queensland, Qld, Australia 2 School of Medicine, The University of Queensland, Qld, Australia 3 Metro South Mental Health Service, Woolloongabba, Qld, Australia 4 Health LinQ, University of Queensland, St Lucia, Qld, Australia 5 Griffith Institute of Health, Griffith University, Qld, Australia 6 Queensland University of Technology, Qld, Australia 7 Centre for Health Policy, Programs and Economics, School of Population Health, University of Melbourne, Melbourne, Vic, Australia *corresponding author Queensland Centre for Mental Health Research University of Queensland School of Population Health Level 3 Dawson House The Park Wacol QLD 4076 AUSTRALIA dan_siskind@qcmhr.uq.edu.au mobile +61 420 680 250 office +61 7 3271 8660 fax +61 7 3271 8698 Short Title for Running Head: Transitional Housing Evaluation Original Submission Date: 22 February 2013 Comments from Reviewers received: 7 September 2013 Resubmission Date: 15 September 2013 Acknowledgments We would like to acknowledge the Queensland Directorate of Mental Health for access to de-identified data extracts and assistance in data linkage, Dr Cathy Mihalopoulos for advice on economic analysis and the staff of the Transitional Housing Team. The authors have no conflicts of interest to declare.            " Abstract  (150 words, max 150) Background: Transitional housing programs aim to improve living skills and housing stability for tenuously housed patients with mental illness. Methods: 113 consecutive Transitional Housing Team (THT) patients were matched to 139 controls on diagnosis, time of presentation, gender and prior psychiatric hospitalisation and compared using a difference-in-difference analysis for illness acuity and service use outcomes measured one year before and after THT entry/exit. Results: There was a statistically significant difference-in-difference favouring THT  participants for bed days (mean difference in difference -20.76 days, S.E. 9.59,  p=0.031) and living conditions (HoNOS Q11 mean difference in difference -0.93, S.E. 0.23, p<0.001). THT cost less per participant (I$14,024) than the bed-days averted (I$17,348). Conclusions: The findings of reductions in bed days and improved living conditions suggest that transitional housing programs can have a significant positive impact for tenuously housed patients with high inpatient service usage, as well as saving costs for mental health services. Key Words Mental Health; Service Evaluation; Homelessness; Transitional Housing             1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65   # Introduction Patients with severe and persistent mental illness (SPMI) (Siskind, Harris, Buckingham, Pirkis & Whiteford, 2012) are more likely than the general population to be homeless (Folsom et al., 2005). Thirteen percent of a community sample of  patients with SPMI in Australia had experienced at least one period of homelessness in the previous 15 months (Harvey, Killackey, Groves & Herrman, 2012). Homelessness and mental illness are associated with increased rates of victimization (Larney, Conroy, Mills, Burns & Teesson, 2009), physical illness (Plumb, 1997) and mortality (Babidge, Buhrich & Butler, 2001). Patients with SPMI have a number of risk factors for homelessness, including functional deficits, poor independent living skills and difficulty negotiating relationships with others such as landlords (Jablensky et al., 2000). They are often in a revolving door of admission, discharge to inadequate housing, non-engagement with community services, and preventable readmission (Folsom et al., 2005; North & Smith, 1993). The provision of housing without personalised support (Siskind, Harris, Pirkis & Whiteford, 2012b) is unlikely to be sufficient to allow patients with SPMI to remain in stable accommodation. It must be in combination with both adequate clinical treatment and the provision of support and living skills training if sustained housing tenure is to be achieved (Newman & Goldman, 2008). There are a wide range of supported accommodation models operating internationally, varying in terms of duration of tenure, patient characteristics, housing characteristics, and service characteristics (Siskind, Harris, Pirkis & Whiteford, 2012a). To date, comparisons between program types have been hampered by a lack of definitional clarity. Programs such as Test and Stein’s Program in Community Living (Test & Stein, 1976) from Wisconsin have been running for more than 25 years, and assist patients to gain independent living skills, achieve stable housing and reduce extended hospitalisations. An evaluation of US Veterans Affairs time-limited transitional housing services found that 78% of patients were stably housed after 12 months (McGuire, Rosenheck & Kasprow, 2011), a rate comparable to that of permanent 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65   $ supported housing programs such as Housing First (Tsemberis, Gulcur & Nakae, 2004). In Queensland, Australia, a Transitional Housing Team (THT) was established in 2005 as part of a government response to homelessness among people with mental illness. The team provided time limited housing and intensive living skills training and support to clinically case managed patients. The service was publicly funded through Australia’s universal health care sy stem. The Australian states fund general and psychiatric hospitals and community mental health services while the federally funded Medicare system covers visits to family physicians and community specialists, although a co-payment may be required. Health insurance may also be purchased for  private sector treatment. Although studies of transitional housing have suggested it can lead to stable housing, its efficacy in reducing time spent psychiatrically hospitalized has not been studied. Further, the relative costs to mental health services of providing transitional housing has not been examined. In this study, we compared total acute psychiatric inpatient days, problems with living conditions, illness acuity and emergency department  presentations for a year before entry and a year after exit from THT with a matched comparison group drawn from neighbouring hospital district mental health services without a transitional housing program. We hypothesised that when compared to controls, THT participants would have greater reductions in psychiatric inpatient bed-days, greater improvements in living conditions, greater reductions in ED  presentations and lower overall costs to the mental health service. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65   % Methods Setting THT services were provided to two tertiary general hospital districts of Brisbane, with a catchment population of 750,000 residents. The total population of greater Brisbane is 2,150,000. Mental health services provided by all of the hospital districts in this study used state-wide models of care which includes an acute inpatient psychiatric unit, community based multi-disciplinary outreach clinical case management teams with a staff to patient ratio of approximately 1:25 (Harvey & Fielding, 2003), an Assertive Community Treatment model team (Harvey, Killaspy, Martino & Johnson, 2012), a psychiatric emergency department and a home based mobile acute crisis team (Hubbeling & Bertram, 2012). Further details on mental health services in Queensland are available elsewhere (Harris, Buckingham, Pirkis, Groves & Whiteford, 2012; Siskind et al., 2012). THT program description THT was based on the place-train model that houses patients first, and then provides support for independent living skills (Corrigan & McCracken, 2005). Services varied according to patient’s needs and included specific living skills training such as cooking, shopping, diet, cleaning, laundry, and using public transport, as well as relapse prevention, crisis management and linkage to community service agencies. THT staff were based off-site and provided 12 hours per week of in-reach support available over extended hours and weekends. Staff included occupational therapists, nurses and non-clinical support workers. THT participants were provided with social housing for the duration of their time in the program, funded by the Queensland Department of Housing. Participants shared two bedroom apartments in geographically dispersed sites across the inner city suburbs. Patients were provided with assistance to identify permanent housing options prior to discharge from THT. The THT program had a planned six-month duration, but could be briefly extended, if necessary, particularly if more time was needed to identify safe housing. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65
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