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A Comparison of Patients with Intellectual Disability Receiving Specialised and General Services in Ontario's Psychiatric Hospitals

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Title: A Comparison of Patients with Intellectual Disability Receiving Specialised and General Services in Ontario's Psychiatric Hospitals
Language: English
Authors: Lunsky, Y., Bradley, E., Durbin, J., Koegl, C.
Source: Journal of Intellectual Disability Research. Nov 2008 52(11):1003-1012.
Availability: Blackwell Publishing. 350 Main Street, Malden, MA 02148. Tel: 800-835-6770; Tel: 781-388-8599; Fax: 781-388-8232; e-mail: customerservices@blackwellpublishing.com; Web site: http://www.blackwellpublishing.com/jnl_default.asp
Peer Reviewed: Y
Page Count: 10
Publication Date: 2008
Document Type: Journal Articles
Reports - Evaluative
Descriptors: Health Services, Substance Abuse, Mental Retardation, Psychiatric Hospitals, Mental Disorders, Mental Health Programs, Patients, Foreign Countries, Clinics, Comparative Analysis, Symptoms (Individual Disorders), Profiles, Intervention, Behavior Problems, Specialists
Geographic Terms: Canada
DOI: 10.1111/j.1365-2788.2008.01049.x
ISSN: 0964-2633
Abstract: Background: Over the years, the closure of institutions has meant that individuals with intellectual disabilities (IDs) must access mainstream (i.e. general) mental health services. However, concern that general services may not adequately meet the needs of patients with ID and mental illness has led to the development and implementation of more specialised programmes. This study compares patients with ID receiving specialised services to patients with ID receiving general services in Ontario's tertiary mental healthcare system in terms of demographics, symptom profile, strengths and resources and clinical service needs. Method: A secondary analysis of Colorado Client Assessment Record data collected from all tertiary psychiatric hospitals in the province was completed for all 371 inpatients with ID, from both specialised and general programmes. Results: Inpatients in specialised programmes were more likely to have a diagnosis of mood disorder and were less likely to have a substance abuse or psychotic disorder. Individuals receiving specialised services had higher ratings of challenging behaviour than those in more general programmes. The two groups did not differ significantly in terms of recommended level of care, although more inpatients from specialised programmes were rated as requiring Level 4 care than inpatients from general programmes. Conclusions: In Ontario, inpatients in specialised and general programmes have similar overall levels of need but unique clinical profiles that should be taken into consideration when designing interventions for them.
Abstractor: As Provided
Number of References: 41
Entry Date: 2008
Accession Number: EJ814211
Database: ERIC
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  Value: <anid>AN0034740821;eul01nov.08;2019Jun04.10:46;v2.2.500</anid> <title id="AN0034740821-1">A comparison of patients with intellectual disability receiving specialised and general services in Ontario's psychiatric hospitals. </title> <p>Background  Over the years, the closure of institutions has meant that individuals with intellectual disabilities (IDs) must access mainstream (i.e. general) mental health services. However, concern that general services may not adequately meet the needs of patients with ID and mental illness has led to the development and implementation of more specialised programmes. This study compares patients with ID receiving specialised services to patients with ID receiving general services in Ontario's tertiary mental healthcare system in terms of demographics, symptom profile, strengths and resources and clinical service needs. Method  A secondary analysis of Colorado Client Assessment Record data collected from all tertiary psychiatric hospitals in the province was completed for all 371 inpatients with ID, from both specialised and general programmes. Results  Inpatients in specialised programmes were more likely to have a diagnosis of mood disorder and were less likely to have a substance abuse or psychotic disorder. Individuals receiving specialised services had higher ratings of challenging behaviour than those in more general programmes. The two groups did not differ significantly in terms of recommended level of care, although more inpatients from specialised programmes were rated as requiring Level 4 care than inpatients from general programmes. Conclusions  In Ontario, inpatients in specialised and general programmes have similar overall levels of need but unique clinical profiles that should be taken into consideration when designing interventions for them.</p> <p>Keywords: intellectual disabilities; mental health; psychiatric services; inpatients</p> <p>In many countries, the practice of normalisation and the related closure of institutions have meant that individuals with intellectual disabilities (IDs) are increasingly being expected to use general population mainstream health services, including mental health care. There is growing consensus, however, that general inpatient and outpatient psychiatric care is inadequate to manage the complex needs of at least some individuals with ID and mental health/behaviour concerns. According to [<reflink idref="bib7" id="ref1">7</reflink>], general services may be sub‐optimal because of a lack of specialist training, limited resources and unhelpful attitudes of healthcare providers. Also patients with ID receiving general inpatient care are particularly vulnerable to exploitation by other patients ([<reflink idref="bib17" id="ref2">17</reflink>]; [<reflink idref="bib41" id="ref3">41</reflink>]; [<reflink idref="bib8" id="ref4">8</reflink>]).</p> <p>Limitations of general psychiatric services have led to the development of specialised psychiatric programmes for patients with ID. Specialised services can be smaller, with higher staff to patient ratios and greater safety, and supported by interdisciplinary teams that are well versed in the biopsychosocial approach to assessment and treatment of individuals with ID ([<reflink idref="bib33" id="ref5">33</reflink>]; [<reflink idref="bib7" id="ref6">7</reflink>]; [<reflink idref="bib8" id="ref7">8</reflink>]; [<reflink idref="bib29" id="ref8">29</reflink>]). Daily programming in specialised inpatient units can be tailored to the cognitive level and adaptive behaviour of the patients and thus can be more stimulating and beneficial to them.</p> <p>A number of studies have described patients with ID using general inpatient services ([<reflink idref="bib1" id="ref9">1</reflink>]; [<reflink idref="bib6" id="ref10">6</reflink>]; [<reflink idref="bib34" id="ref11">34</reflink>]). Other studies have described sociodemographic and clinical characteristics of individuals with ID receiving specialised inpatient services (e.g. [<reflink idref="bib3" id="ref12">3</reflink>]; [<reflink idref="bib32" id="ref13">32</reflink>]; [<reflink idref="bib42" id="ref14">42</reflink>]; [<reflink idref="bib39" id="ref15">39</reflink>][<reflink idref="bib14" id="ref16">14</reflink>]). These studies fail to address an important question, however: in a healthcare system where both services exist, how do individuals with ID accessing specialised vs. general psychiatry services differ? The answer can offer insight into whether individuals are triaged into these different types of care based on higher levels of need, and can set the stage for assessing what patient groups benefit from more specialised treatment settings.</p> <p>In our review, we found two studies that compared inpatients with ID who accessed specialised vs. general mental health services. [<reflink idref="bib2" id="ref17">2</reflink>] contrasted services in two London districts, both with well‐developed community teams in ID, one with a specialised psychiatric inpatient unit, and one with access to beds in a general psychiatric inpatient unit. Through retrospective chart reviews, they found that the most commonly referred individuals to both settings were young men with aggressive behaviour. Patients receiving specialised inpatient services were more likely to have more severe ID but were less likely to be living independently at time of admission, and had significantly longer lengths of stay compared to those in general units. In another London‐based study ([<reflink idref="bib41" id="ref18">41</reflink>]), individuals in the specialised unit were contrasted to adults with ID in general inpatient units. The two groups did not differ with regard to demographics or diagnosis at time of admission, but did differ in terms of length of stay and outcome; Individuals in specialised units had significantly longer lengths of stay than patients in general units and they were less likely to be discharged to an 'out of catchment area' placement.</p> <p>These results suggest that some triaging is occurring in the UK service system, where health policy and statutory health and social service requirements related to mental health and ID are in place, and where ID is a recognised subspecialty of psychiatry and nursing. Practices regarding access to care may differ in other countries, depending on how services are funded, educational opportunities and the existence or lack thereof of specialised service policies ([<reflink idref="bib15" id="ref19">15</reflink>]; [<reflink idref="bib36" id="ref20">36</reflink>]). The present paper takes advantage of a province‐wide study of the needs of patients (that include a subgroup with ID) using psychiatric hospitals in the province of Ontario (largest province in Canada). In Ontario, individuals with ID have been accessing general psychiatry services for the past three decades with the first policy document on their specialised mental health needs appearing in 1997 ([<reflink idref="bib31" id="ref21">31</reflink>]).</p> <p>The Comprehensive Assessment Projects (CAPs) explored the clinical profile and service needs of individuals with ID receiving tertiary level mental health care across Ontario. In an earlier paper ([<reflink idref="bib23" id="ref22">23</reflink>]), all inpatients and outpatients with ID and psychiatric diagnoses were compared with other Ontario psychiatric hospital users and individuals with ID were found to have more severe clinical symptoms and fewer resources than individuals without ID. In this earlier study no distinction was made between patients with ID in specialised vs. general services, however. The goal of the present study was to further examine the group with ID in the CAPs planning study in terms of those who received care in general compared with specialist inpatient programmes. If indeed the access continuum from general to specialised services is working well, we hypothesised that those with the most severe needs, whose needs cannot be met through general services, would be filtered to specialised programmes.</p> <hd id="AN0034740821-2">Methods</hd> <p></p> <hd id="AN0034740821-3">Sample and data collection</hd> <p>The sample for this study was drawn from a mental health services planning study (CAPs) conducted in Ontario during 1998–2003. Study patients were drawn from all nine psychiatric hospitals responsible for providing tertiary inpatient mental health services to urban, semi‐urban and rural communities. Tertiary inpatient programmes in Ontario are mandated to serve individuals with complex or chronic mental health disturbances. Such programmes provide the highest level of care (see Table 1 for description of other levels of care) in the mental health service continuum in Ontario. All programmes included in this study serve persons aged 16 or older with severe and persistent mental health illness.</p> <p>1 Recommended level of care template</p> <p> <ephtml> <table><thead valign="bottom"><tr><th><bold>Level</bold></th><th><bold>Description</bold></th></tr></thead><tbody valign="top"><tr><td>Level 1:</td><td>Self‐management with intermittent use of core community services and supports.</td></tr><tr><td>Level 2:</td><td>Individualised support on a weekly basis. Psychiatric care provided through regular contact with a psychiatrist or mental health nurse in an outpatient setting.</td></tr><tr><td>Level 3:</td><td>Community living with intensive integrated treatment and support (daily with 24 h access). Usually associated with Assertive Community Treatment.</td></tr><tr><td>Level 4:</td><td>Residential treatment with a strong rehabilitation component. This level is appropriate for persons whose behaviours make it difficult to live independently and at times need a secure environment.</td></tr><tr><td>Level 5:</td><td>Tertiary inpatient care.</td></tr></tbody></table> </ephtml> </p> <p>The planning study employed a cross‐sectional design, assessing all facility inpatients on a designated census day. The census date varied by facility, because the planning study occurred over 5 years, one hospital at a time. In total the study assessed 2218 inpatients. The cross‐sectional design was expected to produce a reasonably accurate estimate of patient needs, given the stability of the inpatient population. The assessed patients averaged 3.65 years in hospital at the time of the assessment, and only 13% of inpatients had been in the hospital for less than 1 month ([<reflink idref="bib23" id="ref23">23</reflink>]).</p> <p>Standardised assessments were completed by trained staff based on their familiarity with the patients being rated and medical chart documentation ([<reflink idref="bib11" id="ref24">11</reflink>]). For each patient, staff indicated the presence or absence of a developmental disability in the disability section of the assessment. (In Ontario, the term 'developmental disability' is equivalent to the term 'mental retardation' in DSM‐IV‐TR). Staff also reported any psychiatric diagnoses, including mental retardation, by selecting categories (e.g. mood disorder, substance abuse disorder, anxiety disorder, etc.) based on psychiatric diagnoses in the ICD‐9. A patient was included in this study if he or she was recorded as having a developmental disability or a mental retardation diagnosis in addition to a psychiatric diagnosis ([<reflink idref="bib22" id="ref25">22</reflink>]). Using these criteria, we excluded a small number of cases (<emph>n</emph> = 21) for which there was a designation of developmental disability or a diagnosis of mental retardation, but a precise psychiatric diagnosis was unknown or unavailable. This approach resulted in a final total of 371 inpatients with ID.</p> <p>Of the 371 inpatients included in this study, 102 (27.5%) were enrolled in one of five specialised psychiatric inpatient units across Ontario (for detailed description of these units, see [<reflink idref="bib29" id="ref26">29</reflink>]). When data for the present study were collected, these specialised units were in transition. There was an acknowledgement over many years of the need for additional services beyond general inpatient psychiatric hospital services. By 1998–2003 when the CAPs study was done, each of the five designated wards had a mix of long‐term and short‐term patients with ID, with a range of functioning levels. Each such unit offered specialised programmes of care and an interdisciplinary staff team, but all struggled with staff recruitment and retention ([<reflink idref="bib29" id="ref27">29</reflink>]). At this time, these specialised hospital programmes were designed to serve individuals with ID and mental health needs. General units, although specialised in some cases (e.g. forensic, schizophrenia), were not specialised for patients with IDs.</p> <p>Institutional ethics review board approval for conducting secondary analyses comparing inpatients with ID in general and specialised programmes was obtained.</p> <hd id="AN0034740821-4">Measure</hd> <p></p> <hd id="AN0034740821-5">Colorado Client Assessment Record</hd> <p>The Colorado Client Assessment Record (CCAR) is a standardised tool for conducting a comprehensive assessment of patient functioning ([<reflink idref="bib13" id="ref28">13</reflink>], [<reflink idref="bib12" id="ref29">12</reflink>]). The CCAR allows staff to record basic patient information such as current diagnosis and history of illness; legal, marital, employment and education status; residential stability and service/support needs. Based on their knowledge of the patient, input from other staff and case notes, staff also assess patient impairments and strengths across 25 domains of functioning and two global ratings. Each domain is rated on a 9‐point scale from 1 (high functioning/no special problem) to 9 (low functioning/extreme problem of difficulty). A detailed administration manual defines the CCAR domains and rating anchors, and all raters attended a 1‐day training session and practice using the tool with case examples. Data from both US and Ontario studies support the reliability and validity of the CCAR ([<reflink idref="bib35" id="ref30">35</reflink>]; [<reflink idref="bib11" id="ref31">11</reflink>]; [<reflink idref="bib9" id="ref32">9</reflink>]). As the Ontario CAPs study, the CCAR and level of care template (see Table 1) have been adopted in other Canadian provinces.</p> <hd id="AN0034740821-6">Level of care assessment</hd> <p>For all of the CAPs related studies, a level of care template was developed to provide a systematic approach for matching an individual to a particular level of care, based on need. The template is intended to support needs‐based service planning for various patient groups. It aims to assign the patients to the least restrictive level of care to meet their needs, hence, was intended to support system wide efforts to expand the community care system and discharge long stay individuals who could be served in the community.</p> <p>An individual was assigned to a recommended level of care through use of a standardised algorithm using ratings from six of the 25 CCAR domains: security/management risk, overall problem severity, self care/basic needs, overall lack of resources, danger to self and danger to others. Patients were assigned to one of five recommended levels of care (see Table 1) ranging from self‐management (Level 1) to tertiary level inpatient care (Level 5) based on this algorithm. The template was developed through a combination of literature review and stakeholder input, resulting in good face and content validity. Comparison of patients assigned to different levels of care based on independent measures of need showed that patients with more complex conditions were assigned to a higher recommended level of care, supporting concurrent validity of the algorithm ([<reflink idref="bib11" id="ref33">11</reflink>]). This template is currently being used across hospitals and community mental health services in the province.</p> <hd id="AN0034740821-7">Analyses</hd> <p>Differences between patients with ID receiving specialised and general psychiatric services on demographics, diagnoses and recommended level of care were compared using Chi‐squared tests. Differences between patients in specialised and general programmes on symptom severity and strengths and resources were compared using <emph>t</emph>‐tests. Analyses were performed with spss (version 14, [<reflink idref="bib37" id="ref34">37</reflink>]).</p> <hd id="AN0034740821-8">Results</hd> <p></p> <hd id="AN0034740821-9">Patient characteristics and symptom profile</hd> <p>Inpatients receiving specialised and those receiving general mental health services were compared on the basis of personal characteristics and psychiatric diagnoses. Inpatients in specialised programmes were significantly younger (X̄ = 37.9, SD = 10.44) than their counterparts accessing general inpatient services [X̄ = 49.4, SD = 16.8; <emph>t</emph>(<reflink idref="bib1" id="ref35">1</reflink>, 363) = 6.43, <emph>P </emph>< 0.05] but did not differ in terms of number of days in hospital [<emph>t</emph>(<reflink idref="bib1" id="ref36">1</reflink>, 361) = 1.49, ns], with the average number of days being over 5 years for both groups. As reported in Table 2, individuals from specialised programmes were more likely to be single and less likely to have a history of unstable employment. Inpatients from specialised programmes were less likely to be taking psychotropic medications than those in general programmes, but had similar rates of comorbid medical problems. Inpatients in general services were more likely to have a history of suicide attempts and legal problems than those in specialised programmes. Regarding psychiatric diagnoses (see Table 2), inpatients in general programmes were less likely to be diagnosed with mood disorder and were more likely to be diagnosed with psychotic disorder and substance abuse disorder than those in specialised programmes.</p> <p>2 Comparison of patient characteristics and psychiatric diagnoses for those in general and specialised programmes</p> <p> <ephtml> <table><thead valign="bottom"><tr><th><bold>Category</bold></th><th><bold>Specialised (<italic>n</italic> = 102)</bold> 
 <bold><italic>n</italic> (%)</bold></th><th><bold>General (<italic>n</italic> = 269)</bold> 
 <bold><italic>n</italic> (%)</bold></th><th><bold>χ<sup>2</sup></bold></th><th><bold><italic>P</italic>‐value</bold></th></tr></thead><tbody valign="top"><tr><td>Patient characteristics</td></tr><tr><td> Gender (male)</td><td>60 (59.4%)</td><td>183 (68.3%)</td><td>2.19</td><td>0.112</td></tr><tr><td> Never married</td><td>97 (96.0%)</td><td>220 (82.1%)</td><td>10.67</td><td>0.006</td></tr><tr><td> History of unstable employment</td><td>4 (3.9%)</td><td>78 (29.1%)</td><td>25.57</td><td>0.000</td></tr><tr><td> Psychotropic medication</td><td>80 (83.3%)</td><td>234 (94.4%)</td><td>9.22</td><td>0.002</td></tr><tr><td> Comorbid medical condition</td><td>40 (53.3%)</td><td>150 (65.8%)</td><td>3.23</td><td>0.056</td></tr><tr><td> History of legal problems</td><td>11 (12.2%)</td><td>63 (23.7%)</td><td>4.69</td><td>0.024</td></tr><tr><td> History of fire setting/property destruction</td><td>14 (14.3%)</td><td>49 (18.2%)</td><td>0.76</td><td>0.354</td></tr><tr><td> History of suicide attempt</td><td>4 (4.1%)</td><td>38 (14.1%)</td><td>6.69</td><td>0.005</td></tr><tr><td>Psychiatric diagnoses*</td></tr><tr><td> Mood disorder</td><td>30 (29.4%)</td><td>30 (11.2%)</td><td>16.73</td><td>0.000</td></tr><tr><td> Anxiety disorder</td><td>6 (5.9%)</td><td>8 (3.0%)</td><td>1.00</td><td>0.224</td></tr><tr><td> Substance abuse</td><td>–</td><td>22 (8.2%)</td><td>7.50</td><td>0.006</td></tr><tr><td> Psychotic disorder</td><td>27 (26.5%)</td><td>151 (56.3%)</td><td>25.28</td><td>0.000</td></tr><tr><td> Personality disorder</td><td>17 (16.7%)</td><td>40 (14.9%)</td><td>0.06</td><td>0.747</td></tr><tr><td> Organic disorder</td><td>9 (8.8%)</td><td>36 (14.9%)</td><td>1.07</td><td>0.286</td></tr></tbody></table> </ephtml> </p> <p>1 *  Patients could receive more than one diagnosis.</p> <p>Table 3 reports and compares mean CCAR ratings for inpatients in each group, summarised under three relevant headings: adaptive behaviour and cognition, challenging behaviour and lack of resources. Ratings are generally high in both groups, suggesting a high level of dysfunction. In regard to adaptive behaviour and cognition, individuals in specialised programmes had higher scores on attention problems than those in general programmes (<emph>d = </emph>0.36). In terms of challenging behaviours, the two groups were most different with respect to aggressiveness (<emph>d</emph> = 0.47). Other notable differences were observed with respect to resistiveness (<emph>d = </emph>0.32), security/management risk (<emph>d = </emph>0.29) and violence/danger to others (<emph>d = </emph>0.26). In each case, scores were higher for individuals in specialised programmes. In terms of lack of resources, individuals in general programmes had fewer personal strengths than inpatients in specialised programmes (<emph>d</emph> = 0.30), but overall both groups had very limited resources. The two patient groups did not differ on global ratings of problem severity or lack of resources.</p> <p>3 Comparison of mean problem severity and resources of inpatients in general and specialised programmes</p> <p> <ephtml> <table><thead valign="bottom"><tr><th><bold>CCAR domain</bold></th><th><bold>Specialised</bold></th><th><bold>General</bold></th><th><bold><italic>t</italic>‐score</bold></th><th><bold>d.f.</bold></th><th><bold><italic>P</italic></bold></th><th><bold>Cohen's <italic>d</italic></bold></th></tr><tr><th><bold>Mean</bold></th><th><bold>SD</bold></th><th><bold>Mean</bold></th><th><bold>SD</bold></th></tr></thead><tbody valign="top"><tr><td>Adaptive behaviour and cognition</td></tr><tr><td> Attention problems</td><td>6.00</td><td>1.51</td><td>5.37</td><td>1.87</td><td>−3.05</td><td>366</td><td>0.002</td><td>0.36</td></tr><tr><td> Cognitive problems</td><td>5.63</td><td>1.89</td><td>5.62</td><td>1.91</td><td>−0.03</td><td>323</td><td>0.979</td><td>0.01</td></tr><tr><td> Role performance</td><td>7.47</td><td>1.95</td><td>6.86</td><td>2.93</td><td>−1.91</td><td>364</td><td>0.057</td><td>0.23</td></tr><tr><td> Self care/basic needs</td><td>7.11</td><td>1.83</td><td>6.66</td><td>2.12</td><td>−1.87</td><td>365</td><td>0.063</td><td>0.22</td></tr><tr><td>Challenging behaviour</td></tr><tr><td> Aggressiveness</td><td>5.83</td><td>2.04</td><td>4.79</td><td>2.31</td><td>−3.99</td><td>365</td><td>0.000</td><td>0.47</td></tr><tr><td> Antisocial behaviour</td><td>4.34</td><td>2.67</td><td>3.88</td><td>2.40</td><td>−1.55</td><td>362</td><td>0.122</td><td>0.19</td></tr><tr><td> Legal issues</td><td>2.25</td><td>2.31</td><td>2.29</td><td>2.45</td><td>0.15</td><td>365</td><td>0.882</td><td>0.02</td></tr><tr><td> Resistiveness</td><td>5.49</td><td>1.81</td><td>4.87</td><td>1.99</td><td>−2.74</td><td>367</td><td>0.007</td><td>0.32</td></tr><tr><td> Security/management risk</td><td>5.88</td><td>1.65</td><td>5.37</td><td>1.84</td><td>−2.44</td><td>368</td><td>0.015</td><td>0.29</td></tr><tr><td> Suicide/danger to self</td><td>3.26</td><td>2.49</td><td>3.23</td><td>2.38</td><td>−0.10</td><td>362</td><td>0.919</td><td>0.01</td></tr><tr><td> Violence/danger to others</td><td>4.90</td><td>2.40</td><td>4.28</td><td>2.41</td><td>−2.21</td><td>364</td><td>0.027</td><td>0.26</td></tr><tr><td>Lack of resources</td></tr><tr><td> Educational and social</td><td>8.24</td><td>1.29</td><td>8.47</td><td>1.18</td><td>1.44</td><td>284</td><td>0.152</td><td>0.19</td></tr><tr><td> Economic</td><td>7.88</td><td>1.43</td><td>7.88</td><td>1.68</td><td>0.00</td><td>285</td><td>1.00</td><td>0</td></tr><tr><td> Personal (social support)</td><td>7.04</td><td>2.04</td><td>7.39</td><td>1.99</td><td>1.29</td><td>285</td><td>0.198</td><td>0.18</td></tr><tr><td> Personal strengths</td><td>7.40</td><td>1.53</td><td>7.81</td><td>1.29</td><td>2.25</td><td>283</td><td>0.025</td><td>0.30</td></tr><tr><td>Global rating of problem severity</td><td>6.35</td><td>1.20</td><td>6.40</td><td>1.33</td><td>0.33</td><td>368</td><td>0.740</td><td>0.04</td></tr><tr><td>Global rating of lack of resources</td><td>7.43</td><td>1.54</td><td>7.68</td><td>1.29</td><td>1.62</td><td>365</td><td>0.106</td><td>0.18</td></tr></tbody></table> </ephtml> </p> <p>2 Ratings on a 1‐9 point Likert scale where 1 = high functioning/no special problem and 9 = low functioning/extreme problem of difficulty.</p> <hd id="AN0034740821-10">Patient need: recommended level of care</hd> <p>Despite significant differences in function on some domains, as can be observed from Table 4, overall, the inpatients in the two types of programmes did not differ significantly in terms of recommended level of care. However, few inpatients from either type of programme were assessed as requiring the intensive inpatient support they were receiving (Level 5).</p> <p>4 Recommended level of care for patients in general and specialised programmes</p> <p> <ephtml> <table><thead valign="bottom"><tr><th /><th><bold>Specialised (<italic>n</italic> = 102)</bold></th><th><bold>General (<italic>n</italic> = 269)</bold></th></tr></thead><tbody valign="top"><tr><td>Level 1</td><td>–</td><td>1 (0.4%)</td></tr><tr><td>Level 2</td><td>7 (6.9%)</td><td>14 (5.3%)</td></tr><tr><td>Level 3</td><td>20 (19.8%)</td><td>91 (34.2%)</td></tr><tr><td>Level 4</td><td>64 (63.4%)</td><td>128 (48.1%)</td></tr><tr><td>Level 5</td><td>10 (9.9%)</td><td>32 (12.0%)</td></tr></tbody></table> </ephtml> </p> <p>3 χ<sups>2</sups> = 9.30, not significant.</p> <p>Within both groups, many were recommended for Level 4 care, that is, highly staffed residential settings in the community. Level 4 care assumes a need for close supervision but not the diagnostic and management expertise role of tertiary care.</p> <p>There was a pattern of more inpatients in specialised psychiatric programmes being recommended for Level 4 care compared with those in general programmes (63.4% vs. 48.1%). A substantial number were also recommended for Level 3 care (i.e. independent living situation with intensive home support delivered as needed), although notably fewer specialised than general programme inpatients (19.8% vs. 34.2%). A small portion of patients from both groups were recommended for Levels 1 or 2 care (6.9% vs. 5.7%) and Level 5 care (9.9% vs. 12%). Thus, the recommended level of care was high for all inpatients in the study, although slightly higher for inpatients in the specialised programmes.</p> <hd id="AN0034740821-11">Discussion</hd> <p>The present study was conducted to contrast the patient characteristics and clinical needs of inpatients with ID receiving specialised services to those receiving general services within the tertiary care psychiatric hospital system in Ontario. The study results indicate that individuals receiving specialised services were more likely to be diagnosed with a mood disorder and less likely to be diagnosed with substance abuse or psychotic disorder. Individuals in the two groups had slightly different symptom presentations with higher ratings in challenging behaviour in those receiving specialised services. However, the two groups did not differ in their overall recommended level of care or in their number of days in hospital at time of survey. Thus individuals in both types of programmes have complex needs that warrant special attention.</p> <p>This study has several limitations, which should be taken into consideration when interpreting its findings. First, data reported here are based on secondary analyses of data developed for another purpose. Information regarding level of ID was not available and issues such as accuracy of ID and psychiatric diagnosis cannot be addressed using this database, but should be given consideration in further research (see [<reflink idref="bib20" id="ref37">20</reflink>]). Second, the level of care algorithm adopted here has demonstrated concurrent validity, yet is still relatively new and would benefit from further testing, especially in psychiatric populations with complex comorbidities such as ID. Third, findings are based on the subgroup of individuals with ID and mental health needs being served by Ontario's tertiary level care psychiatric hospitals. This study does not address the needs of those who access services outside of the tertiary care system or who are not receiving any services. Findings may not apply to individuals in other areas where different service models and policies exist. Thus, more research from other countries is required.</p> <p>[<reflink idref="bib14" id="ref38">14</reflink>] argue that a combination of specialised and general services is necessary because specialised services do not have the capacity to serve everyone. Decisions regarding who should access the most specialised services should be informed by research. There was some evidence in this study that certain patients were triaged to specialised services. Patients in specialised programmes tended to be younger and have a more stable employment/day programme history. They were less likely to have a history of suicide attempts and more likely to have always been single and to be diagnosed as depressed. However, they displayed more challenging behaviour (e.g. aggression, security risk, resistiveness, violence) than other patients. This patient profile is consistent with a qualitative follow‐up study conducted across the province to review and interpret the CAPS data that are presented here ([<reflink idref="bib21" id="ref39">21</reflink>]). Community staff participating in regional focus groups reported that the typical patient referred for specialised services tended to be receiving residential services from agencies that support people with IDs, but displaying levels of aggression that could not be safely managed without specialist attention. In contrast, patients referred to general inpatient programmes were less likely to be connected to residential services for individuals with IDs prior to hospital admission and were more likely to have had instability (e.g. more unemployment, substance use and suicidal behaviour) that could not be managed in the community, hence, were admitted to hospital.</p> <p>Similarly, focus group input from inpatient hospital staff suggested that patient behaviour influences decisions to admit patients to one type of programme vs. another ([<reflink idref="bib21" id="ref40">21</reflink>]): staff from general programmes talked about feeling more competent to serve higher functioning individuals and reserving referral to more specialised programmes for more vulnerable and difficult individuals who would not be able to participate in some general treatments offered (e.g. group therapy situations) because of limited communication ability or inappropriate behaviour. Staff also reported that some of the clients who could benefit from general programmes preferred such programmes, because they do not see themselves as having an ID and would feel demoralised or doubly stigmatised in a specialised programme. For such clients, staff requested access to specialist consultation as needed rather than specialised beds. In the current study, inpatients receiving general services were more likely to be diagnosed with a substance abuse disorder and to have a history of suicide attempts than those in specialised programmes, suggesting that there are numerous issues among individuals within general services that may warrant specialist input.</p> <p>Significantly more individuals with concurrent substance abuse problems were served in general than specialised inpatient programmes. Rates of substance abuse diagnoses in the general units reported here are similar to rates in other studies of inpatients in general psychiatry services ([<reflink idref="bib1" id="ref41">1</reflink>]; [<reflink idref="bib34" id="ref42">34</reflink>]). Unfortunately, substance abuse diagnoses are rarely mentioned in studies describing specialised inpatient unit samples (e.g. [<reflink idref="bib32" id="ref43">32</reflink>]; [<reflink idref="bib2" id="ref44">2</reflink>]; [<reflink idref="bib41" id="ref45">41</reflink>]). One wonders whether this is because specialised programmes are not geared towards these individuals or because individuals with ID who abuse substances access mental healthcare through a different pathway. Clearly there is a subgroup of individuals with ID accessing mental health services for which comorbid substance abuse problems is a significant issue. Although level of ID was not available for the inpatients in this study, it is likely that the majority of the subgroup with substance abuse problems were functioning within the mild range and had more independence, less supervision and thus, greater access to substances. More research is needed on these individuals (see also [<reflink idref="bib4" id="ref46">4</reflink>]; [<reflink idref="bib25" id="ref47">25</reflink>]).</p> <p>Patients in specialised and general programmes differed in terms of their psychiatric diagnostic profile. In the larger study of hospital patients comparing those with and without ID ([<reflink idref="bib23" id="ref48">23</reflink>]), the overall rate of psychotic disorder diagnoses was similar in both groups (50%), while the rate of mood disorder was significantly higher in the non‐ID group (Non‐ID : ID (%) = 37:20). In this study, diagnoses of psychotic disorders were more common in ID patients in the general services (Specialised : General (%) = 27:56) and diagnoses of mood disorders were more common among ID patients in specialist services (Specialised : General (%) = 29:11). While one cannot disentangle differences in diagnostic profiles from differences in diagnostic practices with the current dataset, independent evidence that non‐specialist clinicians overdiagnose psychotic disorders in persons with ID is emerging ([<reflink idref="bib30" id="ref49">30</reflink>]; [<reflink idref="bib5" id="ref50">5</reflink>]; [<reflink idref="bib16" id="ref51">16</reflink>]). The same symptoms may result in different diagnoses depending on the expertise of clinicians, with specialist clinicians, experienced in ID and mental health, making fewer diagnoses of psychotic disorder (see [<reflink idref="bib20" id="ref52">20</reflink>] for further discussion) than other clinicians. Further research is required where individuals in both types of programmes are assessed using assessment and diagnostic approaches standardised on the population with ID and administered by clinicians trained in these approaches and blind to the programme type.</p> <p>Using the CAP methodology provided an opportunity to assess the appropriateness of inpatient tertiary care for both groups. The bulk of patients in both programme types were assessed as requiring Levels 3 and 4 care, but only 10% were rated as requiring the inpatient care they were receiving (Level 5) despite the mean number of days in hospital being greater than 5 years. Problems discharging long‐term patients is an acknowledged problem in the Ontario system ([<reflink idref="bib18" id="ref53">18</reflink>]) and is serious, as it means that specialised units cannot admit the complex patients they were designed to serve (see also [<reflink idref="bib28" id="ref54">28</reflink>]; [<reflink idref="bib40" id="ref55">40</reflink>]; [<reflink idref="bib26" id="ref56">26</reflink>]).</p> <p>Discharge problems are due in part to a lack of appropriate community residential placements. The Ontario government has recently prioritised specialised community‐based accommodation for individuals, such as these currently in hospital but ready for discharge ([<reflink idref="bib27" id="ref57">27</reflink>]). A follow‐up project at the hospitals since this initiative could assess whether the changes have resulted in shorter lengths of stay overall, and more admitted individuals receiving Level 5 recommended level of care ratings. A second barrier to discharge is a shortage of community based nurses and physicians trained to work with this population ([<reflink idref="bib19" id="ref58">19</reflink>]; [<reflink idref="bib24" id="ref59">24</reflink>]; [<reflink idref="bib21" id="ref60">21</reflink>]; [<reflink idref="bib38" id="ref61">38</reflink>]). Currently, the challenge of discharging inpatients to appropriate community programmes is a challenge for both general and specialised inpatient services and is likely to remain so in the absence of adequate clinical expertise in community settings.</p> <p>Future research should examine the pathway to specialised services prospectively with a cohort of individuals with ID and mental health issues to determine clinical predictors (e.g. severity of symptoms) and systemic predictors (e.g. already receiving services for people with ID) of specialised care. Future studies evaluating such specialist services could further disentangle the components of what constitutes 'specialist' as opposed to 'segregated' services. This could be achieved by careful examination of the supports, expertise, vision, value base, etc. within such services and from this, identify what structures are needed to integrate these 'specialist' components into mainstream services (e.g. Green Light Toolkit, [<reflink idref="bib10" id="ref62">10</reflink>]). Such examination will ultimately empower persons with ID in their desire and their legitimate human rights for full inclusion into mainstream mental health services.</p> <hd id="AN0034740821-12">Acknowledgements</hd> <p>This research was supported by an Ontario Mental Health Foundation New Investigator Award. 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Koegl</p> <p>Reported by Author; Author; Author; Author</p> </aug> <nolink nlid="nl1" bibid="bib17" firstref="ref2"></nolink> <nolink nlid="nl2" bibid="bib41" firstref="ref3"></nolink> <nolink nlid="nl3" bibid="bib33" firstref="ref5"></nolink> <nolink nlid="nl4" bibid="bib29" firstref="ref8"></nolink> <nolink nlid="nl5" bibid="bib34" firstref="ref11"></nolink> <nolink nlid="nl6" bibid="bib32" firstref="ref13"></nolink> <nolink nlid="nl7" bibid="bib42" firstref="ref14"></nolink> <nolink nlid="nl8" bibid="bib39" firstref="ref15"></nolink> <nolink nlid="nl9" bibid="bib14" firstref="ref16"></nolink> <nolink nlid="nl10" bibid="bib15" firstref="ref19"></nolink> <nolink nlid="nl11" bibid="bib36" firstref="ref20"></nolink> <nolink nlid="nl12" bibid="bib31" firstref="ref21"></nolink> <nolink nlid="nl13" bibid="bib23" firstref="ref22"></nolink> <nolink nlid="nl14" bibid="bib11" firstref="ref24"></nolink> <nolink nlid="nl15" bibid="bib22" firstref="ref25"></nolink> <nolink nlid="nl16" bibid="bib13" firstref="ref28"></nolink> <nolink nlid="nl17" bibid="bib12" firstref="ref29"></nolink> <nolink nlid="nl18" bibid="bib35" firstref="ref30"></nolink> <nolink nlid="nl19" bibid="bib37" firstref="ref34"></nolink> <nolink nlid="nl20" bibid="bib20" firstref="ref37"></nolink> <nolink nlid="nl21" bibid="bib21" firstref="ref39"></nolink> <nolink nlid="nl22" bibid="bib25" firstref="ref47"></nolink> <nolink nlid="nl23" bibid="bib30" firstref="ref49"></nolink> <nolink nlid="nl24" bibid="bib16" firstref="ref51"></nolink> <nolink nlid="nl25" bibid="bib18" firstref="ref53"></nolink> <nolink nlid="nl26" bibid="bib28" firstref="ref54"></nolink> <nolink nlid="nl27" bibid="bib40" firstref="ref55"></nolink> <nolink nlid="nl28" bibid="bib26" firstref="ref56"></nolink> <nolink nlid="nl29" bibid="bib27" firstref="ref57"></nolink> <nolink nlid="nl30" bibid="bib19" firstref="ref58"></nolink> <nolink nlid="nl31" bibid="bib24" firstref="ref59"></nolink> <nolink nlid="nl32" bibid="bib38" firstref="ref61"></nolink> <nolink nlid="nl33" bibid="bib10" firstref="ref62"></nolink>
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  Label: Title
  Group: Ti
  Data: A Comparison of Patients with Intellectual Disability Receiving Specialised and General Services in Ontario's Psychiatric Hospitals
– Name: Language
  Label: Language
  Group: Lang
  Data: English
– Name: Author
  Label: Authors
  Group: Au
  Data: <searchLink fieldCode="AR" term="%22Lunsky%2C+Y%2E%22">Lunsky, Y.</searchLink><br /><searchLink fieldCode="AR" term="%22Bradley%2C+E%2E%22">Bradley, E.</searchLink><br /><searchLink fieldCode="AR" term="%22Durbin%2C+J%2E%22">Durbin, J.</searchLink><br /><searchLink fieldCode="AR" term="%22Koegl%2C+C%2E%22">Koegl, C.</searchLink>
– Name: TitleSource
  Label: Source
  Group: Src
  Data: <searchLink fieldCode="SO" term="%22Journal+of+Intellectual+Disability+Research%22"><i>Journal of Intellectual Disability Research</i></searchLink>. Nov 2008 52(11):1003-1012.
– Name: Avail
  Label: Availability
  Group: Avail
  Data: Blackwell Publishing. 350 Main Street, Malden, MA 02148. Tel: 800-835-6770; Tel: 781-388-8599; Fax: 781-388-8232; e-mail: customerservices@blackwellpublishing.com; Web site: http://www.blackwellpublishing.com/jnl_default.asp
– Name: PeerReviewed
  Label: Peer Reviewed
  Group: SrcInfo
  Data: Y
– Name: Pages
  Label: Page Count
  Group: Src
  Data: 10
– Name: DatePubCY
  Label: Publication Date
  Group: Date
  Data: 2008
– Name: TypeDocument
  Label: Document Type
  Group: TypDoc
  Data: Journal Articles<br />Reports - Evaluative
– Name: Subject
  Label: Descriptors
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22Health+Services%22">Health Services</searchLink><br /><searchLink fieldCode="DE" term="%22Substance+Abuse%22">Substance Abuse</searchLink><br /><searchLink fieldCode="DE" term="%22Mental+Retardation%22">Mental Retardation</searchLink><br /><searchLink fieldCode="DE" term="%22Psychiatric+Hospitals%22">Psychiatric Hospitals</searchLink><br /><searchLink fieldCode="DE" term="%22Mental+Disorders%22">Mental Disorders</searchLink><br /><searchLink fieldCode="DE" term="%22Mental+Health+Programs%22">Mental Health Programs</searchLink><br /><searchLink fieldCode="DE" term="%22Patients%22">Patients</searchLink><br /><searchLink fieldCode="DE" term="%22Foreign+Countries%22">Foreign Countries</searchLink><br /><searchLink fieldCode="DE" term="%22Clinics%22">Clinics</searchLink><br /><searchLink fieldCode="DE" term="%22Comparative+Analysis%22">Comparative Analysis</searchLink><br /><searchLink fieldCode="DE" term="%22Symptoms+%28Individual+Disorders%29%22">Symptoms (Individual Disorders)</searchLink><br /><searchLink fieldCode="DE" term="%22Profiles%22">Profiles</searchLink><br /><searchLink fieldCode="DE" term="%22Intervention%22">Intervention</searchLink><br /><searchLink fieldCode="DE" term="%22Behavior+Problems%22">Behavior Problems</searchLink><br /><searchLink fieldCode="DE" term="%22Specialists%22">Specialists</searchLink>
– Name: Subject
  Label: Geographic Terms
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22Canada%22">Canada</searchLink>
– Name: DOI
  Label: DOI
  Group: ID
  Data: 10.1111/j.1365-2788.2008.01049.x
– Name: ISSN
  Label: ISSN
  Group: ISSN
  Data: 0964-2633
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: Background: Over the years, the closure of institutions has meant that individuals with intellectual disabilities (IDs) must access mainstream (i.e. general) mental health services. However, concern that general services may not adequately meet the needs of patients with ID and mental illness has led to the development and implementation of more specialised programmes. This study compares patients with ID receiving specialised services to patients with ID receiving general services in Ontario's tertiary mental healthcare system in terms of demographics, symptom profile, strengths and resources and clinical service needs. Method: A secondary analysis of Colorado Client Assessment Record data collected from all tertiary psychiatric hospitals in the province was completed for all 371 inpatients with ID, from both specialised and general programmes. Results: Inpatients in specialised programmes were more likely to have a diagnosis of mood disorder and were less likely to have a substance abuse or psychotic disorder. Individuals receiving specialised services had higher ratings of challenging behaviour than those in more general programmes. The two groups did not differ significantly in terms of recommended level of care, although more inpatients from specialised programmes were rated as requiring Level 4 care than inpatients from general programmes. Conclusions: In Ontario, inpatients in specialised and general programmes have similar overall levels of need but unique clinical profiles that should be taken into consideration when designing interventions for them.
– Name: AbstractInfo
  Label: Abstractor
  Group: Ab
  Data: As Provided
– Name: Ref
  Label: Number of References
  Group: RefInfo
  Data: 41
– Name: DateEntry
  Label: Entry Date
  Group: Date
  Data: 2008
– Name: AN
  Label: Accession Number
  Group: ID
  Data: EJ814211
PLink https://search.ebscohost.com/login.aspx?direct=true&site=eds-live&db=eric&AN=EJ814211
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      – Type: doi
        Value: 10.1111/j.1365-2788.2008.01049.x
    Languages:
      – Text: English
    PhysicalDescription:
      Pagination:
        PageCount: 10
        StartPage: 1003
    Subjects:
      – SubjectFull: Health Services
        Type: general
      – SubjectFull: Substance Abuse
        Type: general
      – SubjectFull: Mental Retardation
        Type: general
      – SubjectFull: Psychiatric Hospitals
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      – SubjectFull: Mental Disorders
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      – SubjectFull: Profiles
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      – SubjectFull: Intervention
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      – SubjectFull: Behavior Problems
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      – SubjectFull: Specialists
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      – SubjectFull: Canada
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    Titles:
      – TitleFull: A Comparison of Patients with Intellectual Disability Receiving Specialised and General Services in Ontario's Psychiatric Hospitals
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              Value: 0964-2633
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            – TitleFull: Journal of Intellectual Disability Research
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