National Institute of Health, National Mental Health Programme, Rome, Italy
Department of Biostatistics, University of Trento, Italy
Department of Psychiatry, University of Aukland, New Zealand
Programme on Mental Health and Substance Abuse, Azienda ASL di Rimini, Italy
National Institute of Health, National Mental Health Programme, Rome, Italy
for the PROGRES Group
Correspondence: Dr G. de Girolamo, Department of Mental Health, Viale Pepoli 5, 40123 Bologna, Italy. Tel: +39 51 6584377; fax: +39 51 6584178, e-mail: gdg{at}iss.it
Declaration of interest Funding was received from the National Institute of Health.
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ABSTRACT |
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Aims The Progetto Residenze (PROGRES) residential care project is a three-phase study, the first phase of which aims to survey the main characteristics of all Italian NHRFs.
Method Structured interviews were conducted with the manager of each NHRF.
Results On 31 May 2000 there were 1370 NHRFs with 17 138 beds; an average of 12.5 beds each and a rate of 2.98 beds per 10 000 inhabitants. Residential provision varied ten-fold between regions and discharge rates were very low. Most had 24-hour staffing with 1.42 patients per full-time worker.
Conclusions There is marked variability in the provision of residential places between different regions; discharge rates are generally low.
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INTRODUCTION |
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METHOD |
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Data collection
Each region appointed a coordinator, who organised and supervised data
collection. Information about the number and location of all public and
private NHRFs was obtained from the 21 regional ministries of health and then
from each of the 224 departments of mental health throughout the country. The
manager of each NHRF completed a structured interview, drawn in part from the
Royal College of Psychiatrists' Mental Health Residential Care Study
(Lelliott et al,
1996). The information was checked by the regional coordinators,
who conducted further interviews when necessary.
Statistical analysis
Analysis focused on descriptive statistics. In addition, multiple logistic
regression was used to identify variables associated with the probability of
discharge (Breslow & Day,
1980). The dependent variable was the presence or absence of
discharges from each NHRF during 1999; facilities opened from 1999 onwards
were excluded.
Poisson regression was used to analyse the relationship between the rate of residential beds in each region (number per 10 000 inhabitants), the availability of other types of services, and two basic socio-economic indicators: number of unemployed per region, in millions of people, and overall regional income, in millions of euros (Breslow & Day, 1987; Zheng & Agresti, 2000). Figures used for this analysis were based on 1998 government statistics (de Girolamo & Cozza, 2000), while the number of beds in private in-patient facilities was obtained from the national Ministry of Health; the socio-economic data are the official data for the corresponding year. The very small Valle d'Aosta region was combined with the neighbouring Piedmont region. All analyses were performed using SPSS, version 9.0 for Windows.
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RESULTS |
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Overall, there were 2.98 residential beds for every 10 000 inhabitants, with a large variability between regions; the variation between the region with the highest rate of NHRFs, Abruzzo (6.93 per 10 000), and the region with the lowest rate, Campania (1.55 per 10 000), was more than four-fold. Nineteen regions out of 21 had more than two residential beds per 10 000, which is the standard recommended by the National Mental Health Plan (Progetto Obiettivo, 1999). The average size of facilities also varied widely between regions, with 127 NHRFs (9.2%) hosting more than 20 residents, the maximum recommended by the National Mental Health Plan. The occupancy rate was high (93%), with little regional variation.
Table 1 summarises the main characteristics and staffing of the NHRFs. A high level of supervision was reported, with most facilities (73.4%) having staff on-site 24 hours a day. Around half of these establishments had opened since January 1997. Most (84.5%) catered exclusively for long-term patients, while 15.5% were also used occasionally for patients with acute illness episodes. Two-thirds were located in urban areas, and a quarter were rural; only 7.1% occupied the grounds of former mental hospitals. The relative majority (44.8%) were located in an independent building and 29.7% were in apartments. Most (77.7%) received funding directly from the Italian National Health Service, and the local departments of mental health provided direct management for more than half (51.8%).
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Staffing
The 1370 NHRFs employed 18 666 professionals, of whom 60% (n=11
240) worked full-time (Table
1). The distribution of professional resources was variable. For
example, 285 NHRFs (21%) had no nurses, and almost half had no full-time
nurses. Most (57.8%) were directed by psychiatrists, while 22% had a
coordinator who did not have mental health qualifications. Around 40% of staff
had no specific professional qualification for working with patients with
severe psychiatric conditions. The mean number of staff per NHRF was 13.7
(range 6.9-21.0); the mean number of full-time staff was 8.2 (range 0.6-15.0).
The overall ratio of patients to full-time staff was 1.42:1 (range
0.82-22.3).
Patients
At the census there were 15 943 residents in the 1370 NHRFs, a mean of 11.6
per facility (Table 2). In 18%
of the NHRFs there were only patients discharged from former mental hospitals,
while the largest group of NHRFs (43%) housed only patients who had never been
admitted to a mental hospital. The majority of NHRF residents (58.5%) had
never before been admitted to a mental hospital or a forensic mental hospital,
almost 40% had been admitted at least once to a mental hospital and 1.6% had
been detained in a forensic mental hospital. Most residents (82.7%) had no
current problems of alcohol or substance misuse. Mental
retardation was the primary problem of around 10% of residents; half of
these had come from mental hospitals.
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Turnover of residents
Turnover of residents was low. During 1999, more than a third of NHRFs
(37.7%) had not discharged any patients and 31.5% had discharged only one or
two (Table 2). Consequently,
few new admissions were possible: 24.4% had not admitted any new residents in
1999, and 26.3% had admitted only one or two patients. The results of the
multiple logistic regression analysis for 1091 NHRFs are shown in
Table 3. Of the variables
included in this analysis, intensity of care and type of management were not
significantly associated with low turnover. The variables significantly
associated with lack of discharges were the most numerous age group and the
number of residents, which also showed a significant interaction.
Non-discharge was inversely related to the number of residents and directly
related to the mean age of residents. A first-order interaction between these
variables revealed that in NHRFs in which most patients were from the oldest
age group (>60 years), the probability of non-discharge was higher than in
the other two age groups and was not significantly associated with the number
of residents. However, in NHRFs with patients mainly from the other two age
groups (<40 years and 40-59 years), non-discharge was related to having
more patients.
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The odds for non-discharge in NHRFs hosting only former mental hospital patients was double that of the other NHRFs (95% CI 1.56-3.35) while NHRFs without full-time staff had 1.6 times the risk of non-discharge (95% CI 1.16-2.30) compared with the other NHRFs.
NHRFs and other mental health facilities
Table 4 shows the
relationship between availability of residential places and provision of other
mental health services in each region controlling for two basic socio-economic
indicators (number of unemployed and overall regional income). A high rate of
residential beds was associated with a higher rate of private in-patient beds,
day hospitals and general hospital wards, and fewer community mental health
centres and day centres, but the effect of former mental hospitals was not
significant. More residential beds were found in regions with a lower number
of unemployed people, but the effect of regional income was not significant
(at the 5% level). The impact of these variables on bed numbers has been
quantified using relative risk (RR). For example, with an increase of 1000
private in-patient beds, the rate of residential beds increases by a factor of
1.7 (and similar considerations apply for other variables with RR >1); with
an increase of 100 in the number of community mental health centres, the rate
of residential beds shows a decrease of 2.6 times (1/0.385, which is the RR
for this variable; similar considerations apply for other variables with a RR
<1). The regression equation predicted between-region variation in number
of residential beds both in absolute and relative terms; the linear
correlation coefficient between predicted and actual residential beds was
0.93, while the correlation between predicted and current occupancy rate per
10 000 inhabitants was 0.80.
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DISCUSSION |
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The NHRFs in Italy constitute a heterogeneous system which has developed in response to two basic needs: to provide alternative accommodation to mental hospitals; and to set up a network of rehabilitative facilities for younger patients with chronic disorders, drawn from the community. This system is mainly public, but with substantial subcontracting to forprofit and non-profit private agencies. It has been organised locally in response to local needs with little definition of standards of care. Our study has provided evidence of this heterogeneity, underlying the need for better classification of these facilities and establishment of national and international standards of care and staffing to be matched with patients' needs.
The current provision of non-hospital residential beds is substantially higher than the 2 per 10 000 rate recommended by the Italian National Mental Health Plan (Progetto Obiettivo, 1999). However, there was a high degree of variability between regions. It seems unlikely that regional differences in prevalence of mental disorders can account for this variability. Indeed, data from five psychiatric case registers in dissimilar areas of the country did not show any notable difference in the prevalence of severe mental disorders (Balestrieri et al, 1992). There were more residential beds in regions with smaller numbers of unemployed people, and there was no correlation with regional income. Moreover, the two regions with the smallest provision of residential beds (Tuscany and Campania), respectively located in the centre and in the south, are among the richest and the poorest respectively of all 21 regions; while the two regions with the highest provision of residential beds (e.g. Abruzzo and Molise), both in central Italy, are not wealthy. Therefore, it is difficult to establish any correlation at a regional level between provision of residential beds and socio-economic indicators.
It may be concluded that, at least in part, variations in the provision of residential beds reflect regional differences in health planning (Tognoni & Saraceno, 1989; Fioritti et al, 1997; de Girolamo & Cozza, 2000). The inverse relationships between residential beds and community-based facilities suggests that some regions made provisions for community care, while others merely transferred patients from hospitals to long-term residences, including private acute in-patient facilities. These differences seem consistent with a broader political trend allowing for a large degree of regional autonomy in the planning and implementation of mental health services, known as health devolution.
In any event, the rate of residential beds in Italy is substantially lower than that found in the Mental Health Residential Care Study in eight districts surrounding London (9.46 beds per 10 000) (Lelliott et al, 1996). However, in another UK survey of 35 districts, the rate was 4.29, closer to the 2.98 Italian rate (Faulkner et al, 1993).
It seems difficult to establish precise standards for the provision of residential beds, since housing needs assessments crucially depend on the range and quality of other local services and cannot be separated from the functioning and dynamics of the total service "system" (Shepherd & Murray, 2001).
Rehabilitation centres or homes for life?
Our results suggest that many NHRFs merely provide long-term accommodation.
Lack of mobility was inversely related to the exclusive presence of former
mental hospital patients and to the number of residents, while it was directly
related to the age of residents. Only in NHRFs providing for older patients
was low turnover unrelated to the number of patients. Since the absence of
full-time staff (which suggests low intensity of care) was also related to a
low turnover, it seems that NHRFs hosting more patients, predominantly
elderly, and having no full-time staff to provide intensive rehabilitation,
have few discharges.
Similar low turnover rates have been observed in the USA (Geller & Fisher, 1993) and in British studies of patients discharged from mental hospitals (Trieman et al, 1998). In the Team for the Assessment of Psychiatric Services (TAPS) study, 61% of the patients discharged to community placements (mostly group homes) remained in the same accommodation over the 5-year follow-up (Trieman et al, 1998). Despite a tendency for long-term stay in large NHRFs, it should be stressed that several studies have shown that living in small, domestic environments is associated with better quality of life and higher satisfaction reported by patients, compared with traditional mental health wards (Lehman et al, 1986; Barry & Crosby, 1996).
Staffing: quantity and quality
Three-quarters of the NHRFs provided 24-hour care, representing a real
alternative to long-stay hospital wards. The ratio of patients to full-time
staff of 1.42:1 gave further support to the intensive care notion of
residential services in Italy. However, about 40% of staff had no specific
professional qualification for working with people with severe psychiatric
illness. Similar lack of trained staff caring for patients in NHRFs has been
observed in the USA and the UK (Randolph
et al, 1991; Senn
et al, 1997). Efforts should be made to train mental
health workers to treat residential patients.
In-patient psychiatric care today in Italy
In May 2000 there were 27 649 psychiatric beds in Italy (including hospital
and residential places). Since 1978, when Law 180 was enacted, there has been
a 65% reduction in the provision of residential beds of all kinds. This change
in service provision seems to have occurred without increases in suicide rates
(Williams et al,
1986; De Leo et al,
1997) or in the number of patients admitted to psychiatric
forensic facilities (Fioritti et
al, 2001). Although there is no detailed information, numbers
of homeless people with mental illness do not appear to have increased in
urban areas (de Girolamo & Cozza,
2000). It is also unlikely that community-based services have
reduced the prevalence of serious mental disorders, as implementation of
evidence-based treatment strategies has been delayed as in other countries
(Falloon et al, 1999).
Support for families has been provided unevenly, even though a large
proportion of people with mental illness in Italy live with their families
(Warner et al, 1998;
Magliano et al,
2000).
Regions with better provision of outpatient and day care services had lower rates of residential beds. This suggests that providing more community services might reduce the need for residential care. However, it is also possible that the availability of more residential beds decreases the need for community-oriented services, or that a third factor has an influence on overall service provision. In any case, at a regional level, service planning has focused on developing either a caring supportive approach based on long-term residential care, or a more community-based rehabilitative treatment approach.
Limitations of the study
This study has some limitations. First, the large number of researchers
collecting data might have created inconsistencies. Second, the
cross-sectional design of the study does not allow causal inferences, for
instance regarding the relationship between provision of NHRFs and of other
types of psychiatric services.
Despite such limitations, PROGRES is the first systematic attempt in Italy to fill the gap between psychiatric services planning and evaluation, by setting up a network of investigators throughout the country and evaluating an entire typology of services in a consistent fashion.
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Clinical Implications and Limitations |
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LIMITATIONS
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APPENDIX |
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ACKNOWLEDGMENTS |
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Received for publication June 5, 2001. Revision received April 10, 2002. Accepted for publication April 16, 2002.
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