- Email: [email protected]
Clinical outcomes and length of stay of a co-located psychogeriatric and geriatric unit
Archives of Gerontology and Geriatrics 49 (2009) 233–236
Contents lists available at ScienceDirect
Archives of Gerontology and Geriatrics journal homepage: www.elsevier.com/locate/archger
Clinical outcomes and length of stay of a co-located psychogeriatric and geriatric unit Amanda Chiu a, Huong V. Nguyen a,*, Sharon Reutens b, David Grace b, Robert Schmidtman b, Qing Shen a,c, Jack Chen d, Daniel K.Y. Chan a,c a
Department of Age Care and Rehabilitation, Bankstown-Lidcombe Hospital, Locked Bag 1600, Bankstown, NSW 2200, Australia Department of Old Age Psychiatry, Bankstown-Lidcombe Hospital, Locked Bag 1600, Bankstown, NSW 2200, Australia Faculty of Medicine, University of New South Wales, NSW, Australia d Simpson Centre for Health Services Research, University of New South Wales, Locked Bag 7103, Liverpool BC 1871, NSW, Australia b c
A R T I C L E I N F O
A B S T R A C T
Article history: Received 13 May 2008 Received in revised form 15 August 2008 Accepted 27 August 2008 Available online 30 October 2008
To examine the effect of co-location of psychogeriatric and geriatric services on length of stay and changes in patients’ psychosocial characteristics. A retrospective analysis of the performance indices of psychogeriatric patients aged 50 years admitted to a co-located psychogeriatric and geriatric unit at Bankstown-Lidcombe Hospital, New South Wales (NSW), Australia from April 2004 to June 2006. Comparisons were made between the performance of the Bankstown-Lidcombe’s unit and the NSW state average (consisting of traditional solitary models of care) with respect to patients’ length of stay (LOS) and changes in psychosocial indices. Bankstown’s patients had a higher burden of psychosocial impairments. The mean LOS for psychogeriatric episodes was significantly shorter at BankstownLidcombe Hospital than the NSW state average (28.3 19.6 days vs. 33.4 22.7 days, p < 0.001). The overall improvement in aspects of mental state and social behaviors for psychogeriatric admissions at Bankstown-Lidcombe Hospital was significantly better than the NSW state average. Co-location of psychogeriatric and geriatric services reduced patients’ LOS and improved psychosocial performance compared to traditional models of care. However, more robust studies are required to fully examine the benefits of this type of service. ß 2008 Elsevier Ireland Ltd. All rights reserved.
Keywords: Psychogeriatric service Mental health during aging Length of stay
1. Introduction Psychogeriatric services provide care for older patients who often have physical impairments and welfare needs in addition to mental illness (Cole, 1993; Draper, 2000; Draper and Low, 2005). The complexity of these patients’ needs often requires collaboration between geriatricians, psychiatrists and allied health professionals. Specialized psychogeriatric services in a tertiary setting utilize different models of care with inpatient service delivery located in adult mental wards, geriatric wards, or specialized psychogeriatric wards (Cole, 1993; Draper, 2000; Draper and Low, 2005). In many institutions, geriatric and psychogeriatric services are independent organizations although the relationship between the two services can sometimes be hampered by insufficient personnel and inadequately resourced mental health liaison and support services (Moss et al., 1995). Instinctively, due to a high prevalence of medical comorbidity in older patients admitted to
* Corresponding author. Tel.: +61 2 9722 7218; fax: +61 2 9722 8275. E-mail address: [email protected] (H.V. Nguyen). 0167-4943/$ – see front matter ß 2008 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.archger.2008.08.008
psychiatric units, co-location of psychogeriatric and geriatric services with close consultation liaison between the two services appears medically advantageous and resource-effective (Cole, 1993; Draper, 2000; Draper and Low, 2005); however, few psychiatric services have co-located geriatric and psychogeriatric services. In addition, there have been few studies exploring this model of service provision (Arie and Dunn, 1973; Pitt and Silver, 1980; Porello et al., 1995; Slaets et al., 1997). These studies (Arie and Dunn, 1973; Pitt and Silver, 1980; Porello et al., 1995; Slaets et al., 1997) have been predominantly descriptive and noncomparative with variable outcomes; however, one study did show improved bed turnover, discharge rate and death rate in a service where psychogeriatric patients were managed in medical units (Pitt and Silver, 1980). Another study exploring the close consultation liaison between geriatric and psychogeriatric services in hospital setting also showed reduction in LOS and reduced rate of re-admission for psychogeriatric patients (Slaets et al., 1997). With this in mind we set out to audit the performance of our colocated psychogeriatric and geriatric unit at the BankstownLidcombe Hospital in NSW, Australia, with respect to the performance indicators set out by the NSW benchmarks, the
A. Chiu et al. / Archives of Gerontology and Geriatrics 49 (2009) 233–236
234
Australian National Subacute Non-Acute Patient (AN-SNAP) (Lee et al., 1998) classification, the Health of the Nation Outcome Scales (HoNOS) (Brooks, 2000; Gallagher and Teesson, 2000) and patients’ LOS according to case-mix data. To our knowledge, the Bankstown unit with its model of service provision and geriatric and psychogeriatric co-management structure is a unique arrangement in NSW. Other psychiatric units for older patients are either independent units or have independent management structure from geriatric medicine. Bankstown-Lidcombe Hospital is a 430-bed teaching hospital providing care to a population of about 170,000 (Australian Bureau of Statistics, 2006). 13.3% of population in this area is aged 65 years or over. The psychogeriatric unit consists of 12 inpatient beds. Close supervision of patients is facilitated by a staff desk with 2708 glass panelling. This ward is physically co-located within a greater geriatric ward. Thus the greater ward contains patients with acute and chronic geriatric and psychogeriatric conditions. The psychogeriatric unit is serviced by 1.2 full-time equivalent (FTE) psychogeriatricians, a psychiatric registrar, and an experienced career medical officer, all working closely with geriatricians. There are also 0.25 FTE nurse per patient daytime hours, 0.2 FTE physiotherapist, 0.5 FTE occupational therapist and a full-time social worker. Older psychiatric patients with acute medical illnesses are jointly managed by psychogeriatricians and geriatricians if deemed appropriate after admission. Close formal and informal consultation liaison is also established between the geriatric and psychogeriatric teams which enable rapid assessment of patients with acute medical deterioration.
7. 8. 9. 10. 11. 12.
Problems with depressed mood. Other mental and behavioral problems. Problems with relationships. Problems with activities of daily living Problems with living conditions Problems with occupation and activities.
Each HoNOS item receives a grading from 0 to 4 (0 = no problem and 4 = severe problem). The psychogeriatric episodes described by AN-SNAP and HoNOS are further clarified in Table 1. 2.2. Data collection In this audit, we obtained AN-SNAP and HoNOS data from the NSW Department of Health from April 2004 to June 2006 which included data from the Bankstown unit and the NSW state average (consisting of eight other participating hospitals with psychogeriatric services). Other data collected included age, admission and discharge dates and LOS. All data were de-identified. We included patients aged >50 years with known dates of admission and discharge; those with LOS > 1 day; those who had completion of all 12 items of HoNOS score and AN-SNAP classes 301–305 (class 306 was excluded as this does not reflect inpatient care). A total of 1342 episodes of care were recorded in the AN-SNAP database. 670 episodes of care met the inclusion criteria. 658 episodes of day admission were excluded as were 12 AN-SNAP class 306 and 2 patients aged <50 years. 2.3. Data analysis
2. Methods 2.1. Description of instruments All patients admitted to our psychogeriatric unit had the ANSNAP (Lee et al., 1998) classification data collected. This is a national case-mix system whereby all non-acute patients are categorized according to their clinical characteristics for benchmarking and comparison purpose across different medical institutions. Psychogeriatric episodes are categorized as classes 301–306 on the AN-SNAP database. In addition, these classes are further broken down into more clinically descriptive items using the HoNOS index (Brooks, 2000; Gallagher and Teesson, 2000), which consists of 12 items measuring a patient’s psychosocial performance. The 12 HoNOS items are as follows: 1. 2. 3. 4. 5. 6.
Overactive, aggressive, disruptive behavior. Non accidental self injury. Problem drinking or drug taking. Cognitive problems. Physical illness or disability problems. Problems associated with hallucinations and delusions.
Data were analyzed using SPSS version 14. Comparison between the baseline characteristics of the Bankstown group and NSW average was done using Wilcoxon rank-sum test. We compared the changes in overall HoNOS and individual item scores during admission (i.e., discharge score admission score) between the two groups. We also examined the LOS within each sub-class of the AN-SNAP and compared the Bankstown data with those of the NSW state. A p < 0.05 was considered statistically significant. Data are expressed as mean S.D. 3. Results Six hundred and seventy episodes of care were included in the final analysis 221 episodes were from Bankstown Hospital. There was no statistically significant difference in the age of patients in the Bankstown Unit and the NSW state (77.9 6.5 years vs. 77.3 7.5 years respectively, p > 0.05). On admission, the total HoNOS and scores for items 3–12 for the Bankstown group were significantly higher than those of the NSW average implying that Bankstown psychogeriatric patients had more disabilities, medical co-morbidities and symptoms related to their diseases. Further details are illustrated in Table 2.
Table 1 AN-SNAP classification and meanings. AN-SNAP class (psychogeriatric episodes)
HoNOS items and scores (0 = no problem and 4 = severe problem)
Description of AN-SNAP class
301 302/303 304
Item 1 only: score 3–4 Item 1 only: score 1–2 Item 1: score 0 and items 1–12: total score 18
305
Item 1: score 0 and items 1–12: total score 17
Overactive, aggressive, disruptive behavior Overactive, aggressive, disruptive behavior Overactive, aggressive, disruptive behavior with other psychosocial characteristics Overactive, aggressive, disruptive behavior other psychosocial characteristics Review >90 days later
306
present at moderate to severe intensity present but at mild intensity not present and moderate problems not present and mild problems with
A. Chiu et al. / Archives of Gerontology and Geriatrics 49 (2009) 233–236 Table 2 Patient characteristics on admission.
Age (years) HoNOS Total 1. Overactive 2. Self-injury 3. Drink/drug 4. Cognition 5. Disability 6. Hallucination 7. Depression 8. Other mental/behavioral 9. Relationship 10. ADL 11. sLivingcondition 12. Occupation
Bankstown (n = 221)
NSW (n = 670)
p
77.9 6.5
77.3 7.5
0.365
29.7 6.7
20.9 9.2
<0.001
1.7 1.8 0.6 1.3 1.7 1.5 2.3 1.3 2.7 1.0 2.2 1.6 2.4 1.5 3.0 1.2 3.3 0.9 3.1 1.0 3.5 0.7 3.1 1.0
1.6 1.6 0.6 1.2 0.7 1.3 2.1 1.3 2.2 1.3 1.5 1.6 2.2 1.5 2.5 1.4 1.9 1.7 2.4 1.4 1.6 1.7 1.7 1.7
0.832 0.659 <0.001 0.038 <0.001 <0.001 0.029 <0.001 <0.001 <0.001 <0.001 <0.001
ADL, activities of daily living.
Table 3 Changes in HoNOS score during admission. Bankstown (n = 221) Total 1. Overactive 2. Self-injury 3. Drink/drug 4. Cognition 5. Disability 6. Hallucination 7. Depression 8. Other mental/behavioral 9. Relationship 10. ADL 11. Living condition 12. Occupation
NSW (n = 670)
p
12.2 5.9
7.9 7.0
<0.001
1.0 1.2 0.5 1.1 0.9 1.2 0.2 0.7 0.6 0.9 0.9 1.0 1.0 1.0 1.4 1.0 1.6 0.8 1.2 1.0 1.7 0.9 1.3 0.9
0.9 1.2 0.4 1.1 0.4 0.9 0.3 0.9 0.3 1.0 0.7 1.2 1.0 1.3 1.1 1.3 0.8 1.2 0.7 1.0 0.7 1.2 0.6 1.3
0.471 0.778 <0.001 0.019 <0.001 <0.001 0.849 <0.001 <0.001 <0.001 <0.001 <0.001
Note: More negative scores indicate improvement in parameters measured. ADL, activities of daily living.
235
issues is often complex, joint care allows for effective communication and integration of medical and psychiatric care plans thus enables early detection and management of medical complications. Co-location allows older patients to benefit from the input of a multi-disciplinary mental health, medical and allied health team. As psychogeriatric patients generally have longer and often more complex admissions than acute geriatric patients (Lee et al., 1998), pertinent rehabilitation and discharge planning issues can be jointly addressed by a team with rehabilitation and community resettlement focus. Co-location also allows older patients to experience the expertise of dual mental health and medical skillmix of ward clinical staff as staff in the co-located ward are required to be equipped in the management of acute medical and psychiatric problems. In addition, the physical structure of the ward with its glass-walled staff observation area allowed for close observation of wandering and aggressive patients minimizing the need for chemical or physical restraint thus the potential mental and physical impact of these treatments. There are few limitations with this study. First, information about the completion rate of the AN-SNAP data is not available although it is NSW health policy to collect such data. As case-mix data is utilized for benchmark comparisons, it is assumed that it would be advantageous for the participating hospitals in the NSW state to have an accurate data collection procedure. Second, we cannot control for the inter-rater variability in the data collection process between Bankstown-Lidcombe Hospital and other facilities. However, training on case-mix data collection process is generic and should be available at each participating institution. At Bankstown-Lidcombe Hospital, the data collection was completed by the same Career Medical Officer throughout the period of the study, ensuring that there is consistency in data reporting. Third, there are limitations in the range of data collected such as patients’ characteristics and re-admission rates. While we do not know the re-admission rates for other participating hospitals, the 28-day readmission rate for psychogeriatric patients is low at our institution averaging 2% in year 2003, 7% in 2004 and 6% in 2005. 5. Conclusion
The change in HoNOS scores for psychogeriatric patients admitted to the Bankstown psychogeriatric unit was significantly better than that of the NSW state in most categories including indicators of quality of life such as activities of daily living (ADL) (item 10), disability (item 5), living condition (item 11) and occupation (item 12) (p < 0.05 for all) (Table 3). The overall LOS was significantly shorter in the Bankstown psychogeriatric unit compared with NSW state average (28.3 19.6 days vs. 33.4 22.7 days, p < 0.001). In addition, there was a statistically significant reduction in the LOS for AN-SNAP subclass 301 for the Bankstown group compared to the NSW state average (27.0 17.0 days vs. 33.3 21.7 days, p < 0.001). However, there was no significant difference in the LOS between the Bankstown unit and the NSW state for AN-SNAP sub-classes 302–305. 4. Discussion This study showed that the Bankstown psychogeriatric unit admitted patients with more severe psychiatric and medical problems. It also demonstrated more superior improvement in clinical outcomes and overall reduction in LOS in the Bankstown group when compared to the NSW benchmark. The benefits of the co-located psychogeriatric unit in improving the quality of care of patients can be stipulated as follows. Colocation facilitates communication between psychogeriatricians and geriatricians. As the management of psychiatric and medical
In conclusion, a co-located psychogeriatric and geriatric unit appears medically advantageous due to its ability to address elderly patients’ medical and psychiatric issues efficiently as a result of close consultation liaison between psychogeriatricians and geriatricians. This model of care is worth further exploration and more vigorous analysis of its performance particularly in comparison with traditional models. Conflict of interest None. References Arie, T., Dunn, T.A., 1973. ‘‘Do-It-Yourself’’ psychiatric–geriatric joint patient unit. Lancet 8, 1313–1316. Australian Bureau of Statistics, 2006. Census QuickStats: Bankstown Local Government Area. Australian Bureau of Statistics, http://www.abs.gov.au./. Brooks, R., 2000. The reliability and validity of the Health of the Nation Outcome Scales: validation in relation to patient derived measures. Aust. N. Z. J. Psychiatry 34, 504–515. Cole, M., 1993. The impact of geriatric medical services on mental state. Int. Psychogeriatr. 5, 91–100. Draper, B., 2000. The effectiveness of old age psychiatry services. Int. J. Geriatr. Psychiatry 15, 687–703. Draper, B., Low, F., 2005. What is the effectiveness of acute hospital treatment of older people with mental disorders? Int. Psychogeriatr. 17, 1–27. Gallagher, J., Teesson, M., 2000. Measuring disability, need and outcome in Australian community mental health services. Aust. N. Z. J. Psychiatry 34, 850–865.
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Lee, L.A., Eagar, K.M., Smith, M.C., 1998. Subacute and non-acute case-mix in Australia. Med. J. Aust. (Suppl.169), S22–S25. Moss, F., Wilson, B., Harrigan, S., Ames, D., 1995. Psychiatric diagnoses, outcomes and lengths of stay of patients admitted to an acute psychogeriatric unit. Int. J. Geriatr. Psychiatry 10, 849–854. Pitt, B., Silver, C.P., 1980. The combined approach to geriatrics and psychiatry: evaluation of a joint unit in a teaching hospital district. Age Ageing 9, 33–37.
Porello, P.T., Madsen, L., Futterman, A., Moak, G.S., 1995. Description of a geriatric medical/psychiatry unit in a small community general hospital. J. Ment. Health Admin. 22, 38–48. Slaets, J.P., Kauffmann, R.H., Duivenvoorden, H.J., Pelemans, W., Schudel, W.J., 1997. A randomized trial of geriatric liaison intervention in older medical inpatients. Psychosom. Med. 59, 585–591.
Contents lists available at ScienceDirect
Archives of Gerontology and Geriatrics journal homepage: www.elsevier.com/locate/archger
Clinical outcomes and length of stay of a co-located psychogeriatric and geriatric unit Amanda Chiu a, Huong V. Nguyen a,*, Sharon Reutens b, David Grace b, Robert Schmidtman b, Qing Shen a,c, Jack Chen d, Daniel K.Y. Chan a,c a
Department of Age Care and Rehabilitation, Bankstown-Lidcombe Hospital, Locked Bag 1600, Bankstown, NSW 2200, Australia Department of Old Age Psychiatry, Bankstown-Lidcombe Hospital, Locked Bag 1600, Bankstown, NSW 2200, Australia Faculty of Medicine, University of New South Wales, NSW, Australia d Simpson Centre for Health Services Research, University of New South Wales, Locked Bag 7103, Liverpool BC 1871, NSW, Australia b c
A R T I C L E I N F O
A B S T R A C T
Article history: Received 13 May 2008 Received in revised form 15 August 2008 Accepted 27 August 2008 Available online 30 October 2008
To examine the effect of co-location of psychogeriatric and geriatric services on length of stay and changes in patients’ psychosocial characteristics. A retrospective analysis of the performance indices of psychogeriatric patients aged 50 years admitted to a co-located psychogeriatric and geriatric unit at Bankstown-Lidcombe Hospital, New South Wales (NSW), Australia from April 2004 to June 2006. Comparisons were made between the performance of the Bankstown-Lidcombe’s unit and the NSW state average (consisting of traditional solitary models of care) with respect to patients’ length of stay (LOS) and changes in psychosocial indices. Bankstown’s patients had a higher burden of psychosocial impairments. The mean LOS for psychogeriatric episodes was significantly shorter at BankstownLidcombe Hospital than the NSW state average (28.3 19.6 days vs. 33.4 22.7 days, p < 0.001). The overall improvement in aspects of mental state and social behaviors for psychogeriatric admissions at Bankstown-Lidcombe Hospital was significantly better than the NSW state average. Co-location of psychogeriatric and geriatric services reduced patients’ LOS and improved psychosocial performance compared to traditional models of care. However, more robust studies are required to fully examine the benefits of this type of service. ß 2008 Elsevier Ireland Ltd. All rights reserved.
Keywords: Psychogeriatric service Mental health during aging Length of stay
1. Introduction Psychogeriatric services provide care for older patients who often have physical impairments and welfare needs in addition to mental illness (Cole, 1993; Draper, 2000; Draper and Low, 2005). The complexity of these patients’ needs often requires collaboration between geriatricians, psychiatrists and allied health professionals. Specialized psychogeriatric services in a tertiary setting utilize different models of care with inpatient service delivery located in adult mental wards, geriatric wards, or specialized psychogeriatric wards (Cole, 1993; Draper, 2000; Draper and Low, 2005). In many institutions, geriatric and psychogeriatric services are independent organizations although the relationship between the two services can sometimes be hampered by insufficient personnel and inadequately resourced mental health liaison and support services (Moss et al., 1995). Instinctively, due to a high prevalence of medical comorbidity in older patients admitted to
* Corresponding author. Tel.: +61 2 9722 7218; fax: +61 2 9722 8275. E-mail address: [email protected] (H.V. Nguyen). 0167-4943/$ – see front matter ß 2008 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.archger.2008.08.008
psychiatric units, co-location of psychogeriatric and geriatric services with close consultation liaison between the two services appears medically advantageous and resource-effective (Cole, 1993; Draper, 2000; Draper and Low, 2005); however, few psychiatric services have co-located geriatric and psychogeriatric services. In addition, there have been few studies exploring this model of service provision (Arie and Dunn, 1973; Pitt and Silver, 1980; Porello et al., 1995; Slaets et al., 1997). These studies (Arie and Dunn, 1973; Pitt and Silver, 1980; Porello et al., 1995; Slaets et al., 1997) have been predominantly descriptive and noncomparative with variable outcomes; however, one study did show improved bed turnover, discharge rate and death rate in a service where psychogeriatric patients were managed in medical units (Pitt and Silver, 1980). Another study exploring the close consultation liaison between geriatric and psychogeriatric services in hospital setting also showed reduction in LOS and reduced rate of re-admission for psychogeriatric patients (Slaets et al., 1997). With this in mind we set out to audit the performance of our colocated psychogeriatric and geriatric unit at the BankstownLidcombe Hospital in NSW, Australia, with respect to the performance indicators set out by the NSW benchmarks, the
A. Chiu et al. / Archives of Gerontology and Geriatrics 49 (2009) 233–236
234
Australian National Subacute Non-Acute Patient (AN-SNAP) (Lee et al., 1998) classification, the Health of the Nation Outcome Scales (HoNOS) (Brooks, 2000; Gallagher and Teesson, 2000) and patients’ LOS according to case-mix data. To our knowledge, the Bankstown unit with its model of service provision and geriatric and psychogeriatric co-management structure is a unique arrangement in NSW. Other psychiatric units for older patients are either independent units or have independent management structure from geriatric medicine. Bankstown-Lidcombe Hospital is a 430-bed teaching hospital providing care to a population of about 170,000 (Australian Bureau of Statistics, 2006). 13.3% of population in this area is aged 65 years or over. The psychogeriatric unit consists of 12 inpatient beds. Close supervision of patients is facilitated by a staff desk with 2708 glass panelling. This ward is physically co-located within a greater geriatric ward. Thus the greater ward contains patients with acute and chronic geriatric and psychogeriatric conditions. The psychogeriatric unit is serviced by 1.2 full-time equivalent (FTE) psychogeriatricians, a psychiatric registrar, and an experienced career medical officer, all working closely with geriatricians. There are also 0.25 FTE nurse per patient daytime hours, 0.2 FTE physiotherapist, 0.5 FTE occupational therapist and a full-time social worker. Older psychiatric patients with acute medical illnesses are jointly managed by psychogeriatricians and geriatricians if deemed appropriate after admission. Close formal and informal consultation liaison is also established between the geriatric and psychogeriatric teams which enable rapid assessment of patients with acute medical deterioration.
7. 8. 9. 10. 11. 12.
Problems with depressed mood. Other mental and behavioral problems. Problems with relationships. Problems with activities of daily living Problems with living conditions Problems with occupation and activities.
Each HoNOS item receives a grading from 0 to 4 (0 = no problem and 4 = severe problem). The psychogeriatric episodes described by AN-SNAP and HoNOS are further clarified in Table 1. 2.2. Data collection In this audit, we obtained AN-SNAP and HoNOS data from the NSW Department of Health from April 2004 to June 2006 which included data from the Bankstown unit and the NSW state average (consisting of eight other participating hospitals with psychogeriatric services). Other data collected included age, admission and discharge dates and LOS. All data were de-identified. We included patients aged >50 years with known dates of admission and discharge; those with LOS > 1 day; those who had completion of all 12 items of HoNOS score and AN-SNAP classes 301–305 (class 306 was excluded as this does not reflect inpatient care). A total of 1342 episodes of care were recorded in the AN-SNAP database. 670 episodes of care met the inclusion criteria. 658 episodes of day admission were excluded as were 12 AN-SNAP class 306 and 2 patients aged <50 years. 2.3. Data analysis
2. Methods 2.1. Description of instruments All patients admitted to our psychogeriatric unit had the ANSNAP (Lee et al., 1998) classification data collected. This is a national case-mix system whereby all non-acute patients are categorized according to their clinical characteristics for benchmarking and comparison purpose across different medical institutions. Psychogeriatric episodes are categorized as classes 301–306 on the AN-SNAP database. In addition, these classes are further broken down into more clinically descriptive items using the HoNOS index (Brooks, 2000; Gallagher and Teesson, 2000), which consists of 12 items measuring a patient’s psychosocial performance. The 12 HoNOS items are as follows: 1. 2. 3. 4. 5. 6.
Overactive, aggressive, disruptive behavior. Non accidental self injury. Problem drinking or drug taking. Cognitive problems. Physical illness or disability problems. Problems associated with hallucinations and delusions.
Data were analyzed using SPSS version 14. Comparison between the baseline characteristics of the Bankstown group and NSW average was done using Wilcoxon rank-sum test. We compared the changes in overall HoNOS and individual item scores during admission (i.e., discharge score admission score) between the two groups. We also examined the LOS within each sub-class of the AN-SNAP and compared the Bankstown data with those of the NSW state. A p < 0.05 was considered statistically significant. Data are expressed as mean S.D. 3. Results Six hundred and seventy episodes of care were included in the final analysis 221 episodes were from Bankstown Hospital. There was no statistically significant difference in the age of patients in the Bankstown Unit and the NSW state (77.9 6.5 years vs. 77.3 7.5 years respectively, p > 0.05). On admission, the total HoNOS and scores for items 3–12 for the Bankstown group were significantly higher than those of the NSW average implying that Bankstown psychogeriatric patients had more disabilities, medical co-morbidities and symptoms related to their diseases. Further details are illustrated in Table 2.
Table 1 AN-SNAP classification and meanings. AN-SNAP class (psychogeriatric episodes)
HoNOS items and scores (0 = no problem and 4 = severe problem)
Description of AN-SNAP class
301 302/303 304
Item 1 only: score 3–4 Item 1 only: score 1–2 Item 1: score 0 and items 1–12: total score 18
305
Item 1: score 0 and items 1–12: total score 17
Overactive, aggressive, disruptive behavior Overactive, aggressive, disruptive behavior Overactive, aggressive, disruptive behavior with other psychosocial characteristics Overactive, aggressive, disruptive behavior other psychosocial characteristics Review >90 days later
306
present at moderate to severe intensity present but at mild intensity not present and moderate problems not present and mild problems with
A. Chiu et al. / Archives of Gerontology and Geriatrics 49 (2009) 233–236 Table 2 Patient characteristics on admission.
Age (years) HoNOS Total 1. Overactive 2. Self-injury 3. Drink/drug 4. Cognition 5. Disability 6. Hallucination 7. Depression 8. Other mental/behavioral 9. Relationship 10. ADL 11. sLivingcondition 12. Occupation
Bankstown (n = 221)
NSW (n = 670)
p
77.9 6.5
77.3 7.5
0.365
29.7 6.7
20.9 9.2
<0.001
1.7 1.8 0.6 1.3 1.7 1.5 2.3 1.3 2.7 1.0 2.2 1.6 2.4 1.5 3.0 1.2 3.3 0.9 3.1 1.0 3.5 0.7 3.1 1.0
1.6 1.6 0.6 1.2 0.7 1.3 2.1 1.3 2.2 1.3 1.5 1.6 2.2 1.5 2.5 1.4 1.9 1.7 2.4 1.4 1.6 1.7 1.7 1.7
0.832 0.659 <0.001 0.038 <0.001 <0.001 0.029 <0.001 <0.001 <0.001 <0.001 <0.001
ADL, activities of daily living.
Table 3 Changes in HoNOS score during admission. Bankstown (n = 221) Total 1. Overactive 2. Self-injury 3. Drink/drug 4. Cognition 5. Disability 6. Hallucination 7. Depression 8. Other mental/behavioral 9. Relationship 10. ADL 11. Living condition 12. Occupation
NSW (n = 670)
p
12.2 5.9
7.9 7.0
<0.001
1.0 1.2 0.5 1.1 0.9 1.2 0.2 0.7 0.6 0.9 0.9 1.0 1.0 1.0 1.4 1.0 1.6 0.8 1.2 1.0 1.7 0.9 1.3 0.9
0.9 1.2 0.4 1.1 0.4 0.9 0.3 0.9 0.3 1.0 0.7 1.2 1.0 1.3 1.1 1.3 0.8 1.2 0.7 1.0 0.7 1.2 0.6 1.3
0.471 0.778 <0.001 0.019 <0.001 <0.001 0.849 <0.001 <0.001 <0.001 <0.001 <0.001
Note: More negative scores indicate improvement in parameters measured. ADL, activities of daily living.
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issues is often complex, joint care allows for effective communication and integration of medical and psychiatric care plans thus enables early detection and management of medical complications. Co-location allows older patients to benefit from the input of a multi-disciplinary mental health, medical and allied health team. As psychogeriatric patients generally have longer and often more complex admissions than acute geriatric patients (Lee et al., 1998), pertinent rehabilitation and discharge planning issues can be jointly addressed by a team with rehabilitation and community resettlement focus. Co-location also allows older patients to experience the expertise of dual mental health and medical skillmix of ward clinical staff as staff in the co-located ward are required to be equipped in the management of acute medical and psychiatric problems. In addition, the physical structure of the ward with its glass-walled staff observation area allowed for close observation of wandering and aggressive patients minimizing the need for chemical or physical restraint thus the potential mental and physical impact of these treatments. There are few limitations with this study. First, information about the completion rate of the AN-SNAP data is not available although it is NSW health policy to collect such data. As case-mix data is utilized for benchmark comparisons, it is assumed that it would be advantageous for the participating hospitals in the NSW state to have an accurate data collection procedure. Second, we cannot control for the inter-rater variability in the data collection process between Bankstown-Lidcombe Hospital and other facilities. However, training on case-mix data collection process is generic and should be available at each participating institution. At Bankstown-Lidcombe Hospital, the data collection was completed by the same Career Medical Officer throughout the period of the study, ensuring that there is consistency in data reporting. Third, there are limitations in the range of data collected such as patients’ characteristics and re-admission rates. While we do not know the re-admission rates for other participating hospitals, the 28-day readmission rate for psychogeriatric patients is low at our institution averaging 2% in year 2003, 7% in 2004 and 6% in 2005. 5. Conclusion
The change in HoNOS scores for psychogeriatric patients admitted to the Bankstown psychogeriatric unit was significantly better than that of the NSW state in most categories including indicators of quality of life such as activities of daily living (ADL) (item 10), disability (item 5), living condition (item 11) and occupation (item 12) (p < 0.05 for all) (Table 3). The overall LOS was significantly shorter in the Bankstown psychogeriatric unit compared with NSW state average (28.3 19.6 days vs. 33.4 22.7 days, p < 0.001). In addition, there was a statistically significant reduction in the LOS for AN-SNAP subclass 301 for the Bankstown group compared to the NSW state average (27.0 17.0 days vs. 33.3 21.7 days, p < 0.001). However, there was no significant difference in the LOS between the Bankstown unit and the NSW state for AN-SNAP sub-classes 302–305. 4. Discussion This study showed that the Bankstown psychogeriatric unit admitted patients with more severe psychiatric and medical problems. It also demonstrated more superior improvement in clinical outcomes and overall reduction in LOS in the Bankstown group when compared to the NSW benchmark. The benefits of the co-located psychogeriatric unit in improving the quality of care of patients can be stipulated as follows. Colocation facilitates communication between psychogeriatricians and geriatricians. As the management of psychiatric and medical
In conclusion, a co-located psychogeriatric and geriatric unit appears medically advantageous due to its ability to address elderly patients’ medical and psychiatric issues efficiently as a result of close consultation liaison between psychogeriatricians and geriatricians. This model of care is worth further exploration and more vigorous analysis of its performance particularly in comparison with traditional models. Conflict of interest None. References Arie, T., Dunn, T.A., 1973. ‘‘Do-It-Yourself’’ psychiatric–geriatric joint patient unit. Lancet 8, 1313–1316. Australian Bureau of Statistics, 2006. Census QuickStats: Bankstown Local Government Area. Australian Bureau of Statistics, http://www.abs.gov.au./. Brooks, R., 2000. The reliability and validity of the Health of the Nation Outcome Scales: validation in relation to patient derived measures. Aust. N. Z. J. Psychiatry 34, 504–515. Cole, M., 1993. The impact of geriatric medical services on mental state. Int. Psychogeriatr. 5, 91–100. Draper, B., 2000. The effectiveness of old age psychiatry services. Int. J. Geriatr. Psychiatry 15, 687–703. Draper, B., Low, F., 2005. What is the effectiveness of acute hospital treatment of older people with mental disorders? Int. Psychogeriatr. 17, 1–27. Gallagher, J., Teesson, M., 2000. Measuring disability, need and outcome in Australian community mental health services. Aust. N. Z. J. Psychiatry 34, 850–865.
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