Step-up, step-down mental health care service: evidence from Western Australia’s first – a mixed-method cohort study

Abstract

Background Mental health Step-up, Step-down services (SUSD), also known as subacute services or Prevention and Recovery Services, have emerged to fill an identified gap between hospital-based inpatient care and clinical community-based mental health support. Evidence for the effectiveness of the SUSD service model is limited but growing. Accordingly, this study looked to add to the extant body of knowledge, by (i) assessing change outcomes in mental health and wellbeing, and predictors of these changes, for patients who accessed Western Australia’s first SUSD service; and (ii) evaluating patients’ satisfaction with service, and what patients value from their stay. Methods This was a mixed-method retrospective cohort study. Participants comprised 382 patients who accessed a 22-bed Mental Health SUSD facility and incurred 551 episodes of care during the 01/07/2014–30/06/2016 period. Patients’ change outcomes in psychological distress, general self-efficacy, and work and social adjustment from service entry to service exit were analyzed using generalized linear modeling. Simple Pearson’s correlation coefficients were calculated for preliminary assessment of the associations between patients’ service satisfaction and their change outcomes. Qualitative outcomes that patients valued from their stay were analyzed thematically according to a semi-grounded theoretical approach. Results Significant improvements were observed in patients’ self-reported psychological distress, self-efficacy, and work and social adjustment (all p < 0.0001). A strong and persistent baseline effect existed across the three measures. Older age, female gender, and having a dependent child in the same household were protective/enhancing factors for the patients’ recovery. Satisfaction with service was high. Patients valued having the time and space to recuperate, gain insight, focus, and create changes in their lives. Conclusion The encouraging findings, regarding both patients’ change outcomes and satisfaction with service, support the value of the SUSD service model for patients with mental illnesses. Strengths and limitations were discussed; ensued recommendations were offered to both service providers and researchers to enhance the robustness of future research findings, to help inform more effective policy and funding decisions related to mental health care.

Developing fit-for-purpose funding models for rural settings: Lessons from the evaluation of a step-up/step-down service in regional Australia

“…Admission to the service was associated with improvements in consumers’ self-reported psychological wellbeing, self-efficacy, and work and social adjustment levels; this finding is consistent with existing evidence ( 7 ), including evaluation data from a larger Western Australian suburban SUSD service ( 14 ) and evaluation data from similar services in regional New South Wales ( 7 ), North Queensland ( 16 ), and Victoria ( 13 ) A review of community mental health care programs in Australia identified benefits of programs that incorporated case management and therapeutic elements, and a multidisciplinary team, in delivering positive clinical and psychosocial outcomes ( 31 ). SUSDs occupy a space between community and in-patient care; however, our findings are consistent with this broader review of Australian services.…”

“…Despite its complexity, there is a growing body of literature that demonstrates the clinical and cost-effectiveness of the SUSD model ( 1 ). The evaluation of the growing SUSD sector in Australia has shown positive outcomes regarding quality of life, symptoms and functioning ( 4 , 7 , 13 – 15 ), progress toward achieving goals identified on the individual recovery plans ( 16 ), and consumer satisfaction with service delivery, relating to elements such as service approach and ethos, program activities, safety, and communal qualities and environment ( 7 , 14 , 17 , 18 ). Although more limited, there is also some encouraging evidence of the positive short-term impact on quality of life after discharge ( 15 ).…”

Outcomes of Victorian Prevention and Recovery Care Services: A matched pairs comparison

“…A number of evaluations of single PARC or PARC-like services have been conducted in Australia (Heyeres et al, 2018;Kinchin et al, 2019;Lee et al, 2014;Ngo et al, 2020;Thomas et al, 2017b;Siskind et al, 2013). Collectively, these have found that consumers are positive about PARCS and experience improvements in functioning and reductions in symptoms following a PARCS stay, that the cost of a PARCS admission is lower than that of an inpatient admission, and that PARCS use is associated with a reduction in the number and duration of subsequent inpatient admissions.…”

“…For these reasons, PARCS stays are likely to be viewed as a less restrictive, more acceptable option than inpatient admissions by consumers and, potentially, clinicians and families. Any substitution of PARCS admissions for inpatient admissions may provide an opportunity for more substantive support for personal recovery in an environment that generally receives high rates of satisfaction (Thomas et al, 2017b;Lee et al, 2014;Ngo et al, 2020). Having said this, since the availability of both PARCS and inpatient beds is limited, it is not possible to determine whether the subsequent patterns of service use by the PARCS and inpatient-only consumers in our study reflected consumer choice, clinical decision-making, or availability.…”

Effect of community mental health care programs in Australia: a systematic review

“…Five case management-based studies adopted an integrated housing and recovery model of community support: the Alternatives to Hospitalisation program provided crisis housing and wraparound supports (Siskind et al 2013); the Doorway Program supported participants to choose, access and sustain accommodation alongside clinical case management (Dunt et al 2017); and the Transition to Recovery program (Australian Healthcare Associates 2012) and the Prevention and Recovery Service (Lee et al 2014;Ngo et al 2020) provided supported accommodation with multidisciplinary psychosocial and clinical support to promote recovery. The three remaining studies evaluated the effectiveness of community case management programs after modifications were made, including the addition of a local primary worker (Campbell 2005), Refocus Pulsar training for case management staff (Meadows et al 2019) and the addition of bilingual case workers to the multidisciplinary team (Ziguras 2001).…”