Gold Award: A Community-Based Program Providing A Successful Alternative to Acute Psychiatric Hospitalization

More than 20 years ago, the Community Research Foundation in San Diego envisioned a program of voluntary acute care services that would at once serve as a cost-effective alternative to expensive county hospitalization and improve outcomes for individuals who were experiencing acute psychotic episodes. The realization of that vision is the short-term acute residential treatment program known as START.

From one small experimental, ten-bed facility that opened in 1980, START has expanded to six countywide locations and a total of 77 beds. The program treats the most acutely ill patients, those who would otherwise be at high risk of psychiatric hospitalization. On an annual basis, START facilities provide 24,000 days of client services to 3,000 adults who have been diagnosed as having an acute axis I psychiatric illness. The program currently provides about half of the voluntary, public acute care services in San Diego County.

Although START is a short-term treatment program, its core principles are based on psychiatric rehabilitation. Patients are treated with highly individualized plans that integrate state-of-the-art psychopharmacalogical and cognitive-behavioral interventions directed at problem resolution. The facilities, which have no locks or restraints, are located in residential neighborhoods. Their homelike environment minimizes the barriers between patient and staff and decreases the isolation and stigmatization that often accompany hospitalization.

START has long since put to rest the initial concerns of area mental health professionals, many of whom assumed that it was not possible to manage suicidal and psychotic patients outside a hospital setting. One official has described the program as "the key to the success of San Diego County's Mental Health Plan for Adults and Older Adults."

The START program has been selected as the winner of the Gold Award in the category of large academically or institutionally sponsored programs. The winner of the award for small community-based programs is described in a separate article on page 1380. The awards will be presented on October 10 during the opening session of the Institute on Psychiatric Services in Orlando.

It starts with the staff

Staff is key to START's success. Because the needs of acute care patients are diverse, flexibility and creativity along with a high degree of clinical competence are essential. Staff members must be sufficiently trained in dealing with crisis situations that can range from patients' suicide and homicide attempts to acute psychotic episodes.

But academic background and experience are not the only criteria for selection. Equally important are an attitude and a philosophy that are consistent with a noninstitutional, community-based treatment approach that focuses on psychiatric rehabilitation. Staff members must be willing and able to handle such diverse tasks as leading family therapy and educational groups, promoting individual skills building, aiding substance abuse treatment, overseeing meal preparation, and maintaining the facility. Every effort is made to recruit staff who are representative of and knowledgeable about the ethnic and cultural makeup of the community served by the program and who speak the primary language of the patients.

Typically, the multidisciplinary staff includes a program director, an assistant director, three treatment coordinators, a psychiatrist, a psychologist, a social worker who serves as discharge planner, four or five nurses, and eight to ten mental health counselors. The staff is augmented by social work and psychology interns and, at some locations, a program aide.

Supervisory-level staff are continually trained in the tenets of the psychosocial rehabilitation approach, and all have applied for or have received certification as registered psychosocial rehabilitation practitioners through the International Association of Psychosocial Rehabilitation Services. All staff members are required to complete 20 hours of continuing education a year, which includes a minimum of four hours of cultural competency training.

Psychiatric consultation is provided by fellows and staff of the department of psychiatry at the University of California at San Diego. The psychiatrist is an integral part of the treatment team and is committed to the philosophy and expectations of the START program. He or she is skilled in brief assessment and treatment and is knowledgeable about the care of patients who have a dual diagnosis of mental illness and substance abuse.

The psychiatrist is called for treatment input as soon as a patient is admitted. He or she reviews the counselor and nursing assessments and meets with patients a minimum of three days a week or as often as is necessary during the course of treatment. The psychiatrist is consulted about possible changes in the treatment regimen whenever a patient complains of physical illness, is experiencing side effects of medications, or requests a medication reevaluation. The psychiatrist serves throughout as a teacher and mentor for staff and interns.

The patient is the focus

Treatment in the START program is above all patient-centered. On admission, each patient is assigned his or her own treatment team. Working in conjunction with the psychiatrist, the treatment team—with input from the patient and, with the patient's consent, family members or significant others—develops a dynamic, comprehensive, and individualized plan that serves as a blueprint for treatment. Every effort is made to coordinate treatment with the patient's outpatient psychiatrist or other mental health professionals, who are invited to work with the patient and the treatment team to ensure continuity of care.

In addition to an acute axis I diagnosis, about 28 percent of the individuals who are admitted to the START program have a diagnosed personality disorder, and many have complicating concomitant medical problems. About half have a comorbid substance use disorder. Substance abuse problems are addressed concurrently with mental health problems. A dual diagnosis curriculum created by the staff includes targeted group therapy, "homework" assignments, and attendance at in-house and outside meetings of self-help recovery groups.

A basic tenet of treatment is to identify and build on each patient's adaptational strengths, regardless of his or her diagnosis. Patients are assigned household and community responsibilities, and both staff and patients participate in program activities. Staff members wear casual street clothes as they work alongside patients in preparing meals, doing laundry, and keeping the house and yard neat and clean. This type of interaction promotes personal contact between patients and staff and provides staff with a wide range of opportunities to teach skills and to act as role models.

The average patient stay is eight or nine days, which is much closer to an average hospital stay than the 14 to 60 days that is typical of other crisis residential programs that are used for "step-down" from voluntary hospitalization. In fact, discharge planning begins as soon as possible after the patient is admitted, both to ensure a smooth transition to the patient's discharge destination and to reduce the patient's dependence and, thus, the risk of readmission. The planning emphasizes factors such as adequate social and clinical resources and stable housing. A full-time discharge planner works collaboratively with the patient and his or her treatment team to prepare the most effective plan. At discharge, patients who have an existing relationship with a mental health professional are routinely referred back to that professional.

A strong emphasis is placed on relapse prevention. A relapse prevention plan is developed for each patient before discharge. The plan outlines specific warning signs and symptoms and describes exactly what steps the patient should take if he or she begins to decompensate. Among the strategies used to prevent readmissions are arranging for an outpatient appointment before a patient is discharged, providing medications until the appointment is kept, calling the patient to ensure that he or she keeps the appointment, and removing barriers to getting to the appointment. Assistance with obtaining basic needs, such as food, money, clothing, and shelter, is provided, and other services, such as outpatient therapy, medication monitoring, support groups, job training, and parenting classes, are available.

The measures of success

Patient satisfaction and outcomes

START is constantly evolving to meet the needs of the community and of its clients. Since its inception, the program has conducted in-house surveys on patient satisfaction. The Mental Health Statistical Improvement Program, which is administered to each patient before discharge, is also used as an instrument to gauge patient satisfaction. The test scores are reported to the Community Research Foundation and to the Adult and Older Adult Mental Health Services division of the County of San Diego's Health and Human Services Agency. The scores are generally quite favorable, but areas that receive less favorable scores receive special attention by START staff, and every effort is made to demonstrate improvement in the next quarterly report.

A number of patient satisfaction surveys comparing START and hospital programs have been conducted by several groups, including United Behavioral Health, San Diego State University, and San Diego County. In general, START has consistently received a higher proportion of favorable responses than hospital programs receive.

In 2000, START implemented an outcome management system, which measures, among other things, readmission rates. Readmission rates for all discharged patients are calculated and reported to program staff quarterly. Risk factors associated with readmission are quantified. Patients who present high-risk profiles—for example, young, unmarried men who have a diagnosis of schizophrenia and a concomitant substance-related diagnosis—are the focus of particular attention. Reports of outcome measures are distributed to management, program directors, and staff for the purposes of quality monitoring and improvement.

Cost-effectiveness

The START program has also proved itself a financial success. The cost to San Diego County of a bed at the county hospital, with overhead, is $850 a day; START receives about $220 a day. Relying on START for voluntary acute admissions has helped the county reduce the number of beds in the county hospital from 120 to 22 and still address the demand for acute care.

A study that compared costs for patients in four diagnostic groups who were treated at five START locations or two psychiatric hospitals found that, over a three-year period, per-episode savings for the START patients ranged from $928 for those with bipolar disorders to $2,530 for those with major depression (Psychiatric Services, March 1999). Patients in both programs were found to have similar levels of severity at admission and at discharge, and they demonstrated similar stability of treatment gains after four months.

Benefits to the community and beyond

The benefits generated by the START program reach far beyond those reaped by the individual patients. The monetary savings have allowed the county to redirect resources to new and previously underfunded community-based services that reach populations that would otherwise do without.

The START locations provide excellent training grounds for students in various disciplines of mental health service. Here they experience the principles of psychiatric rehabilitation and community-based mental health in action. The program attracts senior residents and fellows, pre- and postdoctoral psychology interns, psychology practicum students, social work trainees and interns, marriage and family therapy trainees and interns, and trainees from nursing schools. Many clinicians in San Diego have received at least one year of their field clinical training experience at one of the program locations.

Sharing the knowledge

The success of START as a community-based hospital alternative has captured the attention of mental health professionals around the world, and the administrators are very open to sharing their concepts and knowledge with others who wish to develop similar programs. The model has been presented at state, national, and international conferences and has attracted visitors from countries as far away and diverse as New Zealand, Israel, Denmark, and Japan.

Funding

Like most community mental health programs, START is faced with limited financial support and the challenge of making the most of available funds. During the 1999-2000 fiscal year, the program was funded by contracts with San Diego County Health and Human Services, with whom Community Research Foundation has continuously held an annually renewed contract for the program since 1980, and with Kaiser Foundation Hospitals to provide services for its beneficiaries. Other funds were obtained though the Department of Veterans Affairs, a grant from the Substance Abuse and Mental Health Services Administration, patient fees, and insurance and other miscellaneous sources. Total revenue for the fiscal year was $5.25 million.

Accreditation

START locations are licensed as social rehabilitation facilities, and the program is certified as a short-term crisis residential program. START was among the first programs in San Diego to receive accreditation from the Commission on Accreditation of Rehabilitation Facilities (CARF), a private, not-for-profit organization that develops and maintains practical and relevant standards of quality for such programs as adult day services, assisted living, behavioral health, employment and community services, and medical rehabilitation.

Described by one CARF reviewer as "the shining star of crisis stabilization programs," START continues to seek ways to brighten the future for its patients and to improve outcomes for all individuals with acute psychiatric needs.