Residential Facilities as the New Scenario of Long-Term Psychiatric Care

Giovanni de Girolamo; Mariano Bassi


Curr Opin Psychiatry. 2004;17(4) 

In This Article

Structure Data

How many residential facilities are currently available in different countries, and how many residential facilities are needed? Unfortunately it is difficult to answer these questions; the only study which has directly evaluated the provision of residential facilities on a nationwide scale is the PROGRES (PROGetto strutture RESidenziali, Residential Project) study, recently carried out in Italy where all mental hospitals have been closed.[4**] The aim of the first phase of this survey was to obtain data on regional provision of residential facilities, staffing arrangements, demographic and clinical characteristics of residents and discharge rates. In addition, the study aimed to clarify relationships between the availability of residential places and the provision of other mental health resources. The authors identified 1370 residential facilities in the whole country, with a total of 17 138 beds; three-quarters of these facilities had 24 h staff cover. Overall, in the whole country, there were 2.9 residential beds for every 10 000 inhabitants, with a large variability between regions.

The EPSILON study has recently gathered data about the provision of residential beds in five European catchment areas (Amsterdam, Copenhagen, London, Santander and Verona).[5*] For service assessment, the study group used the European Service Mapping Schedule. The rate of nonhospital residential beds varied dramatically, with a 41-fold difference between the area with the highest provision (Copenhagen with 14.6 residential beds per 10 000 inhabitants) and the area with the lowest (Santander, Spain, with 0.35 beds), both with 24 h cover. London and Verona showed intermediate values (3.3 and 3.6, respectively). It is difficult to establish, however, to what extent these figures can be generalized to other areas of the same countries and therefore how they reflect the national average. Indeed, another report, focusing on the German state of Saxony-Anhalt and carried out with the same instrument (European Service Mapping Schedule), has found a much higher rate of residential beds, that is 2.4 places per 10 000 in medium stay residential facilities and an additional 24.0 places in indefinite stay residential facilities, with 24 h cover.[6] In the past, in the UK 'Mental Health Residential Care Study' carried out in eight districts surrounding London, the authors found a rate of 9.46 beds per 10 000.[7**] In another UK survey, however, of 35 districts, the rate was 4.29, closer to the 2.98 Italian rate.[8]

In conclusion, although it may prove to be difficult to establish precise standards of residential facility provision, 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 ',[9**] efforts are needed to identify acceptable ranges of residential facility places in all countries with a developed system of mental health care. Provision of residential facilities largely depends on two key variables: (1) the extent of informal family support, which can substitute and replace the formal support granted by residential facilities; and (2) the availability of comprehensive community resources, including assertive community treatment in each country. In the PROGRES study, the availability of residential places was indeed negatively related to the number of community mental health centres and day centres, and was positively related to the number of beds in private inpatient units in each region.

Of course, additional efforts will be necessary to clarify the need for residential facilities in those developing countries which are trying, with much difficulty, to overcome the traditional asylum system; quantitative standards will have to be adapted to the specific, local contexts and needs of such countries.

In contrast to the Italian data, showing that residential facilities have on average small dimensions (mean size 12.5 beds, with only 5.7% of facilities having more than 20 beds), recent North American data show substantial variability in the size of long-term care settings. In a survey of 68 residential facilities providing acute care and managed by the US Veterans Administrations, Timko et al.[10*] found that they had a mean size of 42.9 beds, with an average stay of 14.4 weeks. The proportion of such facilities on the total number of psychiatric residential facilities run by the Veterans Administrations is not specified, nor is the number or characteristics of residential facilities providing long-term care. There have been no other recent studies providing additional information on this very important issue.

Size represents a critical variable for any taxonomy of these settings, probably the single most important variable. Small residences help create a homely environment which is in huge contrast to the large institutional environments of the past, warehousing hundreds of patients. It is clearly economically unfeasible, however, in an era of reduced costs devoted to health care, to envisage a system based on a large number of very small (e.g. three to four beds) facilities, with intensive support.

In the Italian PROGRES national study, the 1370 residential facilities employed 18 666 professionals, of whom 60% (n=11 240) worked full time. Around 40% of staff had no specific professional qualification for working with psychiatric patients with severe mental disorders. The overall ratio of patients to full-time staff was 1.42 to 1 (range 0.82-22.3). In the Veterans Administrations study, the direct care staff-patient ratio was 0.24,[10*] but these facilities were providing acute care and therefore this ratio may not apply to long-term care. Large percentages of poorly qualified staff were also found in the UK 'Mental Health Residential Care Study'[7**] and in a large survey done in the US.[11]

Staffing is another area needing clarification both in quantitative terms (e.g. how many staff are needed in different typologies of facilities) and in qualitative terms (e.g. staff qualification and training, tasks and roles of different professionals, turnover rate, etc.). Effectiveness trials have shown that a larger number of staff is not automatically associated with better outcomes (e.g. PRISM Psychosis Study).[12**] Indeed, within community-oriented models of care, the quality of staff (and what they do) is more important than the quantity, provided that a 'minimum' quantity is ensured. Unfortunately, in residential care (as well as in other settings) we do not know what the minimum is; in other words, what is the threshold below which there will certainly be a deterioration in the quality of care and in selected outcome indicators?

In the years covered by this review (2000-2004) no studies have assessed the physical environment of residential facilities and its relationship with the satisfaction of residents (and staff). This is surprising, because one of the strongest (and well founded) criticisms of old-fashioned institutions referred to their dehumanizing, alienating physical environment. It would be important to identify the key variables which facilitate (or are strictly needed for) the creation of a home-like, pleasant physical environment for long-term residents. In particular, several studies have highlighted that most residents attribute great importance to privacy (virtually nonexistent in the former mental hospitals), and this has precise implications in terms of architectural features (e.g. availability of single rooms, private bathrooms, etc.).[13,14]

In the years covered by this review, a few studies have investigated sociodemographic, clinical and treatment characteristics of residents. In the Italian PROGRES study,[4**] the authors found 15 943 residents in the 1370 residential facilities, that is 11.6 residents per facility. The majority of residents (58.5%) had never been admitted to a mental hospital or a forensic mental hospital, although in this group all had been admitted to a general hospital psychiatric ward. Two-thirds of the residents had a diagnosis of schizophrenia, with mental retardation being the primary problem in around 10% of residents. Most residents (82.7%) had no current problems of alcohol or substance abuse. This low rate of dual diagnosis, however, may be due to intake screening that excluded residents with either alcohol or drug problems in more than half (59.1%) of the residences. While patients with substance abuse can be treated in a variety of residential facilities, Italian data seem to point to a shortage of settings treating patients with a dual diagnosis, which may also apply to other countries.

By contrast, in the Veterans Administrations survey of 68 residential facilities providing acute care (officially designed for a population of psychiatric patients), Timko et al.[10*] found that only 20% of patients admitted every month had just a psychiatric diagnosis: the largest proportion (52%) had a dual diagnosis and the remaining (28%) only a substance abuse diagnosis.

In a German study, 244 patients with schizophrenia in residential care were studied. Eighty-nine of these patients were living in residential facilities of varying size and degree of cover. This study found, as predicted, that patients in residential facilities with intensive cover exhibited the highest numbers of areas of need.[15] Another survey examined 251 patients with schizophrenia aged 40-97 years. Ninety-nine patients were living in residential facilities in the San Diego county and the rest were living independently. Auslander et al.[16] showed that assisted living was associated with heightened characteristics of the disorder (e.g. earlier onset, longer duration, increased negative symptoms and cognitive impairment), lower probability of having ever been married and a poorer subjective well-being. Residential facilities host a selected population within the overall population cared for by mental health services, made up of patients with the most severe and disabling disorders (mostly psychotic): targets, programmes, and activities run in residential facilities should be clearly based on this assumption and be tied to the specific needs and demands of the residents.


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