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

Process Data

An important area of investigation is the process of care, which can help identify the characteristics which residential facilities should have in order to maximize the likelihood of positive outcomes and improve the QOL of residents (as well as that of staff and relatives). Very few studies on the process of care have recently been conducted in residential settings.

Holmqvist[17*] assessed staff feelings toward patients and treatment outcome after 5 years at 23 residential facilities in Sweden. These residential facilities housed 111 patients (mean age 29.3 years), of whom 52% had a diagnosis of schizophrenia. Outcome was measured with Kernberg's Structural Interview, while staff's feelings were evaluated with a specific feeling checklist administered twice a year. At the end of the survey, a total of 4568 checklists were assessed. In the whole group, there were no correlations between the general staff feelings and outcome. Interesting results were found, however, when data for psychotic and borderline patients were analysed separately. For psychotic patients, the absence of negative feelings, rather than the presence of positive feelings, was associated with a positive outcome. By contrast, for borderline patients, a positive outcome was associated with negative feelings at the beginning of treatment, followed by strong positive feelings later on.

In another study carried out in nine small residential facilities in Sweden, 33 residents (mean age 41 years) and 50 staff members filled in the Community Oriented Program Environmental scales,[18,19] designed by Moos to assess community-based residential settings. According to the results of this study, the social environment of residential facilities should include high levels of social interaction, a supportive profile with organization, programme clarity, and a low level of staff control, anger and aggression. Both studies highlight the importance of a key process variable, that is staff characteristics. In this area, the expressed emotion construct and its application to the study of staff-patient relationships may prove particularly useful to chart the emotional climate between clients and professional caregivers in a reliable and analytical way.[20*]

An important area of improvement for the quality of residential care is represented by the development of specific assessment instruments tailored to the specific features and needs of long-term residents. The Resident Assessment Instrument-Mental Health is a comprehensive, multidisciplinary mental health assessment system for use with adults in various types of facilities, including long-term residential facilities. It evaluates psychiatric, social, environmental and medical issues at entry in a residential programme, emphasizing patient functioning. The instrument includes 166 items covering 28 different areas.[21] The inter-rater reliability and convergent validity of the instrument have been assessed in a sample of 261 patients, of whom 28% resided in residential facilities[22]; almost all domain areas obtained average kappa values in excess of the 0.40 cut-off established for acceptable reliability.

In general, the few studies published in the years 2000-2004 and focusing on the process of care point to a very important issue: how to effectively run residential facilities. This includes the functional characteristics of such settings (also in terms of rules and procedures) associated with positive outcomes, and the staff's prevailing feelings and attitudes and how they should be managed in order to maximize residents' outcomes. If we want that these settings do not become simply custodial institutions, we need evidence-based guidelines on the best staff management strategies (e.g. the ratio of individual patient-centred work to group-based interventions, optimal use of staff's time in terms of meetings, educational activities, etc). So far, all these strategies have been almost entirely based on subjective views of facility managers or of 'local' charismatic figures, whose dicta were rarely disputed.

Interestingly, while in the past there have been a number of studies exploring the relationships between residential facilities and the local neighbourhood,[23,24] in recent years no studies have investigated this area, which is important in order to foster residents' integration and avoid the creation of self-segregating institutions.

The only recent study which has assessed certain aspects of residents' pharmacological treatment has analysed the association between medication adherence and a number of environmental and clinical variables. This took place in a small, convenient sample of 74 patients with schizophrenia living in four residential facilities in New York City.[25] The authors found that lack of direct medication supervision, negative medication attitude and lower GAF score were associated with increased medication nonadherence in the recent past. They recommend adequate supervision in these settings in order to ensure medication compliance.


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