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Biomedical subjects

R L Okin

Publications and source records attributed to R L Okin.

At least 19 recordsLinked to original sources
PubMed2004

Predictors of medical service utilization among individuals with co-occurring HIV infection and substance abuse disorders.

This study examined factors affecting medical service use among HIV-infected persons with a substance abuse disorder. The sample comprised 190 participants enrolled in a randomized trial of a case management intervention. Participants were interviewed about their backgrounds, housing status, income, alcohol and drug use problems, health status and depressive symptoms at study entry. Electronic medical records were used to assess medical service use. Poisson regression models were tested to determine the effects of need, enabling and predisposing factors on the dependent variables of emergency department visits, inpatient admissions and ambulatory care visits. During a two-year period, 71% were treated in the emergency department, 64% had been hospitalized and the sample averaged 12.9 ambulatory care visits. Homelessness was associated with higher utilization of emergency department and inpatient services; drug use severity was associated with higher inpatient and ambulatory care service use; and alcohol use severity was associated with greater use of emergency medical services. Homelessness and substance abuse exacerbate the health care needs of HIV-infected persons and result in increased use of emergency department and inpatient services. Interventions are needed that target HIV-infected persons with substance abuse disorders, particularly those that increase entry and retention in outpatient health care and thus decrease reliance on acute hospital-based services.

Adult↗
PubMed2000

The effects of clinical case management on hospital service use among ED frequent users.

This study examined the impact of case management on hospital service use, hospital costs, homelessness, substance abuse, and psychosocial problems in frequent users of a public urban emergency department (ED). Subjects were 53 patients who used the ED five times or more in 12 months. Utilization, cost, and psychosocial variables were compared 12 months before and after the intervention. The median number of ED visits decreased from 15 to 9 (P < .01), median ED costs decreased from $4,124 to $2,195 (P < .01) and median medical inpatient costs decreased from $8,330 to $2,786 (P < .01). Homelessness decreased by -57% (P < .01), alcohol use by -22% (P = .05) and drug use by -26% (P = .05). Linkage to primary care increased 74% (P < .01). Fifty-four percent of medically indigent subjects obtained Medicaid (P < .01). There was a net cost savings, with each dollar invested in the program yielding a $1.44 reduction in hospital costs. Thus, case management appears to be a cost-effective means of decreasing acute hospital service use and psychosocial problems among frequent ED users.

Adult↗
PubMed1995

Long-term outcome of state hospital patients discharged into structured community residential settings.

OBJECTIVE: This longitudinal study examined various dimensions of the lives of patients with chronic mental illness immediately before and again several years after their discharge from a state hospital into well-staffed structured community residential settings. METHODS: Fifty-three patients with chronic mental illness and long histories of hospitalization were evaluated shortly before their state hospital discharge using a comprehensive structured assessment of nine dimensions of functioning and symptomatology. A follow-up assessment was undertaken a mean of 7.5 years after discharge into four structured group home settings. RESULTS: At follow-up, 57 percent of the patients continued to live in structured community residential settings, 28 percent had moved on to independent living, and 16 percent had returned to an institutional setting. Fifty-five percent needed hospital readmission, but the total sample spent only 11 percent of the time after discharge in the hospital. At follow-up, patients showed significant improvements in cognitive and social functioning, and 94 percent expressed a preference for life in the community. CONCLUSIONS: Many patients discharged to structured community residential settings seem to prefer them to the state hospital, are able to graduate to independent settings, and show improvement in important dimensions of functioning after several years in the community. Other dimensions seem resistant to change despite the structure and support afforded by residential settings.

Activities of Daily Living↗
PubMed1995

Testing the limits of deinstitutionalization.

OBJECTIVE: From 1978 to 1993, under favorable administrative and political conditions and protected by a court-ordered consent decree, a comprehensive community-based mental health system was established in western Massachusetts that entirely replaced Northampton State Hospital. This paper examines that experience to describe the characteristics and comparative department of mental health expenditures on alternative treatment settings and to explore whether the need for state hospitals can be eliminated. METHODS: Data on distribution and department of mental health funding of services in western Massachusetts were compared with similar data from the rest of the state, where state hospital utilization remained relatively high. RESULTS: Between 1978 and 1992, department of mental health expenditures on noninpatient community services in western Massachusetts increased from 15 percent to 74 percent of total expenditures on adult mental health services. In 1992 per capita expenditures on such services in western Massachusetts and the rest of the state were similar. However, per capita expenditures for inpatient services constituted 27 percent of total expenditures in western Massachusetts, compared with 53 percent in the rest of the state. Western Massachusetts spent approximately twice as much per capita on residential and emergency services and one and a half times as much on case management services and support. Very few Northampton patients were transferred to nursing homes, and the inpatient census per 100,000 population supported by the department of mental health in western Massachusetts was one-third of that in the rest of the state. CONCLUSION: Under certain conditions, the role and functions of state hospitals can be completely replaced by a system of comprehensive community services.

Adult↗
PubMed1993

Patients' perceptions of their quality of life 11 years after discharge from a state hospital.

OBJECTIVE: Fifty-three state hospital patients discharged to group homes in the community in 1978-79 were followed up at three and 11 years to assess their quality of life and several other dimensions of their community experience. METHODS: A structured interview was used to obtain data on patients' perceptions of and degree of satisfaction with aspects of their lives one month before hospital discharge and at three and 11 years after. Group home staff rated patients' functioning at follow-up. Data on rehospitalizations over the 11-year period were collected. RESULTS: At 11-year follow-up, 30 of the surviving 40 patients were living in noninstitutional settings: nine in independent or semi-independent settings and 21 in group homes. The 30 patients perceived that their quality of life outside the hospital had improved in several ways, including the extent of their social networks, the quality of their living environment, and their capacity to meet basic needs. When data were averaged over the 11 years and corrected for the shorter time in the study of subjects who died, patients spent only 2.6 percent of the follow-up period in the hospital. Only one patient at 11 years wanted to return to the hospital. CONCLUSIONS: The finding that even the small minority of patients who required multiple rehospitalizations preferred community life may have important clinical and policy implications for setting the threshold of hospital discharge.

Activities of Daily Living↗
PubMed1990

Predictions about new long-stay patients: were they valid?

During 1979-1989, the long-stay population in Massachusetts state psychiatric hospitals declined and then moderately increased, although to far below its initial 1979 level. The increase toward the end of the period was due to a growing number of patients admitted, an increase in the proportion of these new patients who were retained for 1 year or longer, and a decrease in discharges of long-stay patients, especially those hospitalized for 20 or more years. The last factor was particularly important and was due to the fact that the number of these very-long-stay patients had become so small by 1983 that the effect of their continued discharge on the total long-stay population was minimal. The authors point out that more community services, not more hospital beds, may be needed. They recommend that states assess the clinical needs of the long-stay population before determining how to allocate their resources to address this phenomenon.

Community Mental Health Services↗
PubMed1986

The relationship between legal status and patient characteristics in state hospitals.

Concerns raised in response to proposals that general hospitals admit patients who currently receive acute care in state hospitals have focused primarily on certain assumptions about the characteristics of involuntary patients in contrast to their voluntary counterparts. The author compared a group of voluntary and involuntary patients in seven state hospitals. Contrary to some recent reports, legal status was not associated with chronicity, prevalence of psychosis, extent of social ties as measured by marital status and living situation, or need for seclusion or restraint. The two groups differed significantly in median length of stay but in an opposite direction from that previously reported.

Adolescent↗
PubMed1985

Beyond state hospital unitization: the development of an integrated mental health management system.

As commissioner of the Massachusetts Department of Mental Health, the senior author in 1975 initiated a reorganization of the department designed to provide greater continuity of care for deinstitutionalized patients by integrating management of hospital and community services at a local level. The new system continued the practice of dividing hospitals into units corresponding to geographical catchment areas (unitization), but it abolished the hospital superintendent's position and greatly broadened the role of the area directors of community services to include clinical administration of the hospital unit serving patients in catchment areas. The authors believe the new system played a role in reorienting the department's services toward community care of the seriously disabled patient and led to a more effective distribution of departmental resources.

Catchment Area, Health↗
PubMed1985

Variation among state hospitals in use of seclusion and restraint.

The author attempted to determine whether hospitals of the same type, with similar admission and discharge policies and operating under identical regulations, had similar patterns of use of seclusion and restraint. Admissions to seven Massachusetts state hospitals over a two-week period were followed until discharge or up to 16 weeks. The hospitals were found to use confinement to widely varying degrees that could not be explained by patient demographic characteristics, legal status, diagnoses, or violence-related behavior preceding hospital admission. The author suggests that factors relating to individual hospital practices and conditions strongly influence the use of confinement. He discusses the implications of this conclusion.

Adult↗
PubMed1985

Expand the community care system: deinstitutionalization can work.

The author argues that most of the mentally ill should be treated in the community, where they can develop the skills necessary to function in society. The state hospitals should be used only to treat the most unmanageable patients. The author blames the presently inadequate community care system on insufficient funding and on the tendency of states to divide newly available funds between community services and state hospitals so that neither system is adequate. But whereas community care's problems can be resolved through greater commitment of funds and other measures, the author contends, the shortcomings of the state system are built-in and intractable. He examines and refutes the arguments supporting a return to the state hospital system.

Community Mental Health Services↗
PubMed1984

Brewster v Dukakis: developing community services through use of a consent decree.

Filed against the state of Massachusetts in 1977, Brewster v Dukakis involved the claim that psychiatric patients living in state hospitals or at risk of being hospitalized in these facilities have a right to treatment in community settings. The decree that emanated from the suit resulted over a 5-year period in a tenfold increase in state expenditures for community mental health services, a 48% decline in the state hospital census, and a 15% drop in the state hospital admission rate in the region of the state targeted by the suit. Factors that facilitated this outcome are described, as well as the dangers and limitations of exclusive reliance on the judicial process to promote the development of community services.

Community Mental Health Services↗
PubMed1984

How community mental health centers are coping.

Many community mental health centers have had to operate with less funding in the past several years, especially since the advent of block grant funding. Evidence is now accumulating that some centers have had to decrease their overall level of services and staffing. Others have attempted to adjust by increasing their clinician caseloads, closing their satellite facilities, and de-emphasizing services that fail to generate adequate fees and third-party reimbursements, such as consultation and education, partial hospitalization, and programs for children and the elderly. In contrast, and partly as a result of the increased authority of the states over the community mental health centers program, services for the severely and chronically mentally ill appear to be receiving higher priority. This development will require that centers improve their access to the general health care sector, maintain and improve their relationships with academic institutions, and increase the number, responsibilities, and rewards of the psychiatrists they employ.

Aged↗
PubMed1983

Patients' perspectives on community alternatives to hospitalization: a follow-up study.

Few studies of deinstitutionalized patients in the community have focused on the quality of the patients' lives. The authors interviewed 31 patients discharged from a state hospital to community residences and 10 patients who remained in the hospital. Patients were evaluated at three time intervals on eight outcome indexes. Eight months after the patients left the hospital they reported significant positive changes in the quality of their lives. None of the patients were rehospitalized during the study period.

Attitude to Health↗
PubMed1983

The future of state hospitals: should there be one?

The recognition of the serious problems of state hospitals that dominated public policy in the 1960s has been largely overshadowed in recent years by a preoccupation with the problems of deinstitutionalization. The current backlash against the community movement threatens to legitimize once again the state hospital as an acceptable solution to the problems of the severely mentally ill. The author argues that state hospitals are deficient not simply because they provide an inferior quality of care but because they provide the wrong kind of care for most of their patients. He suggests that most state hospitals be completely replaced by a fundamentally different system.

Deinstitutionalization↗