Benefits of boarding home placement in patients with schizophrenia.

Objective: To determine if boarding home placement of patients with schizophrenia decreases the need for acute inpatient treatment, during and after the placement.

Method: Data was collected from the medical records of 74 patients initially diagnosed with schizophrenia in our hospital from July 2001 to June 2002. The progress of these patients was then tracked until February 2005. Data gathered was analyzed for standard deviation, correlations, paired sample test and t test two-tailed analysis.

Results: Of those patients, 35 had no boarding home (BH) placement and used our inpatient services with a frequency of 1.1 day a month on average. Another 20 patients were placed in a BH after an average period often months without placement in a BH. During the pre-BH period they needed more acute inpatient care (3.3 versus 1.1 day/month) than patients that did not receive BH services (P < 0.0003). Following BH placement, these 20 patients spent an average of 14 months in a BH requiring only 0.34 days/month of inpatient treatment. On discharge from the BH, for the next eleven months they needed only 0.22 days/month of inpatient services. This rate of hospitalization was less than that of the same patients before BH placement (P = 0.0003) and patients that were not placed in a BH (P < 0.001). The remaining 19 patients were lost to follow-up, likely as result of their travel patterns.

Conclusion: The patients who received BH care required fewer days of hospitalization than the same patients in the pre-BH period and fewer days of hospitalization than the patients who did not receive BH care. This effect persisted for at least 11 months after leaving the boarding home.

Key Words: schizophrenia, hospitalization, boarding home care, psychosis 

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Schizophrenia is characterized by the presence of at least three main symptom complexes: positive symptoms, negative symptoms, and interpersonal difficulties, (1,2) all leading to gross impairment in psychosocial functioning.

Of factors influencing the disease course, family environment, substance abuse and duration of untreated psychosis, (3-10) are the most important modifiable predictors of outcome. A structured environment, such as a board and care or residential care facility (boarding home), can positively influence some of the modifiable factors. Based on the National Center for Health Statistics definition (http://www.cdc.gov/nchs), a board and care or residential care facility (boarding home) is a facility that has 3 beds or more that provides 24-hour supervision, provision and oversight of personal and supportive services (assistance with activities of daily living and instrumental activities of daily living), and health-related services. Although the definition has some variations from state to state, we could generally describe the boarding home (BH) as a community-based residential placement with a moderate degree of supervision by responsible staff.

Patients with psychiatric disabilities are more likely to prefer living in settings with less behavioral demand, such as living alone, or living in a state of homelessness. Generally the least desirable situation is long-term psychiatric hospitalization and crisis placement. (11,12) Despite the fact that many patients are likely to return to the places where they lived previously upon discharge from inpatient services, they consistently report a much stronger sense of hope regarding a new beginning (13) following discharge and that they were happier living in the community, regardless of predicament, than in the hospital. (14)

Patients living in a BH due to psychiatric disability (schizophrenia) when compared with patients with the same disability living in other settings in the community may not have differences in their level of psychiatric symptoms, but may have less access to social support, less opportunities for employment and lower levels of global functioning. (15,16) Also, living in an urban setting, compared with a rural setting for patients with chronic schizophrenia, predicts more psychopathology, more interpersonal difficulties and a lower level of global functioning, likely due to less practical support and more expressed emotions in relation to others. (17)

Boarding homes remain a common alternative for patients diagnosed with schizophrenia. Despite many disadvantages, they provide a transitional environment for patients between hospitalization and independent living, fostering compliance with medication and other activities of daily living. (18) Furthermore, while family interventions are an important factor in improving prognosis, (19) patients with schizophrenia often lose the support of family and friends. (20,21) A BH may represent one of the few viable options to stabilize such patients outside of the hospital. In terms of cost, boarding homes and group homes are at the lower end when compared with other alternatives, such as extended hospital care. (22) The disadvantages of BH, such as lack of support and stimulation, (23) can be overcome by training staff and creating a therapeutic environment. (24)

Patients who received boarding home care required fewer days of hospitalization than patients who did not receive care in a boarding home setting.

Searching for an optimal environment upon discharge from the hospital appears to be more difficult not only because of politicoeconomic pressure for a shorter length of hospitalization, (25) but also because of the patients' ambivalence. (26)

In this study, we describe the course and need for acute care of 74 patients assessed and initially diagnosed with schizophrenia in our facility between July 2001 and June 2002. We attempt to determine if boarding home placement of patients with schizophrenia decreases the need for acute inpatient treatment as measured by average days spent on the hospital inpatient service, during and after the period in which our patients reside in the boarding home.

Methods

For this study, we selected all the records for patients initially diagnosed with schizophrenia at a publicly funded state hospital, over a period of one year (July 2001 to June 2002). Their progress was then tracked over a three year period. Patients with mental retardation, pervasive developmental disorders, documented moderate to severe CNS damage and degenerative neurologic disease and other medical conditions that might induce psychotic symptoms were excluded. The study cohort was comprised of 74 patients that met the diagnosis of schizophrenia according to the Fourth Diagnostic and Statistical Manual of Mental Disorders, Text Revision (27) (DSM-IV-TR). Data collected reflected psychiatric assessment in terms of diagnosis, treatment history, symptoms and clinical course, and other assessments reflecting psychological status, demographics, and change in social support systems. The clinical assessment tool used by psychiatrists allowed for a variety of data collection and planning for research with the use of valid and reliable scales, including the Brief Psychotic Rating Scale, (28) and Positive and Negative Symptoms Scale (PANSS) for schizophrenia. (29)

Patient report was compared with collateral reports, documented in standardized sections of the social worker comprehensive assessment and psychiatrist assessments, in terms of accuracy and symptom progression. The documentation for duration of boarding home stay was accurately documented. Data was analyzed using the Statistical Package for Social Sciences (SPSS, version 8) software for standard deviation, correlations, paired sample test and t test two-tailed analysis. Institutional review board approval for the study was obtained in 2002.

Results

Of the 74 patients identified, 45 were male and 29 were female. The average age was 30.9 years (standard deviation = 11.4) and level of education was 11.4 years (standard deviation = 1.9). Fifty three of these patients were never married and 32 had medical insurance. After the first presentation to our hospital, we followed the hospitalization patterns of consecutive patients for three years. They were divided into three groups:

1. First group -- after a period of time averaging 10 months, these patients were placed in a BH for an average of 14.1 month and the hospitalization rate decreased 10-fold. After discharge from the BH, the rate of hospitalization was documented over a period of 11.8 months.

2. Second group -- never accepted BH placement, and over the three year period, had an average of one day of hospitalization a month.

3. Third group -- consisted of travelers with documented hospitalizations in two or more states in the past.

There were a total of 20 patients who were treated in a BH setting for an average period of 14.1 month (standard deviation 11.7). They were accepted in the BH on average of 10.15 months (standard deviation 6.2) from the time of initial presentation to our facility. Upon discharge from the BH they continued to use our emergency department (ED) and inpatient services for 11.8 months (standard deviation 9.6) to the end of the data collection in February, 2005. The trigger that prompted BH referral was, in most cases, persistent psychosis requiring inpatient hospitalization (average 3.3 hospitalization days per month). During the BH placement, the need for inpatient stabilization decreased to 0.33 days per month, representing a significant decline from the pre-BH period (P = 0.002, df 19, t = 3.5) using the n-paired sample test. After discharge from the BH, these patients continued to require less inpatient treatment than before BH placement (0.24 d/mo, P = 0.0003, df 19, t = 4.3) comparable to the rate of hospitalization while in the BH (P = 0.21).

Thirty-five patients did not have BH placement and over the 35 months of chart review they had an average of one day per month of inpatient treatment in our facility. They required less inpatient treatment days than the pre-BH placement patients (P = 0.0003, df 34, t = 7.38) but more hospital days than the same patients during and after BH placement (P < 0.001, df 34, t = 7.3). Despite the differences in hospitalization days, the non-BH patients did not differ in the number of visits to the hospital over the 3 years with the patients that had BH (3.5 visits versus 3.05, P = 0.55, Fig. 1).

From all patients with or without BH referrals, 26% lived alone, 44.4% lived with family, and 30% were homeless. There was no difference in housing arrangements except that patients with non-BH placement were more likely to stay with family (18/32 compared with 6/20, P < 0.001, df 34, t = 6.3). Furthermore, there was no correlation between increase in drug use in patients receiving BH care, when compared with patients outside of a BH. Extensive travel history (more than two states) after the schizophrenic diagnosis was documented in 28 patients. Only nine patients from the 28 with an extensive travel history settled in this area as documented in their medical records and by the repeated visits in the following years. The remaining 19 patients had an average of 1.2 visits to the hospital and for those patients that had more than one visit, this occurred within 2 months of the initial contact. Six of the patients that remained in the area were offered boarding home services (Fig. 2).

[FIGURE 1 OMITTED]

Level of education did not have any correlation with utilization of BH. Patients with BH placement achieved an average level of education of 11.3 years, (standard deviation 1.8) while those without BH placement had 11.45 years of education (standard deviation 1.93). Global assessment of functioning (GAF) at the first discharge assessment for patients that received BH placement was less than that of the patients without BH placement (average = 55 and 59, respectively, standard deviation = 7.4 and 11 respectively and P < 0.001, df 19, 34, t = 32).

Discussion

More then one factor influenced the decision to refer the patients for BH placement upon discharge. The most important factor was the high rate of hospitalization of these patients in the months leading to this decision. The second factor was the availability of BH. The third factor was the patient's ability to accept or decline the proposed placement. The fourth criterion was a statistically significant lower GAF at discharge for patients placed in a BH. The patients who were referred to the BH were less likely to live with family, suggesting less family support. We failed to demonstrate the lower level of education in the patients residing in the BH compared with other patient groups, that has been previously suggested in the literature. (30) Our findings support the observation that schizophrenic patients who are placed in a BH have a lower level of global functioning (15,16) when compared with schizophrenic patients living in their own home. We suggest that this finding represents bias of selection at the time of hospital discharge. In other words, patients may be selected for boarding home placement as a result of a lower baseline level of functioning. Patients with an established diagnosis of schizophrenia demonstrated an increased travel pattern, often connected with their delusional symptoms, when compared with patients with a recent diagnosis of schizophrenia. This can also introduce bias, as these patients are often lost to follow-up due to this travel pattern. On the other hand, this suggests that the BH benefit is greater than that observed, as patients in boarding homes are accurately monitored.

[FIGURE 2 OMITTED]

One limitation of this study is typical of retrospective chart reviews, in that there was no control of racial and demographic distribution. A second limitation is sample size (74 patients). Furthermore, because the mission of the hospital public mental health services targets a patient population with a high rate of uninsured status, our patients tend to use our services for acute inpatient treatment as well as outpatient-type services (ED visits for medication refills).

Placement in a BH appears to offer several advantages, including improved quality of life for patients who were more likely to remain in the community (out of the hospital) and lower cost to the community in terms of hospital expenses, police interventions and utilization of homeless shelters. An additional benefit appears to be the opportunity to learn new skills that they can use in the future. This may, in part, explain the persistent effect of lower rates of hospitalization, even months after leaving the BH.

The boarding home placement of schizophrenic patients correlated with a lower rate of need for acute inpatient stabilization. This correlation persisted for at least eleven months after the patients left BH placements.

Acknowledgments

To Dr. Daniela Bota. Without her support this paper could not have been possible. To Dr. RK Hornstra for critical suggestions.

References

1. Carpenter WT Jr, Strauss JS. The prediction of outcome in schizophrenia, IV: eleven-year follow-up of the Washington IPSS cohort. J Nerv Ment Dis 1991;179:517-525.

2. Strauss JS, Carpenter WT Jr, Bartko JJ. The diagnosis and understanding of schizophrenia, III: speculations on the processes that underlie schizophrenic symptoms and signs. Schizophr Bull 1974;11:61-69.

3. Kane JM, McGlashan TH. Treatment of schizophrenia. Lancet 1995;346:820-825.

4. Larsen TK, McGlashan TH, Moe LC. First-episode schizophrenia, I: early course parameters. Schizophr Bull 1996;22:241-256.

5. Loebel AD, Lieberman JA, Alvir JM, et al. Duration of psychosis and outcome in first-episode schizophrenia. Am J Psychiatry 1992;149:1183-1188.

6. Malla AK, Norman RM, Manchanda R, et al. One year outcome in first episode psychosis: influence of DUP and other predictors. Schizophr Res 2002;54:231-242.

7. Malla AK, Norman RM, Manchanda R, et al. Status of patients with first-episode psychosis after one year of phase-specific community-oriented treatment. Psychiatr Serv 2002;53:458-463.

8. Norman RM, Malla AK. Duration of untreated psychosis: a critical examination of the concept and its importance. Psychol Med 2001;31:381-400.

9. Peterson D, Olson G. First admitted schizophrenics in drug era. Arch Gen Psychiatry 1964;11:137-144.

10. Wyatt RJ. Neuroleptics and the natural course of schizophrenia. Schizophr Bull 1991;17:325-351.

11. Owen C, Rutherford V, Jones M, et al. Housing accommodation preferences of people with psychiatric disabilities. Psychiatr Serv 1996;47:628-632.

12. Parker G, Barr R. The exodus of long-stay psychiatric patients. Med J Aust 1975;1:801-803.

13. Johnson B, Montgomery P. Chronic mentally ill individuals reentering the community after hospitalization, phase II: the urban experience. J Psychiatr Ment Health Nurs 1999;6:445-451.

14. Barr R, Parker G. The effects of discharge on long-stay psychiatric hospital patients. Aust N Z J Psychiatry 1975;9:47-49.

15. Browne G, Courtney M, Meehan T. Type of housing predicts rate of readmission to hospital but not length of stay in people with schizophrenia on the Gold Coast in Queensland. Aust Health Rev 2004;27:65-72.

16. Heinemann SH, Yudin LW, Perlmutter F. A follow-up study of clients discharged from a day hospital aftercare program. Hasp Community Psychiatry 1975;26:752-754.

17. Davies MA, Bromet EJ, Schulz SC, et al. Community adjustment of chronic schizophrenic patients in urban and rural settings. Hasp Community Psychiatry 1989;40:824-830.

18. Jorda-Moscardo E, Espinosa Iborra J. Study of alternative accommodation, using the hospital hostel practices profile. Soc Psychiatry Psychiatr Epidemiol 1991;26:151-156.

19. Pitschel-Walz G, Leucht S, Bauml J, et al. The effect of family interventions on relapse and rehospitalization in schizophrenia: a meta-analysis. Schizophr Bull 2001;27:73-92.

20. Bota RG, Sagduyu K, Munro JS, et al. Factors associated with prodromal presentation that influences schizophrenia prognosis. CNS Spectrum 2005;10:937-942.

21. Bota RG, Munro JS, Sagduyu K, et al. Identification of the schizophrenia prodrome in a hospital based patient population. Missouri Medicine 2005;102:154-158.

22. Green T, Hornblow A, Sheerin I, et al. Residential care for the long term mentally ill in Canterbury: options, costs and funding sources. N Z Med J 1992;105:371-373.

23. Blake R. Boarding home residents: new underclass in the mental health system. Health Soc Work 1987;12:85-90.

24. Dubin WR, Ciavarelli B. A positive look at boarding homes. Hosp Community Psychiatry 1978;29:593-595.

25. Jones M. Community care for chronic mental patients: the need for a reassessment. Hosp Community Psychiatry 1975;26:94-98.

26. Sumida K, Tsuda H. [Structuralistic and meta-psychological approaches to ambivalence in schizophrenia]. Seishin Shinkeigaku Zasshi 2003;105:1037-1044.

27. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC, American Psychiatric Association, 2000.

28. Flemenbaum A, Zimmermann RL. Inter- and intra-rater reliability of the Brief Psychiatric Rating Scale. Psychol Rep 1973;32:783-792.

29. Kay SR, Fiszbein A, Opler LA. The positive and negative syndrome scale (PANSS) for schizophrenia. Schizophr Bull 1987;13:261-276.

30. Liberakis EA. Factors predisposing to institutionalism. Acta Psychiatr Scand 1981;63:357-366.

Robert G. Bota, MD, J. Stuart Munro, MD, and Kemal Sagduyu, MD

From the Department of Psychiatry, University of Missouri Kansas City, Kansas City, MO.

Reprint requests to Robert G. Bota, MD, Assistant Clinical Professor, Department of Psychiatry, University of Missouri Kansas City, 415 N Jackson St, Americus, GA 31709. Email: [e-mail]

Parts of these results were presented at: "Boarding home placement in patients with schizophrenia: predictor of better prognosis" (abstract has been chosen as 1 of the best 25) Southern Medical Association, 2005; and "Boarding Home placement in patients with schizophrenia: predictor of better prognosis" Presentation Poster at 57th Institute on Psychiatric Services-APA, October, 2005.

Accepted August 15, 2006.

RELATED ARTICLE: Key Points

* From all the factors postulated to influence schizophrenia, family environment, substance abuse and duration of untreated psychosis are the most important modifiable predictors of outcome.

* A structured environment can positively influence some of the modifiable factors.

* Patients with psychiatric disabilities are more likely to prefer living in a setting with less behavioral demands, such as living alone, or in a state of homelessness. These environments are not conducive to their mental well being, and lead to less desirable situations, such as long-term psychiatric hospitalizations and crisis placement.

* In terms of cost, boarding homes (BH) and group homes are at the lower end when compared with extended hospital care. The disadvantages of BH, such as lack of support and stimulation, can be overcome by appropriately training the staff and creating a better therapeutic environment.