International Journal of Mental Health Nursing (2011) 20, 274283

doi: 10.1111/j.1447-0349.2010.00726.x

Feature Article

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274..283

Is deinstitutionalization working in our community?

Ann Hamden,1 Richard Newton,2 Kay McCauley-Elsom3 and Wendy Cross4
1 Community Mental Health, Latrobe Regional Hospital, Traralgon, 2Mental Health CSU, Austin Health, 3School of Nursing, Monash University, Peninsula Campus, and 4School of Nursing and Midwifery, Monash University, Melbourne, Victoria, Australia

ABSTRACT: This exploratory study examined the impact of deinstitutionalization on consumers admitted to a regional community care unit (CCU) between 1996 and 2007, and looked at lengths of stay and re-admissions to acute psychiatric care units and the impact this might have on quality of life. The results showed that the original and current residents of CCU have improved quality of life through friendships, a home-like environment, and reduced re-admissions to acute psychiatric care units; however, further improvements can be made with more emphasis on employment/vocational services and social inclusion. More concerning is those who are unable to access a CCU bed due to chronic CCU bed shortages. This group, referred to as the new chronic patients, tend to become victims of the revolving door phenomenon, homelessness, and substance abuse. The assertive community treatment model of care and community packages are recommended for people on waiting lists for CCU, or those who do not t the CCU criteria, to try and reduce the level of disability that is likely to occur from frequent relapses. KEY WORDS: assertive community treatment, community care unit, deinstitutionalization, psychosocial treatment, revolving door, substance abuse.

INTRODUCTION
To many, deinstitutionalization was the closing down of psychiatric health institutions and placing the occupants into the community with or without follow-up care. To the reformist, it meant both the closure of the institutions and their replacement with a range of community-based services, including residential and inpatient services and treatment within the home. In early 1990 under the Labor Government multiple asylums across Victoria, Australia were consuming

Correspondence: Ann Hamden, General Manager Community Mental Health, Latrobe Regional Hospital, 20 Washington Street, Traralgon, Vic. 3844, Australia. Email: ahamden@lrh.com.au Ann Hamden, RN, RPN, MN. Richard Newton, MBChB, MRCPsych, AFRACMA, FRANZCP. Kay McCauley-Elsom, RN, RM, PhD. Wendy Cross, RN, PhD. Accepted November 2010.

a large proportion of the state budget. As part of a broader policy of deinstitutionalization community care units (CCU) were established in Victoria to accommodate people remaining in long-term psychiatric settings. The CCU in this study is a 20-bed cluster housing development in a residential setting, staffed on a 24-hour basis by a multidisciplinary team. It was established with the twin goals of clinical care and rehabilitation of the residents. Little is known about the long-term outcomes for these consumers and the impact on the younger generation with chronic, severe mental illness (SMI). A study by Farhall et al. (1999) concluded that after 1 year, there was little change in the symptoms or disability levels of the residents, although residents reported improved levels of quality of life, particularly in their living environment. Relatives and carers also reported a preference for the CCU setting for their relatives over hospitalization.

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Background and literature review

Deinstitutionalization began as far back as the 1950s and has led to the downsizing and closing of multiple asylums across the world (Fakhoury & Priebe 2002). However, Mechanic and Rochfort (1990) believe that deinstitutionalization has not been implemented consistently across geographic areas, and policy does not stipulate the expected outcomes. Although, globally, deinstitutionalization began some 60 years ago, Sealy and Whitehead (2004) assert that it is not complete because there are no measures to determine when the expansion of community-based services has been completed. Furthermore, Fakhoury and Priebe (2007) stated that there are still many large tertiary longterm care facilities and no community-based mental health services in many countries, despite deinstitutionalization occurring in several countries. The process of deinstitutionalization in mental health services seems to be progressing at different paces in several countries where the problems vary in relation to socioeconomic situations, funding arrangements, and specic traditions. According to Fakhoury and Priebe (2002) and Sealy and Whitehead (2004), the quality of mental health systems depends on these factors as well as social acceptance of deinstitutionalization. The Australian National Mental Health Strategy (1992) was the driving force behind deinstitutionalization in Victoria. In addition to the establishment of CCU, it also included the development of the crisis assessment and treatment teams, mobile support and treatment services, continuing care services, and community mental health clinics. Acute inpatient services were co-located and mainstreamed with general hospitals along with secure extended-care units which provide medium- to long-term inpatient treatment and rehabilitation for people who have unremitting and severe symptoms of mental illness with an associated signicant disturbance in behaviour that preclude their living in a less restricted environment (Victorian Government 2007). According to Newton et al. (2000) in the early 1990s large metropolitan psychiatric services were reportedly consuming 45% of the budget of mental and general health services, through administration and infrastructure. To address this issue, the Victorian Government established CCU across the state. The development of supported accommodation in the community has had some encouraging outcomes for residents, at least in the short term, both here and overseas (Farhall et al. 1999; Hobbs et al. 2000; Leff & Trieman 2000). The emergence of consumer and family self-help and advocacy groups

also assisted in the development of a more humanistic treatment system (Lamb et al. 2003). An increase in opportunities for long-stay residents to regain social inclusion was anticipated to be another positive aspect of deinstitutionalization (Newton et al. 2000). Unfortunately, the evidence for the success of deinstitutionalization has not all been positive. There is growing acknowledgement that the mental health system in Australia is failing to adequately support some of the most disadvantaged members of our community (Groom et al. 2003; Meadows & Singh 2003). The largest aw, according to Feldman et al. (2003) was that consumers were discharged to the community without appropriate housing and follow up, resulting in neglect. This is supported by Moxham and Pegg (2000), who suggest that implementation over the past 20 years has resulted in a lack of appropriate accommodation, and it is this consequence that appears central to the ongoing difculties related to deinstitutionalization. Affordable, secure housing for people with mental illness is integral to the provision of mental health care. Importantly mental health care must be provided in the least restrictive manner for those who require it. The provision of appropriate housing has been the least well-developed component of the deinstitutionalization process. Secure, appropriate and affordable housing provides people with an increased chance of effective treatment and rehabilitation and without this the morbidity and mortality rates arising from homelessness or inappropriate housing is compromised (Moxham & Pegg 2000) and often leads to relapse and consequent re-admission to hospital (Lamb & Weinberger 2001). In acute settings in mental health services the revolving door phenomenon is commonplace (de Girolama & Cozza 2000; Dixon & Goldman 2004; Razali 2004; Sawyer 2005). This phenomenon refers to the rapid and repeated admission and discharge of people with mental health problems. Front-end services such as emergency departments (ED) and acute inpatient units are largely governed by key performance output indicators including length of stay (LOS) in hospital (in both ED and inpatient units) and re-admissions to hospital within 28 days of discharge. These two factors, along with an increase in demand for mental health care since the closure of institutions, have contributed to the premature discharge of people who still have acute symptoms of mental illness. In addition comorbidities such as substance misuse and social issues such as homelessness and unemployment are all factors that contribute to relapse and the revolving door syndrome (de Girolama & Cozza 2000; Dixon & Goldman 2004; Razali 2004; Sawyer 2005).

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Sheth (2009) believes that the deinstitutionalization movement has actually resulted in transinstitutionalization, where large numbers of people with a mental illness have landed in the prison system or homeless shelters. Sheth (2009) estimates that up to 40% of people in homeless shelters have an SMI. There is also a view that CCU are mini institutions. More evidence for that view is needed, especially in Australia. Nevertheless, those who have been admitted to CCU in Victoria have had a welcome change to the previous institutional living. Many consumers experienced psychiatric institutions in Victoria that were locked, had dilapidated buildings, and had scant privacy and dignity. CCU are relatively modern cluster homes, where residents have their own unit or a shared unit with one other resident. The psychosocial rehabilitation programmes have improved signicantly and include more social activities, promoting social inclusion. Moreover, LOS ranges from a few weeks or months to over 1 year, rather than for the whole of life, as evidenced in the demographic data from this study. New long-term patients (Lamb & Weinberger 2001) refers to consumers who have spent minimal time in acute inpatient care with little opportunity for initiation of the recovery process. Recovery is viewed by many as regaining a fullling life, with or without symptoms, being able to manage symptoms, retaining ones identity, and accepting ones illness (Bonney & Stickley 2008). Lamb and Weinberger (2001), highlight the needs of a small proportion of people with SMI who might still require 24-hour care including the provision of ongoing, structured environments in order to promote recovery. A key consideration following the reform in mental health care and its effect on those receiving care, is whether the LOS in CCU is reducing for new residents and whether there is an impact on outcomes such as quality of life. This study sought to identify aspects of quality of life for those currently in CCU and for those who were deinstitutionalized and have since left the CCU environment. Notably, Quality of life, as a concept, over the last two decades become a focal point for mental health services, research and service planning for people who experience psychiatric disabilities (Priebe et al. 1999a, p111). Priebe et al. (1999a) also argued that the ultimate outcome for residents is their quality of life as this is the basis of the biopsychosocial model of service delivery that dominates mental health programming today. Priebe et al. (1999a), along with other authors (Bigelow & Young 1991; Bigelow et al. 1991; Brunt & Hansson 2004; Chan et al. 2003; Nieuwenhuizen et al. 1998) support the evaluation of mental health services through quality-of-life studies; however, with less empha-

sis on symptoms and social functioning assessments. There is however, a paucity of current Australian qualityof-life studies reporting on outcomes for those who experienced deinstitutionalization in this country, with the Trauer et al. (2001) study being the only Australian study found in the literature. The study by Trauer et al. (2001) concluded that despite minimal change in symptoms and disability levels there were improvements for the residents quality of life in terms of living environment. The majority of consumers preferred the CCU setting to hospital. Relatives and carers also reported preferring CCU to hospitals. Staff too while initially sceptical of the move, reported changes in the way they related to consumers and their views on rehabilitation. The older age and chronicity of a large majority of the sample could be largely related to the minimal change in levels of disability and symptoms. Trauer et al. (2001) also discussed the need for further studies to look at the function of CCU and their emerging needs now that there is a signicant reduction in the availability of inpatient beds, and this is the motivation behind this research. A further study seeking CCU staffs views about rehabilitation practices within the workplace, their expectations of consumer improvement, and the role of CCU, as well as job satisfaction and stress was conducted but not included in this article.

METHOD Study design

This study is a descriptive, exploratory design using quantitative approaches.

Aim
The research aimed to identify: (i) the quality-of-life variables for past and present residents of CCU; (ii) the attitudes of past and current residents regarding CCU; (iii) if there is a reduction in LOS in CCU; and (iv) the impact on re-admissions to hospital.

Sample
A convenience sample was utilized in this study. There were two key cohorts of eligible participants. The rst group comprised current residents in the CCU (n = 16), and the second group comprised residents admitted to the CCU between 1996 and 2007 (n = 15), as identied via the client management interface (CMI) system.

Data
Data were gathered using the database data of hospital admissions (CMI), which produced the information

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regarding residents demographics and contact details. This was followed with interviews of current CCU residents and a survey of previous CCU residents. Data were analysed using SPSS version 14 (SPSS, Chicago, IL, USA).

Demographic data
Two different streams of demographic data were identied in this study.
Previous residents

coefcient (with 95% condence intervals) measured the extent of agreement between the rst and second interviews. Of the 13 items in the PAQ, all had kappa values in excess of 0.7 showing good agreement. Results from the PAQ show convincingly that consumers prefer the community to hospital living and have far more autonomy, which suggest that in addition to reliability the PAQ also has face validity. The study showed that long-term psychiatric consumers can give clear and concise views regarding their experiences.
MANSA

A retrospective examination of medical record data on CCU residents from 1996 to 2007, relating to LOS, diagnoses and re-admissions to acute psychiatric care units was performed to determine changes in admission patterns over time. This involved identifying and analysing data on residents demographic information (e.g. age, sex, location), as well as diagnoses, LOS in the CCU, and re-admissions to acute care. The CMI was used to collect these data.
Current residents

The same demographic data were also collected on all current residents of the CCU and comparisons were then made between the two groups (discharged vs current residents).

The validity and reliability of the quality-of-life tool, the MANSA was reported by Priebe et al. (1999b). Wellbeing and life satisfaction are referred to as the subjective component, determined by using satisfaction scales related to different areas of life. The objective data are related to areas such as employment, health, safety, relationships, leisure, nances and accommodation. Priebe et al. (1999b) interviewed 55 people with several satisfaction tools including the MANSA. The Pearsons correlations of the subjective quality of life were all 0.83 or higher (0.94 mean score) and Cronbachs alpha for satisfaction ratings was 0.74. The authors concluded that the MANSA is a satisfactory brief instrument for assessing quality of life.

Instruments
Two key instruments used in the study were the Patient Attitude Questionnaire (PAQ) (Thornicroft et al. 1993) and the Manchester Short Assessment for the Quality of Life (MANSA) (Priebe et al. 1999b). The PAQ was developed for the Team Assessment of Psychiatric Services (TAPS) project in the UK. This project evaluated the policy of replacing psychiatric hospitals with district-based services (Leff & Trieman 2000). The PAQ is a 19-item instrument developed to measure consumers views towards hospitals and community services. The MANSA was designed to assess the degree of satisfaction/dissatisfaction with different areas of life (present job/school, nancial situation, personal safety, quality and number of personal friends, relations within the family, mental and somatic health.)

Procedures
This study was undertaken in a regional mental health service. Ethics approval was obtained from the institutional ethics committee prior to data collection. Two key staff working in the CCU were recruited to assist with the recruitment and interviewing of the current CCU residents. These clinicians were trained in the use of the PAQ and MANSA. They also obtained consent from all 16 participants who were current CCU residents. The study was conducted in the residents own environment predominantly in their own residential unit or in the staff ofce. Ex-residents were phoned and invited to participate in the study. For those who were interested in participating a participant information sheet and consent form were posted, along with a simple brief letter asking them their preferred times for interview and a copy of the rating scales to be used for the study. With the rating scales in front of them while being interviewed over the phone it was thought the participants might nd it easier to respond with one of six responses. A stamped, selfaddressed envelope was also included to encourage the return of the consent form. These participants were interviewed via phone or in person.

Validity and reliability of the instruments

PAQ

The reliability and validity of the PAQ were reported by Thornicroft et al. (1993). Forty-three long-stay consumers were interviewed on two occasions (test, retest). Kappa statistics were used to analyse reliability and the kappa

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TABLE 1: Mean age and sex of respondents Age n Male Female 81 40 Mean 36.68 39.90 Standard deviation 9.721 14.069 Standard error mean 1.080 2.225

All residents admitted to the CCU between 1996 and 2007 were identied via the (CMI) system and the resulting data printed out onto a spreadsheet. The current residents of the CCU were extracted and placed on a separate spreadsheet. The clinicians assisting with recruitment obtained consent from 16 of the 20 residents. The interviews were completed over a 6-week period. The sample represented 70% of the current residents. The recruitment of the ex-residents for the interview was more complex than for the current residents. Once the current CCU residents (n = 20) were taken from the original spreadsheet, there were 101 potential ex-residents who could be participants for the study. The data through CMI are updated when there is some form of contact with the mental health services. Commonly this would occur on admission and discharge to hospital on assessment of a previously discharged consumer or each contact that a case manager or doctor has with a consumer. Therefore, if an ex-resident who has been discharged from the service has left the area or is deceased, this might not be entered into the CMI database thus the contacting of ex-residents needed to be managed sensitively. The researcher attempted to phone all previous residents but found that 29 of the phone numbers were incorrect; 18 were not answered despite several attempts to call; 12 declined to be involved in the study; three had died; and four were in a medium secure unit, with one in a psychogeriatric nursing home. The remaining 31 agreed to participate in the study. Of this 31 who were sent information sheets and consent forms, only 11 returned them. The researcher provided one follow-up reminder call and was able to obtain another ve participants, resulting in a sample group of 15 (15%).

Respondents sex

TABLE 2:

Ratio of males to females per age group Age group 1825 11 7 2633 32 12 3441 23 6 4170 15 15 Total 81 40

Respondents sex Male Female

post-move, with the only signicant changes being in the living situation. The present study shows results for 10 years post-move. There are some further pleasing improvements as well as disappointments in other domains found in this study. The domains of friendships and employment are the two signicant areas resulting from ndings in the MANSA.
Friendships

RESULTS Participant demographics

The demographic data, in relation to the sex of the individuals, showed that 81 were males and only 40 were females. When separated into age groups, the older group (4170 years old) had equal numbers of females to males, but this changed signicantly in the 40 years and under age group where the weighting showed 75% male and 25% female. The demographics including sex and age of current and past CCU residents, are outlined in Tables 1 and 2.

Trauer et al. (2001) showed a mean score of 55% satisfaction with friendships (n = 84) 1 year post-move which was actually a decline from the pre-move score (n = 45) of 62.2%, suggesting that residents might have been separated from their friends during the move into CCU. The current and past residents in the present study showed an improvement from those of Trauer et al.s (2001) study with 79.6% expressing happiness with their friendships and 72% of respondents had actually seen a friend in the last week. These data suggest that the deinstitutionalization process has been conducive to residents improvement in socialization and friendship building.
Close friends

Most respondents had a close friend in their lives (Fig. 1).

Satisfaction with number and quality of friendships

Quality-of-life variables for past and present residents of CCU

MANSA

Respondents were asked how satised they were with the number and quality of their friendships. Responses showed higher levels of satisfaction in the past group (Fig. 2).
Employment

In the study by Trauer et al. (2001) the MANSA was completed pre-move to the CCU and 12 months

Trauer et al.s (2001) study found that none of the residents in the hospitals, prior to moving and at the

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80 70 Respondents (%) 60 50 40 30 20 10 7.7% 0 Number of admissions before CCU
FIG. 3:

75.88%

Respondents (n)

10 8 6 4 2 0 Yes Close friends No

16.42%

FIG. 1:
7 6 Respondents (n) 5 4 3 2 1 0

Close friends. ( ), current; ( ), past.

Number of Number of admissions admissions after while in CCU discharge from CCU

Number of admissions to hospital. CCU, community care units.

100 Respondents (%) 80 60 40 20 3.66% 0 LOS in hospital before CCU LOS in hospital during CCU LOS in hospital after CCU 15.83% 80.51%

Displeased

Mostly Displeased

Mixed

Mostly satisfied

Pleased Could not be better

Satisfaction with number and quality of friends

FIG. 2: ( ), past.

Satisfaction with number and quality of friends. ( ), current;

12-month follow up after the move, were employed. Information from the present study is not much more encouraging, in that only two (n = 31) were gainfully employed and they were ex-CCU residents. Furthermore, 34% commented that they would like gainful employment, when asked for suggestions that could improve the CCU programme through the PAQ.

FIG. 4: Number of in-hospital bed days. CCU, community care units; LOS, length of stay.

question was not reported by Trauer et al. (2001), so we were unable to draw comparisons.
LOS in CCU and re-admission to acute psychiatric care units

Attitudes of past and current residents regarding the CCU

PAQ

It was important to understand the participants identication and understanding of changes in their self since admission to the CCU and whether they would recommend the CCU setting to others. The ndings relating to this topic area suggest that despite the severity and chronicity of mental illness in CCU participants there was an appreciation and insight into the benets of CCU. Some residents commented that they would not be able to live independently if it were not for the CCU. This is supported by the responses of several respondents, who believed they were changed for the better by their stay in CCU and would be recommending CCU to others. This

There is evidence from the data that the LOS and number of admissions to acute psychiatric care units reduces signicantly after spending time in CCU. There is a reduced LOS in acute psychiatric care units while residing in CCU (P = 0.035) and admissions to hospital before CCU (P = 0.011). These ndings indicate that receiving 24-hour care and having qualied staff and access to medical intervention when required can assist in keeping residents who are unwell out of acute psychiatric care units (Figs 3,4). Re-admissions to hospital after discharge from CCU also showed a signicant reduction. Although a small group of residents required secure residential care, the idea that a shorter LOS causes increased re-admissions to hospital cannot be validated (Figs 3,4).

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TABLE 3:

A. HAMDEN ET AL.
Number of hospital admissions before community care units (CCU) and lengths of stay (LOS) in wards during CCU stay Sum of squares df 34 84 118 32 71 103 Mean square 68.350 36.471 2378.899 1410.442 F 1.874 P-value 0.011

Admissions before CCU

LOS in ward of CCU

Between groups Within groups Total Between groups Within groups Total

2 323.887 3 063.575 5 387.462 76 124.781 100 141.373 176 266.154

1.687

0.035

Importantly, there has been a marked reduction in admissions to acute psychiatric care units while residing in CCU and after discharge from CCU, with a signicant increase in the number of male residents over the past 10 years. The LOS in CCU has decreased over the years, with more discharges occurring each year. An ANOVA was also used to identify the signicant changes in LOS and number of admissions to acute psychiatric care units. Admissions to acute psychiatric care units before CCU and LOS in wards of CCU showed signicance (Table 3). Furthermore, there is sufcient evidence through the resident questionnaires and demographic data to show that a majority of past residents are living independently or in supported accommodation and that CCU are helpful in providing residents with the skills required to live independently.

DISCUSSION
This study examined CCU in relation to quality of life for past and present residents, attitudes of residents regarding the CCU, LOS in the CCU, and re-admissions to hospital. Demographic data were also gathered and showed more males than females using CCU. Although statistically the incidence of SMI in males compared to females is even (National Centre for Health Statistics 1996), the demographics reported here suggest that men are more likely to require long-term care than women, and this is supported in the literature. The younger, predominantly male group had higher rates of re-admission to hospital, frequently related to substance abuse and homelessness (Treiman et al. 1999). Only two respondents were employed. Notably one of them was employed by the Area Mental Health service to wash the eet cars 2 days per week, 4 hours per day. Although there are generic employment services within the region of this study setting, case managers report a lack of accessibility and employment options due to potential employers poor understanding of mental illness, consequently reducing opportunities of gainful employment for this group of people.

Crowther et al. (2006) and Mueser et al. (2004) suggest that having specic employment staff co-located at the same site as the mental health service would enable more frequent interaction and encourage a collaborative approach to assisting with employment issues for individuals, and would be far more benecial than having the employment service belonging to another service and in a different location. Several references in the literature have been made to the need for the provision of long-term care to this vulnerable group of people; however the likelihood of availability of more CCU beds is not promising (Council of Australian Governments 2006; Victorian Government 2002). In light of this information, alternate models of psychiatric rehabilitation in the community also need to be explored if people with SMI are to be appropriately cared for in the community. The assertive community treatment (ACT) model has a strong focus on keeping this group of patients engaged with treatment and out of hospital. Thirty years of research has repeatedly demonstrated that ACT reduces hospital admissions and improves quality of life for people with SMI (Phillips et al. 2001). ACT has a strong focus on keeping this group of patients engaged with treatment and out of hospital (Bermingham 1999; Garske & McReynolds 2001). Psychiatric rehabilitation including psychosocial treatment approaches has become more prevalent since deinstitutionalization, enhancing interpersonal and social functioning, promoting independent living and community tenure and improving illness symptoms and management. ACT provides treatment within the clients home assists people with SMI to become involved with community agencies, links in with housing and employment services, provides family support, and teaches coping skills so that this vulnerable group is able to live and function in the community. Staff initiating contact rather than waiting for people to keep appointments, continuity, and consistency in an integrated service and combining treatment with rehabilitation, are the hallmarks of ACT (Garske & McReynolds 2001).

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Other government initiatives that can be utilized for this group of people are the Home Based Outreach Support and Intensive Home Based Outreach Support (IHBOS) programmes through Psychiatric Disability and Support Services (PDRS), which provide rehabilitation and disability support to people with SMI. The IHBOS is more intensive and targets people who are homeless or at risk of homelessness but there are only a limited number of these packages available in each region (Victorian Government 2007). The Personal Helpers and Mentors Program (Council of Australian Governments 2006) is another initiative that assists people with SMI to manage daily activities and to access services and supports.

mental health services might provide more robust evidence about Victorian demographic data and the quality of life of all residents of CCU. Consideration must be given to the methodology and ethical issues identied within this study, in particular a change to how consent is obtained. The inclusion of phone consent to enable the ex-resident to be engaged in the study during the initial phone call and offering reimbursements of expenses might encourage increased participation.

CONCLUSION
This study showed that CCU have a positive effect on hospital re-admission rates to acute psychiatric care units, improved LOS, and positive outcomes with regard to social inclusion, employment, and housing. The present study examined the quality of life and attitudes of current and past CCU residents, as well as demographic data in relation to LOS and re-admissions to hospital. Other service provisions that would enhance the work of the CCU and that of Area Mental Health services that are now caring for this group of people in the community as a result of deinstitutionalization include: An evaluation of the CCU model of care and the exploration of more evidence-based models of care, with a strong focus in the areas of vocation and social inclusion Review of discharge policies and procedures to include plans for long-term residents unlikely to improve in their psychosocial functioning. This is required to enable long-term residents who are unlikely to improve in psychosocial functioning to be moved to appropriate community accommodation, thereby freeing up beds for the wait-listed residents Utilization of the ACT model of care for people on waiting lists for CCU in order to try to reduce the level of disability that is likely to occur with frequent relapses Exploration of collaborative options with the psychiatric disability and rehabilitation services sector aiming to provide community packages and outreach services to people with SMI who are either not able to access a CCU bed or do not t the criteria for CCU placement

Strengths and limitations of the study

The demographic data collection provided a good source of information and was all available via a database. The fact that it was a follow-up study gave the researcher a baseline of information to focus on and the study provides several opportunities for conducting further research. The limitations include the ongoing need to continue the follow up of previous residents. While it had been intended to interview the majority of the 101 past residents, this was a very difcult task to achieve in the timeframes of this study. Importantly there were issues with the response rate that hindered the ability to gain consent and which would need to be considered if this study were to be expanded in the future. First, most past residents who were able to be contacted via telephone agreed to participate in the study but several did not send back the signed consent forms despite a stamped, self-addressed envelope being provided and a follow-up phone call. Several offered to complete the questionnaire over the phone at the time of the call, thus this method should be considered in further follow up within this population of people. The lack of signed consents was not necessarily due to unwillingness to participate in the study but could be due to negative illness symptoms, such as apathy and poor motivation. Nevertheless, poor response rates are found among other research groups as well, and in this study could have been mitigated by face-to-face consenting of participants. The small sample size also inhibits stronger conclusions being drawn regarding the clinical signicance of the ndings. Certainly, statistical signicance was found but with a small sample this must be examined cautiously when drawing conclusions about the true clinical impact of CCU. Further research is required to complete the tracking of ex-CCU residents from the area to further strengthen the ndings of this study. A broadening to include other

ACKNOWLEDGEMENTS
The authors would like to thank the staff at CCU for supporting and assisting with this important study, as well as the past and current residents of CCU for their willingness to participate.

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2011 The Authors International Journal of Mental Health Nursing 2011 Australian College of Mental Health Nurses Inc.