International Journal of Psychosocial Rehabilitation
and Community-Based Mental Health Services in the Slovak
A Pilot Study on the
Implications for Hospitalization and Inpatient Length-of-Stay
with Severe and Persistent Mental Illness
Jenny K. Hyun, M.P.H, Ph.D.
Research Health Science
Center for Health Care
Veterans Affairs Palo
Alto Health Care System
795 Willow Road PTSD-334
Menlo Park, CA 94025
Petr Nawka, M.D.
Chair, Association for
Mental Health Integra
Soo Hyang Kang, Dr.P.H.
School of Public Health
University of California,
Teh-wei Hu, Ph.D.
Health Policy and Management
School of Public Health
University of California,
Joan Bloom, Ph.D.
Professor, Health Policy
School of Public Health
University of California,
Nawka P, Hang SH, Hu T, Bloom J. (2008). Recovery- and
Community-Based Mental Health Services in the
Slovak Republic:A Pilot Study on the Implications for
Hospitalization and Inpatient Length-of-Stay for Individuals
and Persistent Mental Illness.
International Journal of Psychosocial Rehabilitation. 13(1), 67-80
Method: Using a
natural experiment design on a five-year, longitudinal
cohort, generalized estimating equation models are used to compare 757
individuals who were hospitalized at the psychiatric hospital in
2001 to 46 individuals who received some type of community mental
service intervention between 2001 and 2005.
community service interventions did not have a statistically
significant effect on the probability of hospitalization, the
were associated with significantly decreased probabilities of 30-day
re-hospitalization and inpatient lengths-of-stay.
support the continuing policy initiative of
building deinstitutionalized, community-based mental health systems in
schizophrenia, community mental health services,
hospitalization, length of stay
As Central and Eastern European countries focus on rebuilding
governmental infrastructure, much attention has turned to mental health
as evidenced by the 2005 Mental Health Declaration for Europe
and the Mental Health Action Plan for Europe
Health Organization, 2005a, 2005b).
central and Eastern European countries, mental health reform has
deinstitutionalization and a greater role for community mental health
(Becker & Kilian, 2006; Becker & Vazquez-Barquero, 2001;
Thornicroft & Rose, 2005).
reform activities to meet these objectives, however, have varied widely
et al., 2002; Becker & Kilian, 2006; Becker & Vazquez-Barquero,
Kallert et al., 2004), and some evidence suggests that little progress
made on de-institutionalization.
et al. (2004) conducted a one-day census of psychiatric patients in
European countries (Austria
Researchers found that patterns
of involuntary admissions and inpatient lengths-of-stay had changed
insignificantly compared to 1996 data and that little progress had been
transitioning psychiatric patients to life in the community
countries lag behind their western European
counterparts with regard to mental health therapies (Jenkins, 2001;
et al., 2003). The Soviet legacy has
perpetuated a system of care that is heavily institutional with little
community services, social work, or multidisciplinary team work. Such legacies include a lack of understanding
for the social needs of individuals with severe mental illness that
a lack of research and training in different types of effective
treatments. Also, the fractionalization
of psychiatric services separated from physical health services
the stigmatization of mental disorders and the isolation of individuals
and chronic mental illness (Mossialos et al., 2003).
Two main challenges
exist to the decentralization of health
services and the development of community services for individuals with
disorders. One challenge is the
development of trained professionals in community settings. Another challenge is the lack of
infrastructure, both in terms of economic and social support, to build
and to sustain
community service reforms (Mossialos et al., 2003; Rutz, 2001). Strategies for mental health reform have
included developing national strategies, supporting system
building linkages between systems of care, encouraging client/user
participation, and de-stigmatizing mental illness (Jenkins, 2001). Some reforms have focused on the development
of collaboratives for sharing and disseminating reform practices. The Network of Reformers in Psychiatry, a
convention of mental health professionals, represents an attempt to
and to share experiences around reform and best practices.
Other reforms aimed at service delivery
changes and professional changes have also occurred (van Voren &
2000). The following section will
describe reforms that have recently been implemented in Slovakia.
Mental Health Reform in Slovakia
a country of approximately 5.4 million persons, is located in Eastern
, surrounded by Poland
and the Czech Republic
to the north, Hungary
to the south, and Austria
and the Ukraine
to the west and east, respectively.
After the pull-out of the Soviet Union
became independent in 1993 and joined the European Union in 2004
Intelligence Agency, 2006).
has approximately 30,000 inpatient beds with 3.6 physicians per 1,000
population (Organisation for Economic Co-operation and Development,
has been actively engaged
in mental health de-stigmatization efforts.
Government and non-government organizations have collaborated on
projects to reduce stigma around mental illness and to develop
services. The “Open the Doors, Open Your
Hearts” anti-stigma program has been engaged in an active media
allowing individuals with mental illness to document their struggles
mental illness on film and collaborating with local media stations for
vocational training of individuals with mental illness (Nawka et al.,
2005). The primary focus of the
reforms is to bring together four stakeholders: mental health
consumers, family members, and the community.
The “Open the Doors, Open Your Hearts” program in combination
community-based mental health programs offers the only integrated
community-based mental health programs in the country to combat mental
illness. In 2002, the government
the Transformation to an Integrated System of Mental Health Care to
model region of standard mental health care in Michalovce, a city of
approximately 40,000 residents in eastern Slovakia
(Nawka et al., 2004; The Government of the Slovak
Mental health reforms
have embraced four core components: 1) building community service
infrastructure through non-governmental organizations; 2) decreasing
on inpatient psychiatric hospitals; 3) reducing stigma associated with
illness; and 4) emphasizing the recovery model.
To date, three types of community services-- rehabilitation
case management, and sheltered housing-- have been developed and are
offered to consumers with severe and persistent mental illness. Rehabilitation services and sheltered housing
were offered beginning in 1997, and case management services were
beginning in 2003. All services are
provided under the recovery model. The
recovery model is fundamentally different from traditional
care because of its focus on the needs and limitations of the
et al.). Therapies and treatments proceed
in accordance with a client’s motivation and possibilities for
highest quality of life. The aim of rehabilitation services is to
client recovery, finding optimal solutions with respect to each
current situation and prospects for the future. Case management
effective health care and social services at home or in the community
clients with mental illness. The nature and needs of each individual
determine the extent of care. Finally,
housing is available year-round for clients with mental disorders
leading life independently with help and supervision. Supervision is
to monitor client behavior and activity during working days, and all
observations are documented.
Studies of the
utilization of community services in other
countries have shown a consistent decrease in the probability of
hospitalization, lengths-of-stay, as well as improved quality of life
indicators (Balestrieri et al., 1987; Baruch et al., 2005; Hobbs et
Rasanen et al., 2000; Ryu et al., 2006).
Analysis of psychiatric admission data in Israel
after their deinstitutionalization reform showed a significant decrease
lengths-of-stay over the five year study period (Baruch et al., 2005). Investigation of community-based
interventions supplementing deinstitutionalization in Italy
have shown similar decreases in hospital lengths-of-stay (Balestrieri
1987). Studies of case management have
found that it is associated with
decreased days of service utilization (Seltzer et al., 1987).
Aims of the study
In 2001, Slovakia
embarked on a project building community mental health service
in the town of Michalovce
There, individuals with severe and persistent
mental illness could receive recovery-based community mental health
such as rehabilitative services, case management, or sheltered housing.
This study investigates probability of
hospitalization and 30-day re-hospitalization, as well as inpatient
lengths-of-stay in a longitudinal, five-year sample of individuals with
persistent mental illness in Michalovce,
comparing those who received community services to those who did not
This study uses a natural experiment design of individuals
with severe and persistent mental illness in the Michalovce region
the adjoining province of Sobrance
The study follows a cohort of severely
mentally ill individuals from Michalovce hospitalized in 2001 (n=803)
years, comparing individuals who received community services to those
not receive community services on the probability of hospitalization or
re-hospitalization, as well as hospital lengths-of-stay. Following the
persons over time reduces confounding due to possible variation in
characteristics of consumers using services at different time periods.
identifying subjects concomitant to the initiation of community-based
initial differences in treatment patterns could also be assessed and
incorporated in the interpretation of community-based service
Hospitalization data is taken from administrative data from
the Psychiatric Hospital in Michalovce for five years between 2001 and
Community-based services data is
taken from the Association for Mental Health Integra in Michalovce.
are three dependent variables included in this study.
Hospitalization records begin on January 1st
for each year.
defined as any hospitalization that occurred during the calendar year.
The variable is coded dichotomously ‘1’ for
any hospitalization during the year and ‘0’ for no hospitalization
Thirty-day re-hospitalization is
measured as the occurrence of any hospitalization within 30 days of the
discharge date of the previous hospitalization. Any single occurrence
30-day re-hospitalization is considered a re-hospitalization during the
and is coded as a ‘1’ for the dichotomous variable.
Hospital length-of-stay is measured as the
total number of days spent in the hospital during the calendar year.
The community-based services in Michalovce include
services, case management, and sheltered housing.
receipt of any one of these services
qualifies as receipt of any community service and is coded as a ‘1’ for
Those who did not
receive any community service are coded as a ‘0.’
terms between community service
and time are also included.
covariates include gender, marital status, diagnosis, age, and time.
Gender and marital status are coded
There are three
diagnostic groups—schizophrenia, bipolar disorder, and other
diagnosis—and diagnosis is coded dichotomously where, for example,
diagnosis of schizophrenia is coded as a ‘1’ and not having
coded as a ‘0.’
Age is centered at the
Time is presented as dummy
variables for each of the five years between 2001 and 2005.
Data Analytic Procedures
Generalized estimating equation (GEE) models are used to
assess the association of explanatory variables with probability of
hospitalization, probability of 30-day re-hospitalization, and hospital
equation modeling is superior to the ordinary least squares (OLS)
because it accounts for correlated data and corrects for clustering in
Analysis of correlated
data, due to the longitudinal design of the study, using OLS methods
in artificially low variance and low p-values (Hanley et al., 2003;
2001). Generalized estimating equation models using PROC GENMOD in SAS
especially useful in analyzing clustered data that have a non-normal
distribution and result in reasonably accurate standard error measures
estimating equation models can be used for both dependent variables
continuous and categorical.
We use an
autoregressive correlation structure, although estimates have been
shown to be
consistent even if the correlation structure is incorrectly specified
& Stokes, 1996).
All analyses are
conducted using SAS version 9.1 (SAS).
hospitalization and 30-day re-hospitalization
is estimated using generalized estimating equation models of a binary
measure. The dependent variable of the
regression is a dichotomous variable indicating any hospitalization or
re-hospitalization during a calendar year.
Results of analyses on binary dependent variables are presented
ratios. Since the data is derived from
hospitalization records, the hospitalization sample is limited to the
through fifth years of data for analyses on the probability of
hospitalization. The comparison group
for time, therefore, is the second year of the study period rather than
are calculated using the formula:
1/1+e-(a+bXi). Predicted probabilities are used to graph
probabilities of 30-day re-hospitalization for both the community
no-community service groups found in Figure 1.
Predicted probability calculations in Figure 1 for individuals
received community services include estimates for the intercept, mean
schizophrenia diagnosis, community service, time, and the interaction
and community service. Predicted
probabilities for those who did not receive community services are
except for the exclusion of the estimates of community service and its
Table 1 presents the demographic characteristics of
individuals who received community services and those who did not.
There are significant differences between the
Individuals who received
community services are younger with a mean age of 39 years (SD=10.5) as
compared to individuals who did not receive community services who have
age of 53 years (SD=19.3).
who received community services are more likely to be male, 2(1, N
3.75, p<0.05; unmarried, 2(1, N = 803) = 29.34, p<0.01; and have
diagnosis of schizophrenia, 2(1, N = 803) = 87.04,
presents the results for the generalized estimating equation model on
probability of hospitalization.
show that those who received community services had over five times the
hospitalization than those who were not in the community service group
(OR=5.52, p<0.01). Individuals with a diagnosis of schizophrenia are
likely to be hospitalized (OR=1.89, p<0.01), while those who are
p<0.01) or older (OR=0.99, p<0.01) are less likely.
The likelihood of hospitalization decreased
significantly over time for all individuals.
The likelihood of hospitalization also decreased over time for
received community services, but differences in the odds of
were not significant.
In summary, both
groups experienced parallel decreases in probabilities of
throughout the study period.
presents the results for the generalized estimating equation model for
lengths-of-stay. Initial lengths-of-stay
were longer for individuals in the community service group. Those individuals who had received community
services spent, on average, 104 more days in the hospital during a year
those who did not receive community services.
Individuals with a diagnosis of schizophrenia had an average of
days in the hospital than individuals with other diagnoses. Those who were married had an average of
seven fewer days of hospitalization than those who were not married.
in overall and community-services
lengths-of-stay appear during the later years of the study period. All individuals showed a significant decrease
in hospital lengths-of-stay during the last year of the study period
(2005). In the community service group,
individuals had a significant reduction in hospital length-of-stay in
fourth year and showed a trend toward a significant difference in
length-of-stay in the last year. On
average, individuals who did not receive community services experienced
hospital lengths-of-stay that ranged from a low average of 71 days in
Year 5 to
a high average of 86 days in Year 3 with very little fluctuation in
between. Individuals in the community
service group, however, experienced continuous reductions in hospital
lengths-of-stay throughout the study period.
Initial average hospital length-of-stay for individuals in the
service group was 185 days, but the average hospital length-of-stay
to 109 days by Year 5.
presents the generalized estimating equation model for the probability
individuals who had received community services had about eight times
of being re-hospitalized within 30 days.
After the initial hospitalization in any given year, individuals
diagnosis of schizophrenia were twice as likely to be re-hospitalized
days than those with other diagnoses.
were no significant changes in the probabilities of 30-day
for those in the no community service group.
Individuals who received community services, however,
significant reductions in the probability of 30-day re-hospitalization
throughout the study period (see Figure 1).
For individuals in the community service group, the
30-day re-hospitalization during Years 4 and 5 were lower than the
probabilities of individuals in the no community service group.
The probability of 30-day re-hospitalization
for individuals who did not receive community services averaged around
negligible change over time evidenced by its slope of 0.005 probability
On the other hand, the probability
of 30-day re-hospitalization for those in the community service
about 36% with a high of 66% in Year 1 and decreasing significantly
evidenced by its slope of -0.13 probability over time.
The results suggest that the
community service interventions
have been appropriately targeted to individuals who are higher users of
hospital services who may have less community support.
Generally, those who received community
services in Michalovce were young, unmarried, and had a diagnosis of
As the results of the
generalized estimating equation models show, there are significant
differences between the community service and no community service
Those who received community
higher odds of hospitalization and re-hospitalization with concomitant
There were time trends
that also significantly influenced
hospitalization and lengths-of-stay for all mental health consumers. The odds of hospitalization decreased
significantly each year. This could be
due to general policies and a growing dissatisfaction with
that limited hospitalizations during this time.
The decreased probabilities of hospitalization over the study
seem to reflect a treatment paradigm shift away from institutional care.
community service interventions appear successful in reducing the
of 30-day re-hospitalizations over time and lengths-of-stay, although
likelihood of hospitalization did not change significantly. There was a significant reduction over time
in the odds of re-hospitalization within 30 days for those who received
community services. Likewise, there was
a significant reduction in lengths-of-stay over time for those who
community services. There were steady
reductions in lengths-of-stay after Year 3 and significant reductions
4 and 5. Recall that community services
were implemented gradually with rehabilitation services and sheltered
offered in Year 1 and case management services offered in Year 3. The full complement of community services,
encompassing rehabilitation services, sheltered housing, and community
services, was implemented in Years 3 through 5.
It is likely that support services in the community were used to
acute symptomatic problems that would have necessitated
were used as a substitute for institutional care thereby encouraging
has a number of limitations. First, the
sample of individuals who received community services is small. While significant findings are a testament to
the effect that community services had on this small sample of
larger sample of community service users would improve the robustness
generalizability of findings. A larger
sample of community service users would assist in identifying if there
differential effects based on the types of community service
the combination of community services used.
Second, lack of randomization in assignment to community
that unidentified variables may have systematically and significantly
influenced results. The study sample was
limited to individuals in the Michalovce region in order to control for
historical and contextual variables between subjects and to reduce
influences of other variables. As the
comparison of baseline data shows, however, significant initial
exist suggesting self-selection into the community services group. Because of limited resources available for
mental health reform and interventions in Eastern European countries,
recipients will most likely continue to be those with the greatest
those with severe and persistent mental illness. Therefore,
these study findings using the
natural experiment design represent a realistic distribution of
found in intervention programs. Finally,
we were unable to test the administrative data for reliability. Future studies would benefit from survey
designs that collect individual information without relying heavily on
administrative data or designs that allow researchers to check the
of hospital administrative data.
findings of this study are encouraging for health systems in Eastern
Europe and in other countries that are moving away from
institutional care toward recovery- and community-based services. Future studies should investigate the
cost-effectiveness of community services, including the optimal
community services. Also, future studies
should investigate clinical and quality of life outcomes for
receiving community services as compared to those who receive only
institutional care. Finally, qualitative
features of the programs themselves, such as organizational design and
recovery-based characteristics, that contribute to the success of the
should be investigated.
Implications for Health Care Provision and Policies
The findings from this study support continuing efforts in
building community-based mental health infrastructure to support
recovery for individuals with severe and persistent mental illness.
Coupled with psychoeducation and anti-stigma
campaigns, community-based mental health services can contribute to
quality of life with decreased reliance on hospital-based treatments.
A growing body of literature supports the use
of family psychoeducation and caregiver support to address and
alienation in persons with severe mental illness (Biegel et al., 1995;
Kopelowicz & Liberman, 2003; Liberman & Liberman, 2003;
al., 2003; Miklowitz et al., 2003; Murray-Swank & Dixon, 2004;
Wolf, 2005; Stewart et al., 1999; Vieta et al., 2005).
Individuals with schizophrenia whose families
participate in mutual support groups show improvements in social
self-maintenance, and community living skills (Chien & Chan, 2004).
Individuals with mental illness can be
re-introduced into the community with supportive services that help
thrive and to contribute to the life of their communities.
The organization and delivery of community-based
mental health services in Michalovce that, as this study finds,
decreased lengths-of-stay in psychiatric hospitals, can serve as an
one type of community-based mental health reform instituted by an
European country faced with many governmental, financing, and health
Finally, an integral
element of the community-based mental
health services offered in Michalovce is that they are recovery-based
services. Recovery-based services focus
on individualization of care founded on the philosophy that recovery
mental illness is possible and that the best course of therapy is one
only draws upon an individual’s strengths and weaknesses, but also
them to make decisions regarding the course of their treatment
(Anthony, 1993). Findings from this study
recovery-based services are effective in reducing hospital
30-day re-hospitalizations when instituted in a supportive
setting. The elements of recovery that
contribute to decreased length-of-stay and reduced probability of
re-hospitalizations are unclear, and more research is required to
influence of the environment, organization, provider, and individual
health client in the delivery of recovery-based therapies.
Funding for this study was generously provided by the
National Institute of Medicine’s Fogarty
Finance and Mental Health Services Training in the Czech and Slovak
D43 TW05810. The authors hold no
financial conflicts of interest in the publication of this work. This research study was completed while the
author was a graduate student in the Health Services and Policy
doctoral program at the University
of California, Berkeley. The views expressed in this article are those
of the authors and do not necessarily reflect the position or policy of
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