The International Journal of Psychosocial Rehabilitation

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 with Severe and Persistent Mental Illness

Jenny K. Hyun, M.P.H, Ph.D.
Research Health Science Specialist

Center for Health Care Evaluation
Veterans Affairs Palo Alto Health Care System
795 Willow Road PTSD-334
Menlo Park, CA  94025
Email: jenny.hyun@va.gov

Petr Nawka, M.D.
Chair, Association for Mental Health Integra

Michalovce, Slovak Republic

Soo Hyang Kang, Dr.P.H.
Associate Researcher

School of Public Health
University of California, Berkeley

Teh-wei Hu, Ph.D.
Emeritus Professor, Health Policy and Management

School of Public Health
University of California, Berkeley

Joan Bloom, Ph.D.
Professor, Health Policy and Management

School of Public Health
University of California, Berkeley
 
Citation:
Hyun J,  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

with Severe and Persistent Mental Illness.  International Journal of Psychosocial Rehabilitation. 13(1), 67-80




Abstract
Objective: This study seeks to assess the impact of community mental health service interventions (i.e., case management, sheltered housing, and psychiatric rehabilitation services) on the probability of hospitalization, 30-day re-hospitalization, and inpatient lengths-of-stay for individuals with severe and persistent mental illness.

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 Michalovce in 2001 to 46 individuals who received some type of community mental health service intervention between 2001 and 2005.

Results: Although community service interventions did not have a statistically significant effect on the probability of hospitalization, the interventions were associated with significantly decreased probabilities of 30-day re-hospitalization and inpatient lengths-of-stay.

Conclusion: Findings support the continuing policy initiative of building deinstitutionalized, community-based mental health systems in Eastern European countries.

MeSH Keywords: Slovakia, schizophrenia, community mental health services, deinstitutionalization, hospitalization, length of stay

 


Introduction
As Central and Eastern European countries focus on rebuilding governmental infrastructure, much attention has turned to mental health reforms, as evidenced by the 2005 Mental Health Declaration for Europe and the Mental Health Action Plan for Europe (World Health Organization, 2005a, 2005b).  In central and Eastern European countries, mental health reform has embraced deinstitutionalization and a greater role for community mental health services (Becker & Kilian, 2006; Becker & Vazquez-Barquero, 2001; Roberts, 2002; Thornicroft & Rose, 2005).  Actual reform activities to meet these objectives, however, have varied widely (Becker et al., 2002; Becker & Kilian, 2006; Becker & Vazquez-Barquero, 2001; Kallert et al., 2004), and some evidence suggests that little progress has been made on de-institutionalization.  Rittmannsberger et al. (2004) conducted a one-day census of psychiatric patients in five European countries (Austria, Hungary, Romania, Slovakia, and Slovenia) in 1999.  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 made in transitioning psychiatric patients to life in the community (Rittmannsberger et al., 2004).

Eastern European countries lag behind their western European counterparts with regard to mental health therapies (Jenkins, 2001; Mossialos et al., 2003).  The Soviet legacy has perpetuated a system of care that is heavily institutional with little focus on 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 accompanied a lack of research and training in different types of effective community treatments.  Also, the fractionalization of psychiatric services separated from physical health services contributed to the stigmatization of mental disorders and the isolation of individuals with severe 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 mental 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 infrastructure, 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 organize and to share experiences around reform and best practices.  Other reforms aimed at service delivery changes and professional changes have also occurred (van Voren & Whiteford, 2000).  The following section will describe reforms that have recently been implemented in Slovakia.


Mental Health Reform in Slovakia
Slovakia, a country of approximately 5.4 million persons, is located in Eastern Europe, 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, Slovakia became independent in 1993 and joined the European Union in 2004 (Central Intelligence Agency, 2006).  The country has approximately 30,000 inpatient beds with 3.6 physicians per 1,000 population (Organisation for Economic Co-operation and Development, 2004).

The Slovak Republic 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 community services.  The “Open the Doors, Open Your Hearts” anti-stigma program has been engaged in an active media campaign allowing individuals with mental illness to document their struggles with 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 de-stigmatization reforms is to bring together four stakeholders: mental health professionals, consumers, family members, and the community.  The “Open the Doors, Open Your Hearts” program in combination with other 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 officially initiated the Transformation to an Integrated System of Mental Health Care to create a 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 Republic, 2004).

Mental health reforms in Slovakia have embraced four core components: 1) building community service infrastructure through non-governmental organizations; 2) decreasing reliance on inpatient psychiatric hospitals; 3) reducing stigma associated with mental illness; and 4) emphasizing the recovery model.  To date, three types of community services-- rehabilitation services, case management, and sheltered housing-- have been developed and are being offered to consumers with severe and persistent mental illness.  Rehabilitation services and sheltered housing were offered beginning in 1997, and case management services were offered beginning in 2003.  All services are provided under the recovery model.  The recovery model is fundamentally different from traditional institution-based care because of its focus on the needs and limitations of the individual (Nawka et al.).  Therapies and treatments proceed in accordance with a client’s motivation and possibilities for achieving the highest quality of life. The aim of rehabilitation services is to support client recovery, finding optimal solutions with respect to each client’s current situation and prospects for the future. Case management provides effective health care and social services at home or in the community for clients with mental illness. The nature and needs of each individual client determine the extent of care.  Finally, sheltered housing is available year-round for clients with mental disorders capable of leading life independently with help and supervision. Supervision is provided 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 al., 2000; Rasanen et al., 2000; Ryu et al., 2006).  Analysis of psychiatric admission data in Israel after their deinstitutionalization reform showed a significant decrease in inpatient 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 et al., 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 infrastructure in the town of Michalovce.  There, individuals with severe and persistent mental illness could receive recovery-based community mental health services, 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 severe and persistent mental illness in Michalovce, Slovakia comparing those who received community services to those who did not receive community services. 

Methods
Study Design
This study uses a natural experiment design of individuals with severe and persistent mental illness in the Michalovce region (including the adjoining province of Sobrance).  The study follows a cohort of severely mentally ill individuals from Michalovce hospitalized in 2001 (n=803) for five years, comparing individuals who received community services to those who did not receive community services on the probability of hospitalization or 30-day re-hospitalization, as well as hospital lengths-of-stay. Following the same persons over time reduces confounding due to possible variation in characteristics of consumers using services at different time periods. By identifying subjects concomitant to the initiation of community-based services, initial differences in treatment patterns could also be assessed and incorporated in the interpretation of community-based service intervention. 

Data Sources
Hospitalization data is taken from administrative data from the Psychiatric Hospital in Michalovce for five years between 2001 and 2005.  Community-based services data is taken from the Association for Mental Health Integra in Michalovce. 

Measures
Dependent variables.  There are three dependent variables included in this study.  Hospitalization records begin on January 1st for each year.  Hospitalization is 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 during the year.  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 of a 30-day re-hospitalization is considered a re-hospitalization during the year 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. 

Explanatory variables.  The community-based services in Michalovce include rehabilitation services, case management, and sheltered housing.  The receipt of any one of these services qualifies as receipt of any community service and is coded as a ‘1’ for the dichotomous variable.  Those who did not receive any community service are coded as a ‘0.’  Interaction terms between community service and time are also included. 

Other covariates.  Other covariates include gender, marital status, diagnosis, age, and time.  Gender and marital status are coded dichotomously.  There are three diagnostic groups—schizophrenia, bipolar disorder, and other psychiatric diagnosis—and diagnosis is coded dichotomously where, for example, having a diagnosis of schizophrenia is coded as a ‘1’ and not having schizophrenia is coded as a ‘0.’  Age is centered at the mean.  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 lengths-of-stay.  Generalized estimating equation modeling is superior to the ordinary least squares (OLS) approach because it accounts for correlated data and corrects for clustering in the standard errors.  Analysis of correlated data, due to the longitudinal design of the study, using OLS methods may result in artificially low variance and low p-values (Hanley et al., 2003; Orelien, 2001). Generalized estimating equation models using PROC GENMOD in SAS are especially useful in analyzing clustered data that have a non-normal distribution and result in reasonably accurate standard error measures (Orelien, 2001).  The generalized estimating equation models can be used for both dependent variables that are 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 (Johnston & Stokes, 1996).  All analyses are conducted using SAS version 9.1 (SAS).

Probability of hospitalization and 30-day re-hospitalization is estimated using generalized estimating equation models of a binary outcome measure.  The dependent variable of the regression is a dichotomous variable indicating any hospitalization or any 30-day re-hospitalization during a calendar year.  Results of analyses on binary dependent variables are presented as odds ratios.  Since the data is derived from hospitalization records, the hospitalization sample is limited to the second 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 the baseline year.

Predicted probabilities 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 service and no-community service groups found in Figure 1.  Predicted probability calculations in Figure 1 for individuals who received community services include estimates for the intercept, mean age, schizophrenia diagnosis, community service, time, and the interaction of time and community service.  Predicted probabilities for those who did not receive community services are identical except for the exclusion of the estimates of community service and its interaction term.

Results
Table 1 presents the demographic characteristics of individuals who received community services and those who did not.  There are significant differences between the two groups.  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 a mean age of 53 years (SD=19.3).  Also, those who received community services are more likely to be male, 2(1, N =803) = 3.75, p<0.05; unmarried, 2(1, N = 803) = 29.34, p<0.01; and have a diagnosis of schizophrenia, 2(1, N = 803) = 87.04,
 p<0.01.

 

Table 2 presents the results for the generalized estimating equation model on the probability of hospitalization.  Results show that those who received community services had over five times the odds of hospitalization than those who were not in the community service group (OR=5.52, p<0.01). Individuals with a diagnosis of schizophrenia are more likely to be hospitalized (OR=1.89, p<0.01), while those who are married (OR=0.71, 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 those who received community services, but differences in the odds of hospitalization were not significant.  In summary, both groups experienced parallel decreases in probabilities of hospitalization throughout the study period.



Table 3 presents the results for the generalized estimating equation model for hospital 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 than those who did not receive community services.  Individuals with a diagnosis of schizophrenia had an average of 36 more 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. 

Significant differences 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 the fourth year and showed a trend toward a significant difference in hospital 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 community service group was 185 days, but the average hospital length-of-stay decreased to 109 days by Year 5.



Table 4 presents the generalized estimating equation model for the probability of 30-day re-hospitalization.  Initially, those individuals who had received community services had about eight times the odds of being re-hospitalized within 30 days.  After the initial hospitalization in any given year, individuals with a diagnosis of schizophrenia were twice as likely to be re-hospitalized within 30 days than those with other diagnoses.  There were no significant changes in the probabilities of 30-day re-hospitalization for those in the no community service group.  Individuals who received community services, however, experienced 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 probabilities of 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 23% with negligible change over time evidenced by its slope of 0.005 probability over time.  On the other hand, the probability of 30-day re-hospitalization for those in the community service
 group averaged about 36% with a high of 66% in Year 1 and decreasing significantly over time evidenced by its slope of -0.13 probability over time.





Discussion
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 schizophrenia.  As the results of the generalized estimating equation models show, there are significant initial differences between the community service and no community service groups.  Those who received community services had higher odds of hospitalization and re-hospitalization with concomitant longer lengths-of-stay. 

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 institutional care that limited hospitalizations during this time.  The decreased probabilities of hospitalization over the study period seem to reflect a treatment paradigm shift away from institutional care.

The community service interventions appear successful in reducing the probability of 30-day re-hospitalizations over time and lengths-of-stay, although the 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 received community services.  There were steady reductions in lengths-of-stay after Year 3 and significant reductions in Years 4 and 5.  Recall that community services were implemented gradually with rehabilitation services and sheltered housing 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 prevent acute symptomatic problems that would have necessitated re-hospitalizations or were used as a substitute for institutional care thereby encouraging shorter lengths-of-stay.

This study 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 individuals, a larger sample of community service users would improve the robustness and generalizability of findings.  A larger sample of community service users would assist in identifying if there were differential effects based on the types of community service interventions or the combination of community services used.  Second, lack of randomization in assignment to community services means 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 systematic influences of other variables.  As the comparison of baseline data shows, however, significant initial differences exist suggesting self-selection into the community services group.  Because of limited resources available for mental health reform and interventions in Eastern European countries, however, recipients will most likely continue to be those with the greatest need, i.e., those with severe and persistent mental illness.  Therefore, these study findings using the natural experiment design represent a realistic distribution of characteristics 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 reliability of hospital administrative data.

The 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 combination of community services.  Also, future studies should investigate clinical and quality of life outcomes for individuals 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 programs 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 treatment and recovery for individuals with severe and persistent mental illness.  Coupled with psychoeducation and anti-stigma campaigns, community-based mental health services can contribute to improved 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 alleviate alienation in persons with severe mental illness (Biegel et al., 1995; Kopelowicz & Liberman, 2003; Liberman & Liberman, 2003; McFarlane et al., 2003; Miklowitz et al., 2003; Murray-Swank & Dixon, 2004; Perese & Wolf, 2005; Stewart et al., 1999; Vieta et al., 2005).  Individuals with schizophrenia whose families participate in mutual support groups show improvements in social functioning, 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 them to 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, contribute to decreased lengths-of-stay in psychiatric hospitals, can serve as an example of one type of community-based mental health reform instituted by an Eastern European country faced with many governmental, financing, and health personnel challenges.

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 from mental illness is possible and that the best course of therapy is one that not only draws upon an individual’s strengths and weaknesses, but also empowers them to make decisions regarding the course of their treatment (Anthony, 1993).  Findings from this study show that recovery-based services are effective in reducing hospital lengths-of-stay and 30-day re-hospitalizations when instituted in a supportive community-based setting.  The elements of recovery that contribute to decreased length-of-stay and reduced probability of 30-day re-hospitalizations are unclear, and more research is required to assess the influence of the environment, organization, provider, and individual mental health client in the delivery of recovery-based therapies.


Acknowledgements
Funding for this study was generously provided by the National Institute of Medicine’s Fogarty International Center, Finance and Mental Health Services Training in the Czech and Slovak Republics 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 Analysis 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 the Department of Veterans Affairs.




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