There is evidence that the use of person-based rehabilitation strategies improves outcomes in patients diagnosed with severe mental illness (SMI) [1
]. Such improvements in turn may result in differences in psychiatric service consumption.
SMI is best characterized as a complex combination of psychiatric, somatic, and social needs. Approximately 75% of SMI patients are diagnosed with schizophrenia, psychosis or bipolar disorder [5
]. Patients require tailor-made rehabilitation strategies in order to bring about an enduring impact on outcome. However, there is evidence that providers do not always systematically focus on patients' needs but rather select patients for available services [6
]. There may be a potential to improve services by introducing need-based treatment plans [7
]. This is only possible when needs are routinely and systematically assessed. Therefore, a Cumulative Needs for Care Monitor (CNCM) was introduced in a geographically circumscribed region in the South of the Netherlands to make mental health systems more responsive to individual treatment needs [5
]. The CNCM represents a set of diagnostic and evaluative tools that allow clinicians to explicitly evaluate patients' needs and negotiate treatment with the patient [5
Several recent papers evaluated the use of the CNCM and other related needs assessments in treatment. First, it was shown that identification of unmet needs in the areas of finances, housing and independence with regard to self-care and household skills are followed by targeted action on the part of professional carers [8
]. However, need for care in the areas of occupation/daytime activities, psychotic symptoms, psychological distress and self-harm proved more difficult to change from "unmet" to "met" need [8
]. Needs are changeable and not only the area of functioning, but also the area of needs requires assessment when evaluating mental health interventions [9
]. It has been suggested that systematic needs assessment may produce changes in service outcomes, however prospective research is required [10
]. Recent RCTs suggested that systematic needs assessment results in changes in treatment and increased patient satisfaction [2
], while another study showed associations between needs assessment and patient satisfaction but not with any other outcome [11
]. Finally, a multicenter study showed associations between the use of DIALOG, a tool to stimulate patient-carer discussion on 11 domains of need, and improvement in quality of life and unmet needs for care after 12 months [3
Furthermore, patients at different stages of illness may respond differently to treatment [8
]. Patients new in care have acute severe psychopathology, but a relatively intact social network, with higher likelihood of return to pre-onset employment. These first episode patients, particularly those with psychotic disorders, often have low insight and therefore are less likely to formulate specific care needs. Patients in persistent care, however, are more likely to formulate care needs as a result of lack of treatment response and chronic social complications. Therefore, the use of needs-based treatment plans may be associated with different changes in service use depending on treatment status at baseline. A third category is patients in a new episode, defined as having had no care for more than a year, but presenting again after a relapse of previous illness. These patients likely will present with care needs representing a mix of those with first-episode and persistent illness.
Ideally, systematic assessment of needs and other clinical parameters as provided in the CNCM will help clinicians to respond early by making changes in out-patient care, thus preventing further deterioration and hospital admission. Therefore, it was hypothesized that CNCM would be associated with changes indicating more out-patient care and less days in hospital. As different patient groups may respond differently to treatment, we expected that results would depend on duration of treatment status at baseline (no care before 2004; new episode after 365 days out of care; or persistently in care).
Aims of the study
We examined whether previously reported benefits of monitoring systems are accompanied by changes in psychiatric care consumption. In order to be able to demonstrate changes independent of trends over time (e.g. changes in health care or health care policy) we included patients from a control region in which no systematic and cumulative assessment of needs was in place. The date of the CNCM assessment was also assigned to the matched controls as a hypothetical date of assessment. We hypothesized that care consumption would change after that date in the CNCM region but not in the control region. In particular, we expected an increase in outpatient care and a decrease in inpatient care. Treatment status at baseline was hypothesized to be a modifier of changes in care.