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					Seven Oaks and South Hills Projects

         Year 2 Assessment Report




                    DRAFT
                 February 6, 2006




        Alain Lesage, MD, FRCP(C), MPhil
        David Groden, BBA
        Patrick Ohana, MEd
        Elliot Goldner, MD, FRCP(C), MHSc
About the Authors
Alain Lesage, MD, FRCP(C), MPhil, is Professor and Researcher,
Department of Psychiatry, Faculty of Medicine, University of Montreal,
Fernand-Seguin Research Centre, Louis-H. Lafontaine Hospital
       Centre de recherche Fernand-Seguin - Unité 218
       7401, rue Hochelaga
       Montréal, QC H1N 3M5
       Tel: (514) 251-4015, Ext. 2365
       Fax: (514) 251-5404
       E-mail: alesage@ssss.gouv.qc.ca
David Groden, BBA, is Research Officer, Riverview Hospital
Patrick Ohana, MEd, is Research Coordinator,
Fernand-Seguin Research Centre, Louis-H. Lafontaine Hospital
Elliot Goldner, MD, FRCP(C), MHSc, is Professor, Simon Fraser University




Acknowledgments
These evaluation projects are funded by the Ministry of Health Services of British
Columbia and the Provincial Health Service Authority. It is made possible by in-
kind support from Riverview Hospital, Seven Oaks and South Hills. It is also sup-
ported by the Mental Health Evaluation and Community Consultation Unit
(MHECCU). Dr. Lesage’s research activities were supported until 2004 by a na-
tional health research scholarship from the Quebec Health Research Fund (FRSQ),
and currently by Louis-H. Lafontaine Hospital in Montreal.
We wish to thank the patients and staff who have agreed to participate in these
project evaluations. The projects have also received continuous support from man-
agers and clinical leaders at Seven Oaks, South Hills and Riverview Hospital, as
well as from the Vancouver Island Health Authority, the Interior Health Authority
and the British Columbia Ministry of Health Services. Altogether, at the individual,
facility, regional and provincial levels, there has been a genuine commitment to the
view that evaluation would support a greater quality of care.


Seven Oaks and South Hills Projects: Year 2 Assessment Report                2 of 35
Executive Summary
Seven Oaks is a 38-bed facility in Victoria, British Columbia. First established in
the early 1990s, it was rebuilt and reopened to new residents in December 2001.
The facility’s mission is to “provide a high level of care, treatment, and rehabilita-
tion in a flexible, deinstitutionalized and interactive community.”
South Hills is a 40-bed tertiary rehabilitation program that opened in April 2003. It
comprises two new 20-bed buildings located in a community residential setting in
Kamloops, British Columbia. The facility’s mission is to provide “units designed to
support individuals with serious and persistent mental illness in acquiring the
skills and abilities to live within their home communities.”
This report, the second in a series of annual reports to be issued over a period of
four years, constitutes a two-year follow-up, focusing on patients’ characteristics
and evolution. For the first time, however, both evaluation projects are brought to-
gether to provide a better perspective of the British Columbia Psychiatric Tertiary
Care Redevelopment Program.
The study, representing the focus of this report, involves the comparison of a cohort
of patients admitted to Seven Oaks with a group of patients still being treated at
Riverview Hospital, and similarly, a cohort of patients admitted to South Hills with
another group of patients still being treated at Riverview Hospital, during a similar
period of time for all four groups. Riverview Hospital groups have been matched for
age, gender, diagnosis, length of stay and level of care. A number of instruments
were administered at intake and will be re-administered each year to measure the
following:
   •   Sociodemographic, educational, residential, occupational and legal statuses
   •   Cognitive deficits
   •   Symptoms
   •   Abnormal behaviours
   •   Daily living skills
   •   Quality of life
   •   Satisfaction with services.
Of the 51 patients transferred to Seven Oaks between December 2001 and October
2003, there are 24 consenting Seven Oaks patients with one- and two-year follow-up
assessments matched with 24 consenting comparison group patients with one- and
two-year follow-up assessments.
Of the 56 patients admitted to South Hills between April 2003 and May 2004, there
are 24 consenting South Hills patients with one- and two-year follow-up assess-
ments matched with 24 consenting comparison group patients with one- and two-
year follow-up assessments.
Positive outcomes have been identified for the Seven Oaks and South Hills patients:
   1. The movement of all patients referred from Riverview Hospital has been suc-
      cessful


Seven Oaks and South Hills Projects: Year 2 Assessment Report                  3 of 35
   2. There is regular movement from Seven Oaks and South Hills to community
      settings
   3. Seven Oaks and South Hills provide more opportunities for development of
      daily living skills (food preparation, care of possessions, money management
      and occupation).
Additional positive outcomes have been identified for the South Hills patients;
namely, more satisfaction related to every sphere, including mental health services,
housing and personal safety.
The clinical characteristics of the patients ascertained with these one- and two-year
preliminary results are compatible with the mandate, mission, aims and program
put forward at Seven Oaks and South Hills, and the clinical outcomes are mostly
positive. The programs developed up to this point at Seven Oaks and South Hills
appear appropriate and seem to work. They should be pursued with further empha-
sis on patient empowerment within each program, which should also consider add-
ing evidence-based individual and group therapies to increase the likelihood of im-
proving psychotic symptoms, distress and depression, cognitive deficits and emo-
tion/stress management. The results so far also support the proposition in first year
reports that the move to regional tertiary care facilities has served as a catalyst for
regular movement of patients from these facilities into less supervised community
settings to the satisfaction of patients and relatives alike.




Seven Oaks and South Hills Projects: Year 2 Assessment Report                   4 of 35
                                                        Contents
                                                                                                                             Page
About the Authors ......................................................................................................... 2
Acknowledgments .......................................................................................................... 2
Executive Summary....................................................................................................... 3

Introduction ................................................................................................................... 6
Background
      Seven Oaks Facility and Program...................................................................... 7
      South Hills Facility and Program ...................................................................... 8
      Tertiary Care Facilities ...................................................................................... 9
Study Design................................................................................................................ 11
Year 1 and Year 2 Follow-Up Populations ................................................................. 11
      Patient Movement............................................................................................. 13
Patient Characteristics................................................................................................ 14
      Cognitive Deficits .............................................................................................. 15
      Symptoms .......................................................................................................... 16
      Abnormal Behaviours ....................................................................................... 17
      Criminal Activity .............................................................................................. 19
      Daily Living Skills ............................................................................................ 20
      Employment ...................................................................................................... 22
      Physical Problems ............................................................................................. 23
      Quality of Life ................................................................................................... 23
      Satisfaction with Services ................................................................................ 25
Findings ....................................................................................................................... 28
Study Limitations ........................................................................................................ 30
Conclusions .................................................................................................................. 32
References .................................................................................................................... 33

Appendix: Instruments Used in the Project ............................................................... 35




Seven Oaks and South Hills Projects: Year 2 Assessment Report                                                           5 of 35
Introduction
The spirit that permeates these research activities consists in supporting through
evaluation the innovation developed and implemented by clinicians, mental health
workers, planners and policymakers. Research lends its expertise in providing a
system perspective and in methodically describing and analysing health services
innovations, as well as their implementation, congruence with stated aims and
impact. Innovation itself, however, originates with clinicians, mental health work-
ers, planners and policymakers. This is recognized by the Canadian Health Services
Research Foundation (created in 1997), which has underlined that expertise does
not flow uniquely from research to practice. Rather, practice is at the forefront in
developing and experimenting with innovations that would be best tailored to
emerging needs.
We came to learn about the Seven Oaks tertiary mental health care facility through
a Health Canada document, Best Practices in Mental Health Reform (Health and
Welfare Canada, 1997). The Ministry of Health Services of British Columbia had
suggested that Seven Oaks could serve as a best practice example in the area of
residential care and alternatives to long-term hospitalization in psychiatric hospi-
tals.
Interested for over a decade by the needs of long-term mentally ill patients, Dr.
Lesage conducted a series of studies on the pursuit of deinstitutionalization and on
the downsizing of a psychiatric hospital in Montreal. The conceptual model that he
adopted to evaluate deinstitutionalization was based on a holistic approach that
takes into account the:
   1. Individual level with its focus on clinical and psychosocial outcomes
   2. Facility/program level with its focus on utilization of services, costs, and phi-
      losophy of care
   3. System level, where the focus is on organizational contacts, leadership, barri-
      ers, facilitating factors and relationships among the various services for se-
      verely mentally ill patients (Lesage, 2000).
The results of the Montreal study were presented in January 2000 at the Ministry
of Health Services of British Columbia, at Riverview Hospital, at Seven Oaks and in
the Interior Health Authority Region that was planning at the time the develop-
ment of the South Hills facility. Visiting Seven Oaks and hearing about the South
Hills project, we understood that this innovative policy with its facilities and pro-
grams could be an answer to the unmet needs for care and services identified for
patients remaining hospitalized in psychiatric hospitals in Quebec. An important
group of these patients were in need of intensive treatment and rehabilitation in a
suitable residential/ward milieu (Lesage et al., 2000).
We also emerged from our discussions with Seven Oaks clinicians, South Hills
managers and Ministry planners with an agreement to support them with an
evaluation project and to seek financial support in an incremental way over the
next few years to find answers to the following questions:


Seven Oaks and South Hills Projects: Year 2 Assessment Report                   6 of 35
   1. What are the characteristics of such facilities and patients: physical, admin-
      istrative, clinical, and experiential?
   2. Can such a facility accommodate all patients requiring tertiary residential
      care from its catchment area?
   3. What are the characteristics of the patients selected for such a facility and
      what is their evolution over a four-year period?
   4. What treatments, rehabilitation and other services are offered to patients at
      such a facility?
   5. What are the organizational issues favouring and impeding the development
      of such a tertiary psychiatric care facility in a regionalized public system of
      health and social services?
The financial support obtained so far allowed us to answer particularly the first two
questions. This report, the second annual report to be presented over the next four
years, provides the two-year follow-up, allowing us to begin to answer the third
question on patients’ characteristics and evolution.

Background
Seven Oaks Facility and Program
Seven Oaks is a 38-bed facility on the outskirts of Victoria in British Columbia
(BC). Originally created in 1994 with two six-bed pavilions, it was subsequently re-
built and opened as a tertiary care facility to new residents in December 2001. The
new facility has three seven-bed pavilions (including one secure unit with a seclu-
sion room), a ten-bed long stay unit (also with a seclusion room), and a seven-bed
transition unit (essentially seven self-contained flats).
In BC, tertiary care is defined as the care of persons with serious, complex and/or
rare mental disorders who by reason of severe psychotic behaviour or specialized
staff and facility needs cannot be managed by the resources available at the pri-
mary and secondary levels of care in the province.
In the context of the regionalization of tertiary care, started at the beginning of the
1990s, the mandate accepted by Seven Oaks was that “there will be no higher level
of care than in these facilities and no referral elsewhere for the identified resident
population” of the region. Seven Oaks’ mission is to “provide a high level of care,
treatment, and rehabilitation in a flexible, deinstitutionalized and interactive com-
munity.” The goals are to:
   1. Provide tertiary care, treatment and rehabilitation in a community or close to
      home
   2. Provide a safe and protective environment that encourages the resident to
      assume personal responsibility
   3. Promote and maintain resident connections with a community, including
      family, friends, advocates and local support services
   4. Actively encourage the cooperation and involvement of residents, family,
      friends, advocates and local support services as community resources.



Seven Oaks and South Hills Projects: Year 2 Assessment Report                   7 of 35
Since its opening in 1994, the Seven Oaks program has evolved into a treatment
approach that emphasizes individualized care planning based on:
   •   Mutually agreed upon goals
   •   Outcome indicators
   •   Modelling
   •   Support and education to maximize independent functioning.
The residents participate in day-to-day planning and decision making with respect
to daily living, recreation and social programs. For example, staff and patients alike
will participate in meals preparation and will eat together. Residents and family
members also participate in program policy planning and reviewing.
South Hills Facility and Program
South Hills is a 40-bed facility divided into two new 20-bed buildings located in a
community residential setting in Kamloops, BC, an Interior BC city of 85,000 in-
habitants. This tertiary care facility is part of the Interior Health Authority Region
that is home to 750,000 people.
These units are designed to support individuals with serious and persistent mental
illness in acquiring the skills and abilities required to live satisfactorily in the envi-
ronment of choice with the least amount of ongoing professional interventions
within their home communities.
The intention was for psychosocial rehabilitation to be the frame of reference for all
interventions, combining empowering principles with practical strategies to facili-
tate recovery for such individuals.
An examination of the program intended for South Hills indicates that staff work 24
hours per day, seven days per week. There is a wide range of health professionals,
including nurses, occupational therapists, physicians, pharmacists, psychiatrists,
rehabilitation workers, social workers and a unit clerk. Everyone is expected to do
any or all general tasks and to ask assistance and support from key members with
specific skills and training. Staff is expected to act as facilitators—doing activities
with the patients and teaching them skills as needed. There are also service coordi-
nators working to bring volunteers into the facility as part of the goal to increase
the community’s awareness and acceptance of people with mental illness. The pro-
gram as intended indicates that “families and consumers are part of the team; they
can participate in the rehabilitation planning meetings and bi-monthly house con-
sultation meetings. Families are welcome to visit or call any time.”
The following description of South Hills can be found in the intended program: “In-
dividuals live in groups of five in an apartment while each building is called a
house. Each apartment has a full kitchen with fridge, stove, dishwasher and micro-
wave, 1.5 bathrooms and shared laundry. Each person has his or her own room with
a lock on the door. Inside each room is a bed, bedside table with alarm clock, writing
desk, two chairs and a closet. Everyone is expected to make his or her own break-
fast. Lunch and supper are provided. However, some apartment groups have al-
ready been making their own lunch, and will eventually make their own supper as


Seven Oaks and South Hills Projects: Year 2 Assessment Report                     8 of 35
well. Each apartment has a monthly budget that they must stay within for food and
other items. They shop twice per week at the local grocery store. House members
are also expected to maintain their own room and to work together to keep their
apartment areas clean and stocked. They are expected to do their own laundry and
to clean the bathrooms. Additionally, every one has his/her own bedding and linen
(including towels) to wash. Individuals also take turns being responsible for the
other items/areas of the building, including plants and patios. Local transit is used
to get around and attend programs, events, volunteer work and other activities. In-
dividuals are also setting up local bank accounts and getting bus passes.”
Tertiary Care Facilities
Tertiary care is defined as the care of persons with serious, complex and/or rare
mental disorders who by reason of severe psychotic behaviour or specialized staff
and facility needs, cannot be managed by the resources available at the primary and
secondly levels of care. The BC Interior Health Authority shared this view when it
presented the following graphic (Figure 1) situating tertiary care in relation to sec-
ondary and primary care.
Figure 1: Tertiary, Secondary and Primary Care



                    A New Approach

     Concentrated, Highly
         Specialized                Tertiary Services


General Hospital Psychiatry Units         Secondary Services
  Group/Family Care Homes


 Health Promotion,
Prevention, Care and                            Primary Services
     Treatment



Figure 1 also illustrates that people requiring tertiary care represent only a small
percentage of all people with severe mental disorder, and that people with current
mental disorders are much more numerous. The people currently suffering from
mental disorder (estimated at 10 to 20% of the general population) are mainly af-
fected by disorders of anxiety, depression or substance/alcohol abuse; they are most
likely not being treated, and if they are, it is by primary care providers, such as
general practitioners. People with severe mental disorders (about 1 to 2% of the
population) are likely to suffer from severe forms of depression, anxiety, substance
abuse or psychotic disorders like schizophrenia or bipolar (manic-depressive) disor-
ders. People with severe mental disorders are most likely to be in contact with sec-
ondary and tertiary care services. The proportion of people in contact with tertiary
care services is about 0.1 to 0.2% of the general population (or 10 to 20% of severely


Seven Oaks and South Hills Projects: Year 2 Assessment Report                  9 of 35
mentally ill patients).
No country has been able to completely close its psychiatric hospitals. This is partly
due to the intensive treatment and rehabilitation needs of a very small group of se-
verely mentally ill patients who cannot be accommodated in existing community-
based support programs, residential facilities that provide case management or as-
sertive community treatment programs. As early as 1984, Gudeman and Shore
(1984) in the US estimated that there would be a need for tertiary care facilities for
about 15 per 100,000 inhabitants (0.015% of the general population). These patients
would fall into one of five groups:
   1. Elderly with dementia, psychosis and physical problems that render them
      dangerous to themselves and/or others
   2. Intellectually handicapped with concomitant psychiatric illness and aggres-
      sive behaviour
   3. Those with a serious loss of impulse control consequent to brain damage fol-
      lowing head injuries or degenerative disorders
   4. Those with schizophrenia who are unremittingly assaultive/suicidal and op-
      positional
   5. Patients with schizophrenia who exhibit behaviours that are embarrassing in
      any community and who are vulnerable to exploitation.
Facilities like Seven Oaks and South Hills particularly aim groups 4 and 5 for
which the total number of places required would be 7.5 per 100,000 inhabitants.
Gudeman and Shore (1984) proposed that an appropriate alternative to large psy-
chiatric hospitals for these patients would be a regional facility of no more than 200
beds with small wards of about 25 patients where intensive treatment and rehabili-
tation would be provided. But there has been little or no description of such facili-
ties in the US since then. The closest to these innovations, like Seven Oaks and
South Hills, are hostel wards developed in the UK in the beginning of the 80s
(Wykes, 1982). The hostel wards concept is one of home-like environments, provid-
ing intensive treatment and rehabilitation very much in line with the approach
adopted by BC Tertiary Psychiatric Residential Facilities (TPRF) like Seven Oaks
and South Hills.
The evaluation of several hostel wards has shown that such facilities were viable,
providing better care at no more cost than could be provided by acute care facilities
(Hyde et al., 1987; Shepherd, King & Fowler, 1995). Over a period of several years,
it was found (Reid & Garety, 1996) that about:
   •   1/3 of patients moved “rapidly” (within three to five years) from the facility to
       less supervised residential settings, some of which were set up by the facility
       itself
   •   1/3 remained in the facility, some of these eventually moving, over a period of
       five to ten years or more, to less supervised residential facilities
   •   1/3 were sent back to hospital-type wards, mainly because of unpredictable
       aggressive behaviours (some were actually sent to forensic psychiatric facili-
       ties).


Seven Oaks and South Hills Projects: Year 2 Assessment Report                   10 of 35
The South Hills TPRF units fit within the complete integrated mental health sys-
tem for tertiary care and would include 66 community beds and 44 acute tertiary
beds. It was also planned that following treatment of patients in acute rehabilita-
tion beds, the macro region communities would accept continuing management.
The target population for these TPRF beds in South Hills was to be people over 18
years of age with a chronic mental illness, who pose a low level of risk to others,
who are medically stable and who require the development of skills and abilities. It
would therefore accommodate patients who require a longer stay to continue with
intensive treatment, which offers a psychosocial rehabilitation program focusing on
work, education, leisure and life skills. On that count, the target population differs
from that of Seven Oaks, which was intended to try and accommodate all patients
from their catchment area who would require tertiary psychiatric care.

Study Design
The general design relating to this study of patient characteristics and evolution
involves the comparison of a cohort of patients admitted to Seven Oaks from River-
view Hospital with a group of patients who are being treated at Riverview Hospital
at the time of the cohort's initial (T0) assessment, and similarly, the comparison of a
cohort of patients admitted to South Hills from Riverview Hospital with another
group of patients who are being treated at Riverview Hospital at the time of the co-
hort's initial (T0) assessment (see Figures 2 and 3). The Riverview Hospital groups
have been matched for age, gender, diagnosis, length of stay and level of care.
A battery of instruments administered at intake and to be re-administered each fol-
low-up year measures:
   •   Sociodemographic information as well as educational, residential, occupa-
       tional and legal statuses
   •   Cognitive deficits
   •   Symptoms
   •   Abnormal behaviours
   •   Daily living skills
   •   Quality of life
   •   Satisfaction with services.
The appendix features short descriptions of the instruments used in the project.

Year 1 and Year 2 Follow-Up Populations
The present report focuses on the characteristics and evolution of patients admitted
to Seven Oaks and South Hills since their respective opening for which a two-year
follow-up was available in May 2005 and that of their available comparison group
patients.
Figures 2 and 3 (see next page) illustrate the overall design of the Seven Oaks and
South Hills projects respectively.




Seven Oaks and South Hills Projects: Year 2 Assessment Report                   11 of 35
Figure 2: Overall Seven Oaks study design




   Intake and Follow-Up of Seven Oaks and Comparison Group Patients

           T0                    T1     T2             T3         T4
                        N = 40




                        N = 40


                 Intake until
                 Oct. 3, 2003

       New facility         Year 1      Year 2           Yearly follow-up;
        opened             follow-up   follow-up   2006, 2007 (ends Oct. 2007)
       Dec. 2001          2003-2004      2005




Figure 3: Overall South Hills study design




   Intake and Follow-Up of South Hills and Comparison Group Patients

           T0                    T1     T2             T3         T4
                        N = 40




                        N = 40


                 Intake until
                 May 4, 2004

       New facility         Year 1      Year 2           Yearly follow-up;
        opened             follow-up   follow-up   2006, 2007 (ends May 2008)
       Mar. 2003          2004-2005      2005




The objective was to have 40 participants from Seven Oaks and 40 comparison pa-
tients from Riverview Hospital, and similarly for South Hills. The intake of patients
at Seven Oaks started at the opening of the new facility in December 2001 when an


Seven Oaks and South Hills Projects: Year 2 Assessment Report                    12 of 35
initial group of 13 patients was transferred to the new facility. These patients had
been previously placed at Seven Oaks subsequent to its original opening in 1994 (for
two to three years on average) and had been relocated to a temporary facility prior
to moving to the new one in December 2001. In August 2002, a group of 24 patients
was transferred from Riverview Hospital to Seven Oaks, and during the following
months, 14 more patients were admitted from Vancouver Island care facilities. Of
the 51 individuals admitted to Seven Oaks prior to October 2003, 42 consented to
participate in the research project. This report only examines the results relating to
24 Seven Oaks patients with Year 1 and Year 2 follow-up assessments with 24
matched comparison group patients with Year 1 and Year 2 follow-up assessments.
The intake of patients at South Hills started at the opening of the new facility in
March 2003 until May 2004 to take into account the patients who refused to par-
ticipate and to ensure a total number of participants close to 40. Accordingly, this
report only examines the results relating to 24 South Hills patients with Year 1 and
Year 2 follow-up assessments (out of 56 patients admitted to South Hills between
March 2003 and May 2004). There are 24 matched comparison group patients with
Year 1 and Year 2 follow-up assessments.
Patient Movement
Of the 51 patients who were admitted to Seven Oaks between December 2001 and
October 2003, 24 (47%) made the move to community settings prior to January 1
2005. Of the initial 42 participants, 16 (39%) made the move to community settings:
10 to residential care, 4 to independent/supported care, and 2 to long-term care. One
participant died from complications linked to long-term physical illnesses.
In the comparison group, 7 out of 24 (29%) patients have made the move to commu-
nity settings in the form of group homes.
Of the 56 patients who were admitted to South Hills between March 2003 and May
2004, 30 (54%) made the move to community settings prior to January 1, 2005. Of
the 24 participants, 11 (46%) were transferred to community settings: 8 to group
homes, 2 to independent living, and 1 to a family care home.
In the comparison group, 4 out of 24 (17%) patients have made the move to commu-
nity settings in the form of group homes and 2 out of 24 (8%) were transferred to a
long-term care facility.
Figure 4 (see next page) illustrates all patient movement between baseline and both
follow-ups for the combined patients of Seven Oaks and South Hills and the com-
bined patients of the comparison groups. The figure indicates three levels: Tertiary
Psychiatric Residential Facilities (dark colour), supervised residential settings
(lighter colour), and more autonomous settings, such as own apartment with rela-
tives (white colour).




Seven Oaks and South Hills Projects: Year 2 Assessment Report                  13 of 35
Figure 4: Seven Oaks, South Hills and comparison groups patients movement


                              Where are the patients?

                                                                 1                                      1
                                                         5                          5
       R
       E                                                 4                          3
       D                                                                                                1
       E
       V                                                     3                                  3
                                                                           1
       E
       L      Riverview Hospital                                                                        4
       O           (N = 48)               Seven Oaks/                                         12
                                                                        Seven
       P                                   South Hills
       M                                                                Oaks/
                                            (N = 35)                  South Hills
       E
       N                                                               (N=19)
       T


       C
       O                                                             Riverview
       M                                                              Hospital
       P                               Riverview Hospital             (N = 29)
              Riverview Hospital
       A                                    (N = 42)
       R           (N = 48)
       I                                                                                       12
       S
       O
       N
                                                             4                                      4
                                                                 2                                      2

                   Baseline                st
                                          1 Follow Up                          2   nd
                                                                                        Follow Up




Patient Characteristics
Table 1 (see next page) presents Seven Oaks and South Hills patient characteristics
at intake as well as those relating to the comparison groups using the Canadian
Toolkit questionnaire (see Appendix). The majority of patients are single males in
their 40s who have not graduated from high-school. Most of them have been diag-
nosed with schizophrenia, about a third also have personality disorders, over a third
had a concurrent diagnosis of substance abuse in the past, and about a quarter have
a dual diagnosis of at least mild mental retardation. Their first admission occurred
in their early 20s, and thus they have been in contact with services for over 20
years. Their average length of stay for their admission at T0 varies between 5 and 9
years with the number of admissions varying on average between 6 and 13. The
overall profile is therefore one of long-stay psychiatric inpatients with severe and
co-morbid mental disorders.




Seven Oaks and South Hills Projects: Year 2 Assessment Report                                               14 of 35
Table 1: Seven Oaks, South Hills and comparison groups patients characteristics at intake

                                       Seven Oaks      Comparison        South Hills   Comparison
Characteristics
                                        (N = 24)        (N = 24)          (N = 24)      (N = 24)
Male                                      58%             58%               62%           62%
Female                                    42%             42%               38%           38%
Average Age                                47              47                51            49
Age Range                                29 – 62         24 – 64           24 – 80       24 – 64
Single                                    79%             79%               71%           83%
High-School Graduate                      25%             50%                8%           38%
Non-Affective Diagnosis                   71%             71%               75%           83%
Affective Diagnosis                       29%             29%               25%           17%
With Axis II Diagnosis                    58%             38%               38%           54%
Past substance disorder                   38%             33%               58%           38%
Mental retardation                        29%             21%               29%           21%
Avg. Age at 1st Admission                  24              24                25            25
Avg. Length of Stay (years)                4.8             5.9               8.5           6.7
Avg. # of Previous Admissions              13               8                11             6

Cognitive Deficits
Cognitive deficits were assessed using the Cambridge Neuropsychological Test
Automated Battery (see CANTAB in Appendix), and specifically, the Motor Screen-
ing (MOT), Paired Associates Learning (PAL) and Spatial Recognition Memory
(SRM) tests. As Table 2 shows, between-group differences were statistically signifi-
cant at T0 for Seven Oaks and comparison group patients in the PAL and SRM tests
(lower mean scores for Seven Oaks in both cases) and for South Hills and compari-
son group patients in the PAL test (lower mean score for South Hills). A notable
within-group difference (statistically significant decrease from T0 to T1) appeared
for the South Hills comparison group in the PAL test. These tests would indicate
that patients selected for TPRFs may have more deficits and that changes are ab-
sent at this point but not impossible and shall be watched for in the coming years.
Table 2: Seven Oaks, South Hills and comparison groups patients mean CANTAB scores

                        MOT Mean Latency           PAL First Trial Memory          SRM Correct
Groups
                           (seconds)                         (%)                      (%)
Seven Oaks T0                 1.53                          13.8                      51.0
Comparison T0                 1.13                          49.0 *                    66.3 *
Seven Oaks T1                 1.28                          39.2                      61.3
Comparison T1                 1.42                          33.2                      70.7
Seven Oaks T2                 0.92                          42.3                      74.0
Comparison T2                 1.15                          34.2                      63.6

South Hills T0                  1.46                         29.8 **                   60.0
Comparison T0                   1.24                         43.0 *                    58.5
South Hills T1                  1.21                         28.2                      59.9
Comparison T1                   1.29                         30.4                      64.8
South Hills T2                  1.24                         33.7                      67.1
Comparison T2                   1.21                         38.5                      65.3
Between-group (*) and within-group (**) statistically significant differences



Seven Oaks and South Hills Projects: Year 2 Assessment Report                                 15 of 35
Symptoms
Patient symptoms were measured using the Brief Psychiatric Rating Scale (see
BPRS in Appendix). As Figure 5 shows, Seven Oaks and comparison group patients
seem to differ especially in terms of their negative symptoms (statistically signifi-
cantly higher for Seven Oaks at T0 and T1) and positive symptoms (statistically sig-
nificantly higher for Seven Oaks at T2). Seven Oaks patients showed apparent
changes in their negative symptoms (statistically significant decrease from T0 to T1)
and positive symptoms (statistically significant increase from T1 to T2). The com-
parison group showed apparent changes in manic excitement (statistically signifi-
cant increase from T1 to T2) and in negative symptoms (statistically significant de-
crease from T0 to T1).
Figure 5: Seven Oaks and comparison group patients mean BPRS scores



  Comparison T2


  Seven Oaks T2                                                                     *



  Comparison T1
                                                          **                                 Depression-Anxiety
                                                                                             Positive Symptoms
  Seven Oaks T1                                                           **
                                                *                                            Negative Symptoms
                                                                                             Manic Excitement
  Comparison T0                                **


  Seven Oaks T0                                          * **

                  0    2      4     6      8        10          12   14        16       18
                                          Mean Score


* Between-group statistically significant difference
** Within-group statistically significant difference

As Figure 6 shows (see next page), South Hills and comparison group patients were
about the same from T0 to T2. South Hills patients showed apparent changes in
their negative symptoms, positive symptoms and depression-anxiety (statistically
significant increases from T1 to T2). The comparison group did not show any notable
differences from T0 to T2.
Overall, there is no substantial change in the new facility groups but an impression
of stability with fluctuations. The recent increase in positive symptoms in all groups
and the little gain in negative symptoms are noted and to be balanced in the follow-
ing instruments-based evidence.



Seven Oaks and South Hills Projects: Year 2 Assessment Report                                           16 of 35
Figure 6: South Hills and comparison group patients mean BPRS scores



  Comparison T2


   South Hills T2


  Comparison T1
                                                                             Depression-Anxiety
                                          **                                 Positive Symptoms
   South Hills T1                                             **
                                                   **                        Negative Symptoms
                                                                             Manic Excitement
  Comparison T0


   South Hills T0


                    0   2     4      6         8   10   12   14    16   18
                                          Mean Score


** Within-group statistically significant difference

Abnormal Behaviours
As indicated in Year 1 reports, the results with the following instruments-based
evidence will be interpreted with one methodological caveat. The questionnaires are
self-reported by staff about the patients without intervention by the independent
research interviewer (in contrast with the previous BPRS and the ILSS to be re-
ported later). For a similar behaviour, psychiatric hospital staff may have developed
tolerance and may rate it as less problematic with instruments that do not provide
clear anchor points. Staff in the new TPRFs or in community placements may rate
the same behaviour as worse. The interpretation of results will therefore be cau-
tious if differences are observed between groups, except: 1) at T0 where all assess-
ments were done when patients were at Riverview, and 2) when changes occur for
patients who remain at the same facility (same staff assessment).
Abnormal behaviours were assessed using the Social Behaviour Schedule and the
Riverview Patient Inventory (see SBS and RPI respectively in Appendix). As Figure
7 (see next page) shows, according to the SBS, Seven Oaks and comparison group
patients seem to differ in terms of their severe behaviours and severe and mild be-
haviours (statistically significantly higher for Seven Oaks at T0). As Figure 8 (see
next page) indicates, such a difference was not observed for the South Hills group.
Seven Oaks patients showed apparent changes in terms of their socially unaccept-
able habits or manners, personal appearance and hygiene, slowness, and under-
activity (statistically significant decreases from T0 to T1), but with some deteriora-
tion at T2, so the difference is not statistically significant from T0 to T2.



Seven Oaks and South Hills Projects: Year 2 Assessment Report                           17 of 35
Figure 7: Seven Oaks and comparison group patients mean SBS scores

  Comparison T2



  Seven Oaks T2                                   *
                                                                                              Under-activity
  Comparison T1        **                                                                     Personal Appearance
                                                                                              Socially Unacceptable Habits
                                                                                              Laughing and Talking to Self
  Seven Oaks T1                          *                                                    Severe and Mild Behaviours
                                                                                              Severe Behaviours

  Comparison T0             **


                                             * **
                                                     * **
  Seven Oaks T0                                 * **
                                              *
                                                                                      *
                                                                 *
                   0                 1                2      3            4   5   6       7
                                                            Mean Score


* Between-group statistically significant difference
** Within-group statistically significant difference

South Hills patients showed apparent changes in terms of their severe behaviours
and severe and mild behaviours, and more specifically, in their communication, so-
cial mixing, socially unacceptable habits or manners, personal appearance and hy-
giene, under-activity, and other behaviours, which increased from T0 to T1, and per-
sonal appearance and hygiene, which decreased from T1 to T2.
Figure 8: South Hills and comparison group patients mean SBS scores

  Comparison T2



  South Hills T2

                                                                                              Under-activity
  Comparison T1             **                                                                Personal Appearance
                                                                                              Socially Unacceptable Habits
                                     *                                                        Laughing and Talking to Self
                                                          * **
  South Hills T1                         *                                                    Severe and Mild Behaviours
                                 *
                                                                                              Severe Behaviours

  Comparison T0


                             **              **
  South Hills T0             **
                                                                     **
                                             **
                   0                 1                2      3            4   5   6       7


* Between-group statistically significant difference
** Within-group statistically significant difference


Seven Oaks and South Hills Projects: Year 2 Assessment Report                                                                18 of 35
Table 3 shows RPI results. A similar tendency seen with the SBS is observed with
the Seven Oaks group but not with the South Hills group, who showed more overall
difficulties than their comparison group from the start. When moved to the new
TPRF, Seven Oaks patients seem to experience more difficulties with daily routines
at T2; the apparent deterioration for South Hills from discharge to first year shall be
interpreted with the caution indicated initially because of a potential different
threshold between psychiatric hospital staff and new TPRF staff.
Overall, taking into account the methodological caveats of a differential threshold,
these results would indicate that:
   1. Seven Oaks patients were more severely mentally ill, and this is in line with
      the previously reported CANTAB results on cognitive deficits;
   2. Little gains are observed in abnormal behaviours, and if anything, more diffi-
      culties appear, but not substantial ones as the program of rehabilitation is
      put into place to improve daily routines and social interactions (these will be
      put in the perspective that the increase was not substantial clinically and
      that a number of patients successfully moved to less supervised residential
      settings).
Table 3: Seven Oaks, South Hills and comparison groups patients mean RPI scores

                       Daily        Psychological        Social          Aggressive
                                                                                         Overall diffi-
Groups                Routine        Symptoms          Interaction       Behaviours
                                                                                           culties
                     problems                           problems
Seven Oaks T0          30.3              27.6             15.8                  12.8         86.5
Comparison T0          25.8              22.3             13.7                  11.2         73.0 *
Seven Oaks T1          28.7 **           27.5             15.0                  13.0         84.3
Comparison T1          23.2              19.9 *           11.4                   9.6         64.2 *
Seven Oaks T2          32.4 **           29.8             17.5                  14.4         94.1
Comparison T2          26.8              23.8 *           14.0                  10.2 *       74.8 *

South Hills T0         26.9              22.7              13.0                 12.4         73.5
Comparison T0          27.0              24.3              15.0                 11.7         77.9
South Hills T1         30.4 **           22.9              13.7                 11.5         76.1
Comparison T1          27.3              24.7              13.6                 11.5         77.1
South Hills T2         31.0              26.5              17.0                 14.1         88.2
Comparison T2          28.0              24.6              15.0                 11.2 *       77.4
Between-group (*) and within-group (**) statistically significant differences

Criminal Activity and involvement with the police
Questions may arise about criminal activities in relation to abnormal social behav-
iours. The majority of patients had previous judiciary involvement: 54% in each of
the South Hills, Seven Oaks and comparison groups. Moreover, between 33% and
50% in each group had been incarcerated in the past before their current or last
admission to Riverview Hospital or discharge to Seven Oaks or South Hills.
Between baseline and the first follow up, about one in eight subjects (13%) in the
combined Seven Oaks and South Hills group were involved with law enforcement.
One incident involved police, the ER and the local mental health team with no


Seven Oaks and South Hills Projects: Year 2 Assessment Report                                 19 of 35
charges being laid; two others involved police but were minor in nature; and three
others were internal.
Twelve Redevelopment Program subjects (26%), including three repeaters from the
year before, were involved in criminal activity between their first and second follow-
up assessments. Five were relatively serious, two were charged with theft, one as-
saulted facility staff (no charges were laid, but subject was discharged to the re-
gional Psychiatric Intensive Care Unit), and two others caused considerable distur-
bances in the community (neither was charged). One example of the latter involved
a client who suddenly showed up at a dentist's office without an appointment that
day, and being denied immediate attention, started vociferating. The police was
called in and the client was brought back to the tertiary care facility. Six clients
were involved with police because of minor matters. One such example involved a
client being drunk around a local bar and being brought back to his group home;
another involved a shoplifting incident at a local facility; another where a client
filed a complaint about another resident’s threatening remarks; and finally, two
cases involving only facility staff, but police were called in to support psychoeduca-
tional discussion with the clients about in-house prostitution or theft.
We realised that our questionnaires were not capturing the security interventions
in a psychiatric hospital; either the interventions of security staff or the tolerance of
certain behaviours on the protected psychiatric hospital grounds and premises. This
biases the comparison with the impression of an increase in activities involving the
police. A perspective should be kept in regards to these behaviours. Only in one se-
rious occurrence was a patient transferred to the regional intensive care unit. On
the contrary, these behaviours are targeted by rehabilitation efforts and local com-
munity resources, including the police who are involved as partners in this rehabili-
tation effort.
Daily Living Skills
Daily living skills were measured using the Independent Living Skills Schedule (see
ILSS in Appendix). As Figures 9 and 10 (see next page) illustrate, Seven Oaks and
South Hills showed significant improvements when they moved to the new facili-
ties. Seven Oaks patients showed statistically significant increases in terms of care
of personal possessions, food preparation, money management, job seeking and
overall from T0 to T1, and this was somewhat maintained at T2. South Hills patients
showed statistically significant increases in terms of their appearance and clothing,
care of personal possessions, food preparation, health maintenance, money man-
agement and overall from T0 to T1, as well as a statistically significant decrease in
personal hygiene in that same period. South Hills patients also showed a statisti-
cally significant increase in health maintenance from T1 to T2.
Seven Oaks comparison group patients (see Figure 11) seem to differ in terms of
care of personal possessions, food preparation, money management, job seeking and
overall (statistically significantly higher for Seven Oaks at T1) and in terms of
money management, job seeking and job maintenance (statistically significantly
higher for Seven Oaks at T2). The comparison group showed statistically significant


Seven Oaks and South Hills Projects: Year 2 Assessment Report                    20 of 35
decreases in terms of care of personal possessions, food preparation, health mainte-
nance and money management from T0 to T1, and statistically significant increases
in terms of care of personal possessions, food preparation, health maintenance and
overall from T1 to T2.
South Hills comparison group patients (see Figure 12) seem to differ in terms of
health maintenance (statistically significantly lower for South Hills at T0),
appearance and clothing, care of personal possessions, food preparation and overall
(statistically significantly higher for South Hills at T1) and appearance and clothing,
care of personal possessions, food preparation, money management, transportation
and overall (statistically significantly higher for South Hills at T2). The comparison
group showed a statistically significant decrease in terms of personal hygiene from
T1 to T2.
Overall, the results indicate significant gains in independent living skills for the
patients transferred to the new TPRFs; the program and the milieu seem quite ef-
fective here. Moreover, since patients are performing more activities, these amount
to an improvement in under-activity and the negative symptoms of schizophrenia
when the appropriate program and milieu are offered.
Figure 9: Seven Oaks patients mean ILSS scores


        100%
         90%
         80%
         70%
         60%
         50%
          40%
          30%                                                   Seven Oaks T0
          20%                                                   Seven Oaks T1
          10%
           0%                                                   Seven Oaks T2

              nce ene ns on
          ar a yg i   io ti  l th    y
       p e H se ss pa ra Hea one ati on ur e ng
     Ap         os   re        M or t     is   ki   ce  ll
           r e P od P             sp   Le See enan vera
                                n                 t
         Ca F o             Tra
                                           b
                                        J o Mai n    O
                                             b
                                         Jo




Figure 10: South Hills patients mean ILSS scores


        100%

          80%

          60%

          40%
                                                                 South Hills T0
          20%
                                                                 South Hills T1
            0%                                                   South Hills T2
              e
            nc ene       s      n
         ara Hyg i ss ion rati o al th e y
       pe          e     a                   n
                                He Mon tati o sure ing
     Ap         s s rep                                   all
             Po d P                      po
                                           r   i   k
                                             Le See O ver
           re oo                       ns
        Ca     F                  T ra        J ob




Seven Oaks and South Hills Projects: Year 2 Assessment Report                     21 of 35
Figure 11: Seven Oaks comparison group patients mean ILSS scores

        100%
         90%
         80%
         70%
          60%
          50%
          40%
          30%                                                        Comparison T0
          20%                                                        Comparison T1
          10%                                                        Comparison T2
            0%

            nce ene ns         n
         ara Hyg i ss io rati o eal th ne y
       pe         se    a                   n
                               H Mo tati o sure ing c e
     Ap       os Prep                     r   i    k         ll
             P
                                       spo  Le See tenan vera
        C are Food                   an         b    n  O
                                 Tr          J o Mai
                                                 b
                                               Jo




Figure 12: South Hills comparison group patients mean ILSS scores


         100%

          80%

           60%

           40%
                                                                     Comparison T0
           20%                                                       Comparison T1
             0%                                                      Comparison T2
                ce ene ns
            ran     i   o     on    h
          ea Hyg e ss i a rati eal t ne y on
       pp             s         H           i       e
      A
                 Pos Pre
                          p         Mo ortat ei sur         g
                                                        k in erall
              re ood                    sp    L       ee
           Ca     F                 ra n          bS        Ov
                                  T             Jo




Employment
Questions may arise about employment activities in relation to daily living skills. In
Seven Oaks at T0, 5 of the 24 (21%) participants had some employment status: 3
had on-site jobs, 1 was attending vocational training at Riverview Hospital, and 1
was doing non-paid work in the community. At T1, 7 of the 24 (29%) had some em-
ployment status: 5 had on-site jobs, 1 was still doing non-paid work in the commu-
nity, and 1 had a job in his/her boarding home. At T2, 9 of the 24 (38%) were work-
ing for wages: 5 on site and 4 in the community. At T0, 2 of the 24 (8%) comparison
group participants were attending vocational training at Riverview Hospital. At T1,
2 of the 24 (8%) were also attending vocational training at Riverview Hospital (1
from T0 and 1 new). At T2, 7 of the 24 (29%) had employment: 4 were attending vo-
cational training at Riverview Hospital, 1 had occasional employment at Riverview
Hospital, and 2 were working in the community.
At T0, 7 of the 24 (29%) South Hills and 6 of the 24 (25%) comparison group partici-
pants were earning money attending vocational training at Riverview Hospital. At
T1, 9 of the 24 (38%) South Hills and 5 of the 24 (21%) comparison group partici-
pants were earning money attending vocational training at Riverview Hospital. At


Seven Oaks and South Hills Projects: Year 2 Assessment Report                        22 of 35
T2, 9 of the 24 (38%) South Hills and 7 of the 24 (29%) comparison group partici-
pants were earning money through employment.
Physical Problems
Physical health problems were assessed using the Levels of Care Survey (see LOCS
in Appendix). Table 4 presents selected item or scale results underlining how pa-
tients present significant physical problems. Seven Oaks and South Hills groups
seem to differ at intake with lower number of physical problems indicating that pa-
tients selected for the TPRFs were less physically handicapped, but as we saw pre-
viously, more severely mentally ill, especially the Seven Oaks group. Over time,
both TPRF groups seem to present more physical problems to be identified with
more weekly care requirements. Seven Oaks patients showed statistically signifi-
cant increases in terms of mean number of physical health problems and weekly
care requirements from T0 to T1, but their comparison group also showed statisti-
cally significant increases in terms of mean number of physical health problems,
mean number of physical health problems with incontinence, and impaired ability
to walk and weekly care requirements from T1 to T2.
Both South Hills and comparison group patients showed a statistically significant
increase in terms of weekly care requirements from T1 to T2.
These results point to the increasing physical frailty of these tertiary psychiatric
care patients and the need to take into account physical care as well as mental
health care in developing adequate residential and care plans.
Table 4: Seven Oaks, South Hills and comparison groups patients selected LOCS results

                                        Mean number of physical
                    Mean number of                                                   Personal care
                                          health problems with         Weekly care
 Groups             physical health                                                    requiring
                                       incontinence and impaired      requirements
                      problems                                                        supervision
                                             ability to walk
 Seven Oaks T0             2.4 **                  2.9                     46% **        37%
 Comparison T0             3.2 *                   3.4 *                   71%           37%
 Seven Oaks T1             2.8                     3.1                     71%           42%
 Comparison T1             3.0 **                  3.2 **                  62% **        21%
 Seven Oaks T2             2.6                     2.9                     71%           46%
 Comparison T2             3.2 *                   3.5                     79%           33%

 South Hills T0            1.8                      2.1                    58%           29%
 Comparison T0             2.9 *                    2.9                    75%           46%
 South Hills T1            1.7                      2.0                    46% **        25%
 Comparison T1             2.6 *                    2.6 *                  71% **        30%
 South Hills T2            1.9                      2.3                    71%           46%
 Comparison T2             2.6                      2.9 *                  83%           54%
Between-group (*) and within-group (**) statistically significant differences

Quality of Life
Patient quality of life was measured using the Wisconsin Quality of Life Index (see
W-QLI in Appendix). As indicated in Figures 13 and 14 (see next page), little differ-


Seven Oaks and South Hills Projects: Year 2 Assessment Report                              23 of 35
ences are observed between the overall quality of life and satisfaction with social
relations between the TPRF and comparison groups. A significant improvement in
overall satisfaction is reported however by the Seven Oaks group in relation to the
time they were in the psychiatric hospital at Riverview Hospital (statistically sig-
nificant increases in terms of overall satisfaction from T0 to T2). The apparent in-
crease in overall satisfaction for South Hills from T0 to T2 was not statistically sig-
nificant. When patients who moved from a TPRF or Riverview Hospital to less su-
pervised community residential settings are considered, they report higher satisfac-
tion with quality of life and social relations (see Figures 15 and 16); their movement
seems very successful in that regard.
Figure 13: Seven Oaks and comparison group patients mean W-QLI scores


  Comparison T2


  Seven Oaks T2


  Comparison T1

                                                             **    Overall Satisfaction
  Seven Oaks T1
                                                                   Social Relations

  Comparison T0

                                                        **
  Seven Oaks T0
                                          *

                   0   10   20       30       40   50         60

                                 Mean Score




Between-group (*) and within-group (**) statistically significant differences

Figure 14: South Hills and comparison group patients mean W-QLI scores


  Comparison T2


  South Hills T2


  Comparison T1

                                                                   Overall Satisfaction
  South Hills T1
                                                                   Social Relations

  Comparison T0


  South Hills T0

                   0   10   20      30        40   50         60

                                 Mean Score




Seven Oaks and South Hills Projects: Year 2 Assessment Report                             24 of 35
Figure 15: Seven Oaks, South Hills and comparison groups patients W-QLI scores


                                                         Community Placements
                                            Quality of Life: Satisfaction with Social Relations

                                                                                       Number of friends
            M ean S atisfactio n R atings




                                                                                       Relationship with
                                                                                       friends
                                                                                       Relationship with
                                                                                       family

                                                                                       Relationship with co-
                                                                                       residents
                                                                                       Relationship with
                                                                                       other people

                                                                                       Overall



                                                Tertiary Care   Community Placements




Figure 16: Seven Oaks, South Hills and comparison groups patients W-QLI scores


                               Subjects Moving in Community Placements
                                                    Quality of Life: Satisfaction Ratings

                                                                                         Housing

                                                                                         Neighbourhood
    Mean Satisfaction Rating




                                                                                         Food

                                                                                         Clothing

                                                                                         Personal safety

                                                                                         Access to
                                                                                         transportation
                                                                                         How time is spent

                                                                                         Mental health
                                                                                         services received

                                               Tertiary Care    Community Placements




Satisfaction with Services
Satisfaction with services was also assessed using the Verona Service Satisfaction
Scale (see VSSS in Appendix). The rating scale and questions proved too complex
for many patients to answer, but the open-ended question at the end in regards to


Seven Oaks and South Hills Projects: Year 2 Assessment Report                                                  25 of 35
what they liked and disliked most about the facility provides a direct testimony of
the clients' perspective, whose life is directly influenced by the changes. Verbatim
T1 samples of comments were presented in separate Year 1 reports for Seven Oaks
and South Hills. Tables 5 and 6 present verbatim samples of comments for the Year
2 follow-ups.
Table 5: Seven Oaks and comparison group patients selected VSSS comments at Year 2 follow-up

Liked about services: Seven Oaks                    Liked about Services: Comparison
True concern for the well-being of the patient.     Having a place to live.
The nurses and patients are like good friends       Attendance at work program at the Vocational
and can help when you are in need.                  Training Centre.
Food, exercise like swimming, walking, leisure      The food.
time, fresh air and socialising.
I have found myself getting much better with        They treat you moderately and not discussed with
my mental illness one day or step at a time.        anyone but you. I get along with everyone.
Staff have been beneficial in that the help they    The recreation trips or outings or joking with the
offer does a lot of good.                           staff.
I think the best thing I like about the local       The nurses are all helpful. The cook here lets me
mental health services is the fact that they are    hang around the kitchen and teaches me things.
always there for you. The best thing about it is    There is good access to the bus.
they are honest and caring.
Disliked about services: Seven Oaks                 Disliked about Services: Comparison
Just some of the people I know.                     The attitudes of some staff and other patients.
No one talks to me or listens to my problems.       Perhaps theft in the place and/or bad language.
The whole system.                                   The medication (six patients).
Everything: staff is unfair with my money, it is    The repetition of some aspects of our lives here;
meant to be enjoyed; they use us. Two male co-      sometimes I wish I could have more privacy and
residents pick on me, call me names.                more challenge.
We don't get very much money or freedom.            Want me to eat meat but I’m a vegetarian.
I do not like the medications.                      Like more transportation.

Table 8: South Hills and comparison group patients selected VSSS comments at Year 2 follow-up

Liked about services: South Hills                   Liked about Services: Comparison
I like the the way the staff motivates us in our    Learning all kinds of new and different ideas
rooms. From the washing to the hygiene is very      about anything. Also, there is always someone to
important. Also, the meals that we cooked in        talk to or to be referred to a crisis line.
the house, and the way we do our own chores
each day is very important to me in this envi-
ronment.
Staff/residents are better behaved, friendly        I don’t feel threatened by staff and co-patients
than at RH. Have more mutual respect.               any longer, I feel they are my friends now.
Having a good time eating their wonderful food.     Having a place to live.
They do a good job here. Amount of freedom          I like that they know I’m going to Seven Oaks and
they give you: they let you walk to the store and   am comfortable waiting. Like my art when I bring
don't bother you.                                   it back. I’m just happy.
They are very supportive and caring.                The food is good and there are things to do.
On the ball. Work hard to take care of us, give     They listen to what I have to say to them about
us a better life.                                   my problems so they can better help me to have a
                                                    more fulfilling life.




Seven Oaks and South Hills Projects: Year 2 Assessment Report                                 26 of 35
Disliked about services: South Hills              Disliked about Services: Comparison
Sometimes it is hard to get to know people (co-   That they were not always there to listen and
patients).                                        help me with my problems in the past.
The medications have an adverse effect on my      I see other patients off grounds using drugs and
health.                                           alcohol.
Some of the food I don’t like, too much white     Would like to cook on weekends. Sometimes rude
rice.                                             comments are made.
I don't like the way that the choices are being   Having to pick up meds from pharmacy, having to
made in the kitchen. There is too many people     stay on meds that don't do anything, the $2/hour
in there sometimes and it gets too confusing.     vocational pay.
Then people take the whole entire back porch to
the cleaners because it should be left clean.
Worry about other residents stealing from me.     Want me to eat meat but I am a vegetarian.
The thing I have disliked the most about my       The conflict over my use of (non-psychiatric) pain
experience with local mental health services is   medication (morphine).
the years of institution I had to endure.

Initial overall impressions of the interviewers who gathered these comments about
what patients liked and disliked in regards to the services that were offered are
those of satisfaction with being at Seven Oaks or South Hills and the freedom that
these patients have to express their opinions.
Good rehabilitation practice represents a balance between stimulation and pres-
sure, and tension should be expected, which partly explains some of the comments
in terms of dislikes. On the other hand, these comments may indicate that some
individuals did not entirely “buy into” the program that had been developed for
them.




Seven Oaks and South Hills Projects: Year 2 Assessment Report                               27 of 35
Findings
   1. Positive outcomes have been identified for Seven Oaks and South Hills pa-
      tients:
       1.1 Successful movement of all patients referred from Riverview Hospital
       1.2 Regular movement from Seven Oaks and South Hills to community set-
           tings
            The extent of movement from Seven Oaks and South Hills to less super-
            vised residential community settings has been close to 50%. This is in
            line, if anything, higher, with previously reported statistics in the litera-
            ture on the comparable hostel ward settings in the UK.
       1.3 More opportunities for improvement of daily living skills (food prepara-
           tion, care of possessions, money management, occupation, etc.) associ-
           ated with the Seven Oaks and South Hills facilities and milieu programs
       1.4 Overall satisfaction on the part of Seven Oaks and South Hills patients
           with these opportunities, especially when they moved to more independ-
           ent community residences
   2. Improvements
       Concerns could be raised in regards to the modest gains in symptoms, ab-
       normal behaviours, involvement with police and cognitive deficits. Firstly,
       one should keep in mind that these behaviours did not prevent patients from
       moving to less supervised settings to their satisfaction and in only one occur-
       rence was a patient brought to an intensive care unit in the regional hospital.
       Secondly, experience with similar patients moved to hostel wards in the UK
       showed less gains in the first years. Overall, the programs at Seven Oaks and
       South Hills seem to work. The facilities should consider, however, recent de-
       velopment in psychosocial interventions with severely mentally ill patients to
       be added to their program. Evidence-based individual and/or group therapies
       have been reported to improve psychotic symptoms, distress and depression,
       cognitive deficits and emotion/ stress management in severely mentally ill pa-
       tients as part of an overall rehabilitation program (Briand et al., 2005; Pilling
       et al., 2002).
   3. More changes are observed for comparison group patients at Year 2 follow-
      ups: Not static control groups but reference groups
       Regular Riverview Hospital ward patients showed no apparent changes at
       the first year follow-up. However, the picture is different at the second year
       follow-up: patients were discharged directly to community placements and
       this move was associated with quality of life gains for those patients (not
       those remaining in the hospital).
       The moves that occurred in the second year follow-up also illustrate that both
       comparison groups are not static and cannot be considered as a type of control
       group of patients remaining indefinitely at Riverview Hospital while being


Seven Oaks and South Hills Projects: Year 2 Assessment Report                    28 of 35
       compared to patients who moved to Tertiary Psychiatric Residential Facili-
       ties. Because of the continuous BC Redevelopment Program applied to River-
       view Hospital's patients, things are changing. It would be best to describe the
       comparison group as a reference group and expect to learn as much from
       them and the changing environment that they have been exposed to as from
       the Seven Oaks and South Hills experiments.




Seven Oaks and South Hills Projects: Year 2 Assessment Report                  29 of 35
Study Limitations
Several limitations of this study must be taken into account in weighing the conclu-
sions of this Year 2 follow-up report:
   1. Patient samples are incomplete.
       Complete patient samples were not available for analysis at the time of re-
       porting. Results for the total expected sample (40 patients per group) will be
       available subsequently, providing a greater basis for analysis with more
       meaningful comparisons. Only evident comparisons were conducted to con-
       firm apparent differences. Moreover, the comparison group included patients
       from Connolly Lodge, a facility at Riverview Hospital that differs in its pro-
       gram and physical setting from other wards. Reported differences or changes
       focused on regular Riverview Hospital ward patients to contrast what would
       have happened if Seven Oaks patients would have stayed in these regular
       wards.
   2. This report only considers the first two yearly follow-ups of a study designed
      to cover four years.
       With such a severely mentally ill group of patients, changes are expected to
       take place over a period longer than merely two years. Evidence to this can be
       found in the literature on hostel wards, which showed that movements were
       observed to less supervised community settings over a period of five and even
       ten years. More recent literature reports have shown changes only after a pe-
       riod of two or three years with evidence-based approaches, such as cognitive
       behavioural psychotic symptoms modification or with optimal care packages
       for schizophrenia (including medication, individual psychotherapy, rehabili-
       tation and family psychoeducation) (Hogarty, 2002; Pilling et al., 2002). Simi-
       larly, experience with the implementation of the Integrated Psychological
       Treatment program in Montreal (addressing cognitive deficits, problem-
       solving and management of emotions and stress with groups of patients)
       showed that younger and less severely affected patients with schizophrenia
       required a nine-month program, whereas continuous care outpatients re-
       quired double the usual time (Briand et al., 2005). Indeed, program
       evaluations for such clients should be planned for at least five to ten years to
       be able to ascertain all the clinical, psychosocial and administrative impacts.
   3. A methodological issue has been raised with the “threshold for intensity” in
      staff questionnaires.
       Two instruments rely entirely on staff reporting: the Social Behaviour Sched-
       ule and the Riverview Patient Inventory. In theory, the same behaviour may
       be rated as less intense by staff facing this behaviour daily or in a milieu
       where some form of tolerance to the behaviour has developed. The same effect
       may also occur when staff has less time to make individual observations. This
       may have occurred to some extent with these instruments. Lower overall ab-
       normal behaviours were ascertained in the comparison groups from the start.


Seven Oaks and South Hills Projects: Year 2 Assessment Report                   30 of 35
       Given the matching, there is no other plausible explanation for this than to
       state that selected patients for redevelopment were at least if not more se-
       verely mentally ill than the comparison group. The magnitude of this bias
       will be further assessed in subsequent years as more cases from other related
       studies are reported. This effect could be calibrated and taken into account in
       between-groups comparison analyses. Some behaviours that are mostly ob-
       servational, well defined and on a yes/no scale, like the skills measured with
       the Independent Living Skills Schedule, are less prone to such over- and un-
       derreporting of the behaviour. The impact of this bias is also counterbalanced
       by the utilisation of other instruments that cover some of the same dimen-
       sions and rely on interviewer judgment, which is based on staff reporting, cli-
       ent reporting and case notes. For example, we are more confident with the in-
       crease in positive psychotic symptoms reported with the Brief Psychiatric
       Rating Scale. Also, when a convergence of the results occurs with various
       measurement instruments, it allows us to attribute more certainty to the
       findings. Abnormal behaviours increased according to most instruments for
       the two redevelopment groups at Year 2 follow-up. However, the clinical and
       social significance of this was counterbalanced by the continuous integration
       of patients and by the absence of returns to Riverview Hospital or any acute
       tertiary care units in general, and by the mobilisation of community re-
       sources, like the police and further psycho-educative efforts from staff.




Seven Oaks and South Hills Projects: Year 2 Assessment Report                  31 of 35
Conclusions
   1. The clinical characteristics of the patients who were ascertained with these
      one- and two-year preliminary results are compatible with the mandate, mis-
      sion, aims, and program put forward at Seven Oaks and South Hills, and the
      clinical outcomes are positive for this group of the most severely mentally ill
      patients.
   2. The programs developed until now at Seven Oaks and South Hills appear ap-
      propriate and seem to work. The programs should also consider adding evi-
      dence-based individual therapies and/or group therapies to increase the like-
      lihood of improving psychotic symptoms, distress and depression, cognitive
      deficits and emotion/stress management.
   3. The results so far also support the proposition that the move to regional ter-
      tiary care facilities has served as a catalyst for regular movement of patients
      from these facilities into less supervised community settings to the satisfac-
      tion of patients with their quality of life.




Seven Oaks and South Hills Projects: Year 2 Assessment Report                 32 of 35
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Seven Oaks and South Hills Projects: Year 2 Assessment Report                34 of 35
                  Appendix: Instruments Used in the Study
                              (Instruments are available upon request)

      Instrument                                           Characteristics
Cambridge Neuropsy-           •   Computerized cognitive battery; motor screening, paired associates
chological Test Auto-             learning, and spatial recognition memory sections
mated Battery                 •   Completed by patient on touch-screen computer with research assis-
(CANTAB)                          tant
(Elliot & Sahakian, 1995)
Canadian Toolkit              •   Socio-demographic (age, sex, marital status, education and work his-
(Ontario Federation of            tory), residential, financial, legal situation, and diagnostic information;
Community Mental                  will allow comparisons with other patient groups; recommended and
Health and Addiction              used extensively in North America by the International Association for
Programs, 1999)                   Psychosocial Rehabilitation Services (IAPSR)
                              •   Completed by research assistant with staff, patient and case notes
Brief Psychiatric Rating      •   Psychiatric symptoms (four subscales)
Scale (BPRS)                  •   24-item version
(Overall & Gorham,            •   Completed by research assistant with staff, patient and case notes
1962)
Independent Living            •   Nine dimensions: appearance and clothing, personal hygiene, care of
Skills Schedule (ILSS)            personal possessions, food preparation/storage, health maintenance,
(Cyr et al., 1994; Wallace        money management, transportation, leisure and community, and job
et al., 2000)                     seeking; overall score
                              •   47 items
                              •   Completed by staff
Levels of Care Survey         •   Three dimensions: levels of physical problems, medical care, and nurs-
(LOCS)                            ing care
(Furman & Lund, 1979;         •   10 items
also used in Lesage et al.,   •   Completed by research assistant from case notes and staff interviews
2000)
Riverview Patient Inven-      •   Nursing scale with five areas: daily routine, psychological symptoms,
tory (RPI)                        social interaction, aggressive behaviours, and problems in relation to
(Haley, Iverson &                 community preparation
Moreau, 2002)                 •   57 items
Social Behaviour Scale        •   Abnormal behaviours, negative symptoms, and other psychiatric symp-
(SBS)                             toms
(Wykes & Sturt, 1986)         •   21 items
                              •   Completed by staff
Verona Service Satisfac-      •   Seven dimensions: general satisfaction, staff attitudes and behaviours,
tion Scale (VSSS)                 information, access, efficacy, types of interventions, and relatives’ in-
(Ruggeri & Dall’Agnola,           volvement; open-ended questions also included
1993; Ruggeri et al.,         •   32 items
2000)                         •   Completed by relatives and clients with help of interviewer
Wisconsin Quality of Life     •   Overall satisfaction and social relations sections
Index for Mental Health       •   22 items
(W-QLI)                       •   Completed by the patient with the help of a trained interviewer
(Becker, Diamond &
Sainfort, 1994; Caron et
al., 2003)




Seven Oaks and South Hills Projects: Year 2 Assessment Report                                      35 of 35

				
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