HOME-BASED VERSUS HOSPITAL-BASED CARE FOR PEOPLE WITH SERIOUS MENTAL-ILLNESS

Background. A controlled study tested whether the superior outcome of community care for serious mental illness (SMI) in Madison and in Sydn ey would also be found in inner London. Method. Patients from an inner London catchment area who faced emergency admission for SMI (many wer e violent or suicidal) were randomised to 20 months or more of either home-based care (Daily Living Programme, DLP; n = 92),or standard in-p atient and later out-patient care (controls, n = 97). Most DLP patient s had brief in-patient stays at sometime. Measures included number and duration of in-patient admissions, independent ratings of clinical an d social function, and patients' and relatives' satisfaction. Results. Outcome was superior with home-based care. Until month 20, DLP care i mproved symptoms and social adjustment slightly more, and enhanced pat ients' and relatives' satisfaction. From 3 to 18 months DLP care great ly reduced the number of in-patient bed days as long as the DLP team w as responsible for any in-patient phase its patients had. Cost was les s. DLP care did not reduce the number of admissions, nor of deaths fro m self-harm (3 DLP, 2 control). One DLP patient killed a child. Even a t 20 months many DLP and control patients still had severe symptoms, p oor social adjustment, no job, and need for assertive follow-up and he avy staff input. (Beyond 20 months most gains were lost apart from sat isfaction.) Conclusions. It is unclear how much the gain until 20 mont hs from home-based care was due to its site of care, its being problem -centred. its teaching of daily living skills, its assertive follow-up , the home care team's keeping responsibility for any in-patient phase , its coordination of total care (case management), or to other care c omponents. Home-based care is hard to organise and vulnerable to many factors, and needs careful training and clinical audit if gains are to be sustained.