A variety of models of psychiatric hospital alternative care have been developed over the past several decades. San Diego’s Short-Term Acute Residential Treatment (START) model is one of the best established of these alternatives, comprising a network of 6 facilities with a total of 77 beds. Although veterans have been among those served at START programs for many years, no previous study of START or any other model has focused specifically on veterans.
The study tested the hypotheses that veterans treated in a START program would demonstrate greater improvement in symptoms and quality of life, as well as greater satisfaction with treatment and lower costs of care than veterans treated at the VA inpatient unit.
This study includes elements of both efficacy and effectiveness studies. VA psychiatric unit treatment and START are compared in a randomized trial, with follow up of subjects at 2, 6, and 12 months as they experience real-world treatment-as-usual. Symptoms, functioning, quality of life, and satisfaction with services are assessed on multiple standardized measures, as well as by qualitative assessments.
Mean index episode costs for START subjects were significantly lower than those for the hospital group (hospital: $6,345; START: $2,577, p<.001), as were mean total acute care costs through the two-month follow up period (p=.002). Regarding symptoms and functioning, START and hospital subjects showed very similar improvements between admission, discharge and two-month follow up on multiple measures, with the exception that START subjects showed greater improvement in symptoms on the SF-36V Mental Component Summary between admission and discharge. Veterans randomized to START also reported statistically significantly higher levels of satisfaction on two of the four Perceptions of Care subscales (p=.04; p=.05) and rated their treatment environment more favorably on six of ten Ward Atmosphere Scale subscales.
Conclusions. Results suggest that the START model is a cost-effective alternative to hospital-based psychiatric inpatient treatment and one that leads to higher levels of patient satisfaction among veterans.
This study has implications both within and outside of VHA. Findings suggest that the development of START-like programs at other locations around the country could provide a less costly alternative for many veterans in need of acute psychiatric care. Given VHA's status as the largest public-sector mental health service provider nationwide, adoption of this model could have a major impact outside VHA as well.
- Ta S, Goldzweig C, Juzba M, Lee M, Wenger N, Yano EM, Asch S. Addressing physician concerns about performance profiling: experience with a local Veterans Affairs quality evaluation program. American journal of medical quality : the official journal of the American College of Medical Quality. 2009 Mar 1; 24(2):123-31.
- Lohr JB, Hawthorne WB, Green EE, Mittman BS, Lee M. Patient-centered acute inpatient alternative for veterans: Preliminary findings. Paper presented at: American Psychiatric Association Annual Meeting; 2002 May 1; Philadelphia, PA.
- Lohr JB, Hawthorne WB, Green EE, Mittman BS, Lee M, Garcia P, Hough RL, Gilmer T. A Patient-Centered and Cost-Effective Psychiatric Inpatient Alternative: Model for the Future? Paper presented at: VA HSR&D National Meeting; 2002 Feb 14; Washington, DC.
- Hawthorne WB, Lohr JB, Green EE, Mittman BS, Lee M, Garcia P, Hough RL, Gilmer T. A patient-centered acute inpatient alternative: Results of a randomized trial. Paper presented at: AcademyHealth Annual Research Meeting; 2001 Jun 1; Atlanta, GA.
- Hawthorne WB, Green EE, Farmer J, Garcia P, Lohr JB. Preliminary findings of a randomized services trial comparing crisis residential and VA acute psychiatric unit outcomes in San Diego County. Paper presented at: International Association of Psychosocial Rehabilitation Services Annual Conference; 2001 May 1; Houston, TX.
Mental, Cognitive and Behavioral Disorders, Health Systems
Epidemiology, Treatment - Observational
Acute illness, Organizational issues, Outpatient
Health Services, Mental Health