Needs-Based Planning for Persons With ...

Needs-Based Planning for Persons With Schizophrenia Residing in Board-and-Care Homes by Janet Durbin, Paula Qoering, Jeanette Cochrane, Dianne Macfarlane, and Tess Sheldon

Data available from a recent planning project provided an opportunity to examine impairment and service needs of individuals with schizophrenia spectrum diagnoses living hi a large board-and-care program. When first implemented, this minimum-support custodial program was assumed to be adequate for discharged long-term inpatients with schizophrenia and other chronic mental illnesses. However, the needs assessments indicated considerable heterogeneity in resident level of Impairment When a validated planning template was applied to assign residents to an appropriate level of care, almost one-quarter were assigned to independent living with minimal support, one-third to community living with intensive support, and 40 percent to residential or inpatient treatment The authors conclude that this program is not able to meet the varying needs of residents. Despite a common diagnosis, many can function in more independent settings, while others need more treatment and rehabilitation than they are currently provided. Keywords: Residential care, schizophrenia, level of care, planning, mental health. Schizophrenia Bulletin, 30(1): 123-132,2004. The mental health reform movement of recent decades in Ontario and throughout North America has set out a number of priority goals for system reform, including delivery of care in the least restrictive setting and greater involvement of consumers and families in developing the service system and managing their own care. The reform movement has been fueled in part by changing perceptions of the course of severe and persistent mental illness, and the capabilities of individuals suffering from severe conditions such as schizophrenia and major mood disorders. These changing perceptions have been accompanied by the development of new psychopharmacologic interventions and emphasis on integration of individuals with

Send reprint requests to Janet Durbin, M.Sc., Centre for Addiction and Mental Health, 33 Russell Street, Tower 301, Toronto, Ontario M5S 2S1; e-mail: [email protected].

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mental disorders into full community living (Pandiani et al. 1996; Jibson and Tandon 1998). While newer models of care reflect these goals, a number of older models persist. In the area of residential care a body of literature is emerging supporting approaches that emphasize normal housing, give consumers choice and control, and promote community integration (Srebnik et al. 1995; Parkinson et al. 1999; Fakhoury et al. 2002; Wong and Solomon 2002). Yet more custodial approaches, such as board-and-care homes where only basic care services are provided, routines are rigid, and staff make most decisions, remain part of the care continuum in many jurisdictions (Randolph et al. 1991; Trainor et al. 1993; Nelson et al. 1997). This raises the question of whether there continues to be a role for these more custodial/maintenance approaches, and where current residents of these programs would best be served. In the province of Ontario, a long-standing boardand-care home program called Homes for Special Care (HSC), operated by provincial psychiatric hospitals, is under review. This program was established in 1964 to provide a low-support, community-based residential care option for hospital patients ready for discharge. These individuals, many of whom suffered from schizophrenia, were expected to experience an illness course of inevitable chronicity and as such, to require no more than custodial care. However, views on the life course of individuals with psychotic disorders have changed during the last several decades, in part because of longitudinal studies that have demonstrated improvement and recovery in symptoms, self-care, and social and community functioning (Harding et al. 1987; McGlashan 1988; Breier et al. 1991; Harding and Zahniser 1994; Huber 1997). In this context, the HSC program has been criticized for being custodial, doing little to promote resident choice, growth,

Abstract

Schizophrenia Bulletin, Vol. 30, No. 1, 2004

J. Durbin et al.

and independence (Trainor 1996; Trainor and lives 1999). Yet patient-level information has not been available to describe the level of impairment of HSC residents and assess whether other approaches to treatment and support can more appropriately meet their needs. As a result of a planning project to evaluate the service needs of provincial psychiatric hospital patients, assessments of functioning and level of care recommendations became available for a sample of HSC residents. In this article, we use these data to learn more about the current functioning and service needs of a particularly vulnerable subgroup of HSC residents, those with schizophrenia spectrum disorders. The goals of this article are as follows: 1. Review evidence about housing approaches for individuals with mental illness, including those with schizophrenia spectrum disorders. 2. Describe current levels of impairment and service needs of a sample of HSC residents with a schizophrenia spectrum diagnosis. 3. Discuss alternative approaches to providing treatment and support for this subgroup based on assessment data and current knowledge about evidencebased practices.

Review of Housing Approaches and Evidence Housing became a major concern in the 1960s with recognition that deinstitutionalization was discharging many individuals into the community without providing adequate housing or support (Lamb 1984). This period saw a proliferation of boarding home programs that provided safe, secure housing in the community but few opportunities for growth and community integration (Randolph et al. 1991; Trainor et al. 1993). During the 1970s and 1980s, the linear residential continuum approach became popular, offering varying levels of support to individuals living in small, homelike settings. However, optimism about this model dissipated in the face of high costs and client resistance to repeated uprooting in order to meet changing levels of need (Ridgway and Zipple 1990; Geller and Fisher 1993). In keeping with the current emphasis on providing care in the least restrictive setting, on community integration, and on respect for client preferences, interest has shifted to models that separate support services and housing components. Support is perceived as portable and follows the client wherever he or she chooses to live. The client is a full tenant in regular housing, and eligibility for accommodation is not affected by service needs (Carling 1993; Pyke and Lowe 1996; Parkinson et al. 1999).

Program Description In the 1960s, psychiatric hospitals in Ontario assumed responsibility for operating community residences for long-term inpatients who no longer required active treatment but lacked lodging and possessed very limited community living skills. The underlying assumption of the HSC program was that people with serious and persistent mental illnesses never improved or recovered, and required only custodial care. Meals, housekeeping, and laundry services were provided; residents were not involved in house decisions; and care was not titrated to need. On-site supervision was provided by operators who

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While evidence indicates that living in more normalized settings with flexible support benefits many individuals, there is a subgroup whose symptoms and behaviors make independent community living inappropriate (Trieman et al. 1998;Wasylenki et al. 2000). For this group, high-support residential treatment facilities (RTFs) are emerging as a more appropriate community-based alternative to hospitalization. These facilities offer enriched treatment and rehabilitation in small, secure settings with skilled staff and a high ratio of staff to patients (Shepherd 1995; Rothbard et al. 1997; Trainor and lives 1999). RTFs are intended to provide an alternative to institutional care but are not a replacement for more independent housing options (Fields 1990). This is consistent with Bachrach's view (1994) that an array of residential opportunities are needed to respond to varying levels of need. A recent review of best practices in housing support under mental health reform recommended that systems of care offer a range of housing alternatives, including residential treatment, but give priority to community-based, supported housing models (Health Canada 1997). Evidence from numerous studies reinforces the need for a range of housing support options for individuals with schizophrenia. A growing body of research on deinstitutionalization demonstrates that long-term psychiatric inpatients, including many with schizophrenia spectrum diagnoses, are discharged into various types of housing, including supervised community residences and more independent situations. At followup, researchers have found low rates of rehospitalization (Okin et al. 1995), stability of placement (McGrew et al. 1999), and high levels of satisfaction (Leff et al. 1996). A recent review of the effectiveness of assertive community treatment (ACT) and intensive case management found that these high-support interventions can help very ill individuals sustain independent living situations and increase community tenure (Mueser et al. 1998). In the reviewed studies, the percentage of individuals with schizophrenia spectrum diagnoses ranged from 30 percent to 84 percent.

Needs-Based Planning in Board-and-Care Homes


received minimal reimbursement and had no special training. A hospital fieldworker was assigned to each HSC resident to help with adjustment and management problems within the home. Psychiatric consultation was available but not routinely accessed. The HSC program has remained unchanged, despite the impact of mental health reform on other parts of the care system. A recent review identified numerous weaknesses in the model (Trainor 1996) related to its maintenance rather than growth orientation, inadequate funding, and isolation from the rest of the community and care system.

Data Collection and Measures The Ontario Ministry of Health recently commissioned a series of needs-based planning projects to identify services and supports required by current users of provincial psychiatric hospital services. In each facility, needs data are obtained on a cross-sectional sample of patients. A clinical staff member who knows the patient or resident well completes the assessment based on personal knowledge and chart information. Using a standardized assessment tool, the most recent version of the Colorado Client Assessment Record (CCAR) (Ellis et al. 1991), staff rate impairment across 21 domains related to symptoms, risk behaviors, and social and community functioning. A global impairment rating assesses overall severity, and a global strengths rating assesses overall resources, such as the patient's economic and skill base, and support from family and friends. All ratings are scored on an ordinal scale from one to nine (slight to severe problem) and pertain to the preceding 3 to 4 weeks. Ratings in the "slight" range indicate that problems are intermittent or persist at a low level and that intervention may be required in the future. Ratings in the "moderate" range indicate that problems persist at a moderate level or become severe on occasion and that intervention is required. "Severe" end ratings indicate that problems are subacute but chronic, or acute and severe. Intervention is required and may include hospitalization. In a tool requiring clinical judgment, reliability is a concern. Rater consistency was enhanced through availability of a manual that provided individualized documentation for each rating domain, outlining its scope and defining five anchor points along the nine-point response continuum. In addition, all raters (i.e., HSC, inpatient, and outpatient staff) participate in a full-day training session to maximize consistent interpretation of items and to calibrate ratings. Given the heterogeneity of staff completing CCAR assessments, the authors conducted an interrater reliability study at one facility to assess whether variation in training and skills influenced

1 Raters in the reliability study were not randomly selected but, with such a large sample, represent a wide range of staff skills and experience.

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rating consistency. When possible, two raters were asked to independently assess the same patient. Out of 571 patients in the assessment sample, 219 cases had 2 ratings submitted.1 Intraclass correlations were found to exceed 0.70 for all CCAR domains, regardless of discipline or years of experience (Goering et al. 1999). Using a similar version of the CCAR, Ward et al. (1998) reported moderate to high intraclass correlations that exceeded 0.50 for 17 out of 18 ratings. The assessment package also includes a Service Needs Profile in which, for each of a number of treatment and rehabilitation areas, clinicians rate current service needs (in terms of frequency of contact) and whether the amount of support currently received is less dian needed, more than needed, or appropriate. Clinicians also report patient sociodemographic characteristics, primary and secondary diagnoses, and previous hospitalizations (based on patient charts). At each facility, the methodology was reviewed and ethics approval obtained. Because completion of the CCAR did not require a patient interview and confidentiality was protected in all reporting, patient consent was not required. To link needs assessment data with a recommended package of services, a planning template was developed based on best practice evidence and consultation with local stakeholders. Figure 1 presents the algorithm and criteria by which patients were linked to one of five levels of care, based on assessed need. The levels are broadly defined as self-management (level 1), community support (level 2), intensive community support (level 3), residential treatment (level 4), and inpatient care (level 5), with higher levels providing more supervision, individualized support, and frequent contact (table 1). Patient need is based on ratings in six CCAR domains (security/management issues, suicide/danger to self, violence/danger to others, global severity rating, self-care/basic needs, and global strengths rating). Consistent with the goal of helping patients achieve desired outcomes in the least restrictive setting, only those with the most severe ratings (related to security, self- and other harm, and selfcare) are assigned to levels 4 and 5 (i.e., inpatient care or residential treatment). Those with lower levels of impairment are assigned to independent living situations with varying levels of support. Final placements consider patient strengths (resources and support from family and friends), assigning those with more personal resources to a lower level of support. Correlations between the assigned level of care and independent measures of patient severity and service

J. Durbin et al.


Figure 1. Placement algorithm linking CCAR ratings of need to level of care.

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Note.—CARR = Colorado Client Assessment Record.

115 assessed HSC residents), and outpatients with schizophrenia not living in HSCs (277 out of the 603 assessed outpatients) formed the comparison group. These outpatients were enrolled in a variety of facility services, including rehabilitation programs, community treatment teams, and specialty clinics but excluding forensic programs. The two groups are described in table 2. Over onequarter of the HSC residents are 65 years of age or older. Most have never married (83%), and their education is limited. More than 40 percent have a second diagnosis, and 98 percent are taking psychotropic medications. Thirty-six percent have been hospitalized at least once in the past 2 years. In comparison, the outpatients are younger, are more likely to be married or living with family, and have more education. Yet the HSC residents are less likely to have been recently hospitalized, suggesting a more stable group.

need support the validity of the template for placing those who require more services into a higher level of care (Durbin et al. 2001).

Sample Description Data were collected from three psychiatric hospitals located in the southwestern, central western, and eastern regions of the province. At each facility, a sample was drawn of all inpatients on a specified census day and a random selection of outpatients and HSC residents, stratified by program. A minimum sample of 30 per program was sought where possible. Because of variation in program size, overall, 15 percent of outpatients and 20 percent of HSC residents were sampled. Assessments were returned for 95 percent HSC residents with a schizophrenia spectrum diagnosis formed the study group (88 out of

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Table 1. Level of care continuum Description

Level of care 1: self-management

Individual is capable of self-management, resides in the community, accesses family physician or psychiatric services periodically, and may intermittently use community services and supports.

2: community support

Individual resides in the community, needs assistance approximately weekly to identify needs and access community services and supports, and can obtain psychiatric care from an outpatient clinic or private office

3: intensive community support

Individual lives in the community, needs intensive assistance (i.e., up to daily visits and 24-hour availability of support) to obtain needed mental health treatment and rehabilitation services and access other community services.

4: residential treatment

Individual needs 24-hour support and access to treatment and rehabilitation services in a securable setting and may access some services and supports in the community.

5: inpatient care

Individual needs 24-hour care provided by a multidisciplinary team of highly trained experts in a securable setting with the capacity to do comprehensive assessment and treatment.

Table 2. Demographic and Illness characteristics HSC sample (n = 88)1

Characteristic

Outpatient sample (n = 277)1

% female

28.9

38.7

% > 65 yrs o l d "

26.1

7.2

% never married"

82.8

67.6

0.0

26.1

% whose highest level of education was primary school or less*

53.7

39.3

% hospitalized at least once in last 2 yrs**

36.4

54.6

% prescribed psychotropic medication

97.7

99.3

% with more than 1 diagnosis

40.9

48.7

% living with family/relative/spouse"

Note.—HSC = Homes for Special Care. 1

Sample sizes per characteristic vary slightly because of missing responses.

Results of x 2 test: HSC vs. outpatient sample: * p< 0.05; " p< 0.001

few family problems, but this likely reflects lack of family contact rather than positive relations. Regarding strengths, residents are severely impoverished, lacking economic resources, job skills, and personal support from family and friends. Compared with the outpatient group, this HSC cohort is significantly more impaired in self-care management and has more safety management problems and fewer strengths. While overall levels of impairment are slight to moderate, there is considerable variation among residents. Table 4 summarizes clinician ratings of patient need for specific services. Regarding treatment, clinicians estimate a high level of need among HSC residents for med-

Assessment Results Mean CCAR ratings are reported in table 3. Regarding clinical functioning, ratings suggest that HSC residents continue to experience moderate impairment in most symptom areas. Risk behaviors are slight in most domains, with the exception of security management, where raters assessed a moderate need for supervision related to medication compliance and behavior management Impairment in social and community functioning ranges from mild to moderate but is most pronounced in the area of self-care and meeting basic needs. Residents were rated as having

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Note.—Services and supports available to all levels: acute Inpatient care, crisis services, psychiatric services, consumer and family Initiatives, primary medical care, housing support, and rehabilitation services (e.g., income support, vocational and educational support, leisure and recreational activities).


J. Durbin et al.

ication monitoring and assessment/diagnosis, most of which is being met. However, of the 62 percent of residents estimated to need psychotherapy/counseling, half are not receiving the required care. Few HSC residents are estimated to need substance abuse treatment, but half of

these are receiving less than needed. Regarding rehabilitation, the need for support with activities of daily living (ADL), social/recreational activities, housing support, and income assistance is estimated to be very high, with most of this need rated as being met. Estimated need for voca-

Table 3. Impairment among HSC residents with schizophrenia spectrum diagnoses Impairment Rating1: CCAR Domain (Mean, SD) CCAR Domain

None-slight (1-3.49)

Moderate (3.5-6.49)

Depression (3.4, 2.0) Hyper affect (2.9, 2.3) Danger to self (2.0,1.8)

Emotional withdrawal (4.0, 2.1) Anxiety (3.8, 2.3) Attention problems (4.0, 2.3) Thought processes (4.4, 2.2) Cognitive problems (4.4, 2.2) Resistiveness (4.5, 2.2)

Risk behaviors

Substance abuse (1.8, 1.7 ) Antisocial (2.6, 2.0) Legal (1.3, 1.3) Danger to others (2.0, 1.9) Aggressiveness (3.1,2.6)

Security management (4.6, 2.5)"

Functioning

Medical/physical (2.6,2.2) Family context (2.2, 2.2) Family relationships (2.3, 2.3)+

Self-care/basic needs (5.9,2.3)** Interpersonal (4.3, 2.4)+ Role performance (4.6, 3.2)

Global ratings

Severity (5.1, 1.8)

Strengths (6.6, 1.7)*

Note.—CCAR = Colorado Client Assessment Record; HSC = Homes for Special Care; SD = standard deviation. Ratings range from 1 to 9, with higher ratings indicating more Impairment. Results of x2 test: HSC versus outpatient sample: HSC more impaired than outpatient sample: * p < 0.01 ** p < 0.001 HSC less Impaired than outpatient sample: + p < 0.01 1

Table 4. Service need among HSC residents and outpatients with schizophrenia spectrum diagnoses > Needing Service1 Service area

HSC

Outpatients

%Wtth Unmet Need for Service2 HSC

Outpatients

Treatment Medication management Assessment/diagnosis Psychotherapy/counseling Substance abuse programming

99 87 62 20

98 98** 77** 23

0 15 50 53

9** 7 21" 59

Rehabilitation Self-care/ADL Vocational Educational Social/recreational Housing support Income/financial assistance

96 44 33 96 98 95

76" 53 35 92 71" 79"

3 69 65 14 1 5

29** 51 57 57" 18" 23*

Note.—ADL - activities of daily living; HSC = Homes for Special Care. 1

Need Is a dichotomous variable (none vs. any); denominator» total sample.

2

Denominator = individuals who need service.

Results of x 2 test: HSC residents vs. outpatients: * p < 0.01; ** p < 0.001

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Symptoms

Severe (6.5-9.0)



tus of a sample of HSC residents. These individuals were placed in board-and-care programs with an expectation of an unremitting illness course and continued low functioning. The CCAR needs assessments show that, as a group, the individuals remain moderately troubled by psychiatric symptomatology, have difficulty meeting basic needs, require close supervision related to behavior and medication management, and have few personal resources. Other studies of residents in intermediate care facilities report similar profiles (Segal and Kotler 1993; Anderson and Lyons 2001). Yet, consistent with the findings of longitudinal research (McGlashan 1988; Harding and Zahniser 1994), within this group there is considerable heterogeneity. When a planning template based on best practices was applied to assign residents to an appropriate level of care, almost one-quarter were assessed as able to live independently in the community with minimal support, one-third were assigned to community living with intensive support, and about 42 percent were assessed as requiring high-support residential or inpatient treatment. These findings underscore the weaknesses inherent in congregate residential programs that have a custodial orientation and treat all residents more or less uniformly. The HSC program is ill-equipped to respond to the diversity of resident needs evident in these assessments. Without more resources and highly trained on-site staff, the program is not positioned to provide intensive treatment and rehabilitation to those who are experiencing extreme difficulty. Without an emphasis on integration and linkage with community resources such as case management, crisis intervention, psychiatric treatment, and self-help, the program is not positioned to promote more independence and meet die needs of the higher functioning subgroup. As a result, few residents are receiving the support tiiey need to achieve a better quality of life. The incongruence between support needed and support received is also reflected in the Service Needs Profile, where clinicians identified high levels of unmet need for psychotherapy/counseling, substance abuse treatment, and vocational and educational support. Minimal unmet need was identified in areas of self-care, social recreation, and income assistance. This may be misleading, as clinicians were asked to rate amount of support rather than appropriateness or quality of support. We know that the HSC program has little capacity to customize support to individual need so that, for example, residents are provided with meals even if interested in and capable of cooking for themselves. Similarly, residents lack opportunities to develop money management skills, as almost all are under the Public Trustee and receive only a small comfort allowance (Trainor 1996; Trainor and lives 1999). Given past undue pessimism regarding the prognosis of individuals with schizophrenia, one wonders about the

Discussion A series of provincial planning projects have provided valuable information about the clinical and functional staTable 5. Level of care assignment Level of care*

HSC residents (n = 86),%

Outpatients (n = 267), %

4.7

9.0

2: community support

19.8

27.3

3: intensive community support

32.6

40.1

4: residential treatment

39.5

22.5

3.5

1.1

1: self-management

5: inpatient care" 'X

2

-13.2, £#=4, p = 0.01.

" Unstable estimates because of small cell size.

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tional and educational support is lower, but about twothirds of residents are not adequately supported in these areas. Compared with the outpatients, fewer HSC residents are perceived to need treatment (i.e., assessment and psychotherapy), but rates of unmet need are higher. This finding is consistent with the assertion that HSC residents have limited access to psychiatric care and may reflect the program's emphasis on custodial, not growth-oriented, services (Trainor 1996). Regarding rehabilitation, more HSC residents than outpatients are rated as needing support for self-care/ADL, maintaining housing, and securing income. However, more outpatients are rated as having an unmet need for these services. Both groups lack vocational support. Many outpatients also lack adequate social/recreational opportunities. Table 5 describes the recommended level of care based on the planning template. Despite setting a high threshold for assignment to more restrictive levels of care, about 40 percent of HSC residents were assigned to residential or inpatient treatment. This is not surprising, given their limited skills in self-care, few strengths, and significant need for security management. These residents require more support than is currently provided. At the same time, over half of HSC residents were assigned to independent living situations, with one-third perceived as requiring intensive community support and one-quarter requiring up to weekly assistance to identify needs and access services. These individuals have the potential to live more independently, despite current placement in congregate-care situations with limited opportunities for growth. While a greater portion of the outpatients were assigned to independent settings (76% versus 57%), there is much more overlap in support needs among these two groups than current perceptions of HSC residents would have predicted.


J. Durbin et al.

potential iatrogenic effect of long-term residence in a custodial setting. Residents have limited self-care and interpersonal skills, and almost no family involvement or friendship support. Most have never married. In the absence of longitudinal studies of comparison groups exposed to different interventions, we cannot assess whether the constraints of living in a restricted setting have stunted social and skill development. We can observe whether level of functioning improves for individuals who are transferred to more independent settings. However, many residents are older and have already missed opportunities to create more normalized lives. Under mental health reform, treatment close to home is a priority. Unfortunately, many HSC residents were separated from home communities and family when first admitted to the psychiatric hospital, a separation that continued when they were discharged to the HSC program. While our data show that many residents suffer from impoverished social networks, reconnection with family may not be possible after so many years. Still, if efforts are made to move residents into more independent living situations, their preferences related to locating closer to family need to be explored. Use of the CCAR and planning template provided a standardized method for assessing resident needs and identifying appropriate service responses that can benefit both system planning and individual placement (Bachrach 1996). In Ontario, results from planning projects are providing each region with similar evidence on which to base new service development. Common themes include the need for more intensive community support programs such as ACT and for initiatives (mental health and general community) to help consumers develop richer social lives and obtain real jobs. A future repeated application of the methodology could help to assess system progress in these important areas. Several study limitations need to be noted. The patient sample was drawn from three psychiatric hospitals and may not be broadly representative of HSC residents and outpatients with schizophrenia. In addition, HSC homes vary considerably in size and quality of support, characteristics that could not be incorporated into the sampling strategy. Regarding study measures, diagnostic classifications were based on information recorded in patient charts rather than current psychiatric assessments or structured interviews. The Service Needs Profile is not a standardized tool, and ratings were based on subjective impressions of service need rather than objective criteria. While we have found considerable consistency across settings in areas where unmet need was greatest, explicit rating criteria would help to increase the reliability of ratings and clarify interpretation.

The level of care continuum used in this project excludes low-intensity residential support as an option, assuming that individuals who do not require intensive residential treatment can manage independently in the community if needed support (including wraparound services such as ACT) is available. While we have assessed the concurrent validity of the level of care template, we recognize that prospective studies are needed to evaluate the appropriateness of the recommended level of care, compared with other options. It is possible that some individuals need a type of support that falls between levels 3 and 4—that is, a low-intensity supervised setting combined with community-based treatment and rehabilitation.

Conclusion

References Anderson, R., and Lyons, J. Needs-based planning for persons with serious mental illness residing in intermediate care facilities. Journal of Behavioral Health Services Research, 28(1): 104-110, 2001. Bachrach, L. Residential planning: Concepts and themes. Hospital and Community Psychiatry, 45:202-203, 1994. Bachrach, L. The state of the state mental hospital in 1996. Psychiatric Services, 47(10):1071-1078, 1996. Breier, A.; Schreiber, J.L.; Dyer, J.; and Pickar, D. National Institute of Mental Health longitudinal study of chronic schizophrenia. Archives of General Psychiatry, 48:239-246,1991. Carling, P.J. Housing and supports for persons with mental illness: Emerging approaches to research and practice. Hospital and Community Psychiatry, 44:439-449, 1993.

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Clinician ratings of a sample of HSC residents with schizophrenia spectrum diagnoses demonstrate a range of functional levels within a group previously felt to have an unremitting illness and poor prognosis. The current HSC program, a custodial model of care with minimal flexibility, is not positioned to respond to this diversity, yet many individuals have lived in HSC programs for decades. A best practices planning template has suggested alternative approaches for meeting the housing, treatment, and support needs of these individuals. Some require a higher level of residential support Others could live more independently in the community if appropriate services and support were available. While this study demonstrates the inadequacy of board-and-care homes for meeting resident needs, research must continue on the effective housing and support combinations for people with different levels of need.



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Janet Durbin, M.Sc, is Assistant Professor, Department of Psychiatry, University of Toronto, Toronto, Ontario; and Scientist, Health Systems Research and Consulting Unit, Centre for Addiction and Mental Health, Toronto, Ontario. Paula Goering, Ph.D., is Professor, Department of Psychiatry, University of Toronto; and Director, Health Systems Research and Consulting Unit, Centre for Addiction and Mental Health. Jeanette Cochrane, B.A., is deceased. Formerly Lecturer, Department of Psychiatry, University of Toronto; and Consultant, Health Systems Research and Consulting Unit, Centre for Addiction and Mental Health. Dianne Macfarlane, M.A., is Assistant Professor, Department of Psychiatry, University of Toronto; and Senior Consultant, Health Systems Research and Consulting Unit, Centre for Addiction and Mental Health. Tess Sheldon, M.Sc, entered law school. Formerly Project Coordinator, Health Systems Research and Consulting Unit, Centre for Addiction and Mental Health.