Assessment of dependency level and community placement for the long-term mentally

The Mental Health of the Nation document (Royal College of Psychiatrists, 1992) recommends that health and local authorities be jointly accountable for the establishment, funding and management of services for those disabled by chronic mental illness. A wide range of facilities matched to individual needs should be developed, including both in-patient beds and domestic style environments in the community. Designated rehabilitation teams should have responsibility for the care of the long-term severely mentally ill. The rehabilitation service for West Gloucestershire serves a population of 314000 with approximately 250 patients under its direct care. The multidisciplinary rehabilitation team, led by a consultant rehabilitation psychiatrist, meets to review in-patients weekly and those in community facilities on at least an annual basis. Individual team members are in regular liaison with the patients, their carers and primary care services. All patients in the community are registered with a local general practitioner who attends to their physical health needs, psychiatric problems being served by the rehabilitation team who respond rapidly to requests to review problems as they arise. A range of facilities is used to accommodate the long-term severely mentally ill. These facilities include group homes, supported lodgings, long-stay rehabilitation hostels and an in-patient slow stream rehabilitation ward, providing increasing levels of support according to levels of dependency. The Clifton Assessment Procedures for the Elderly Behaviour Rating Scale (CAPE BRS) was used to assess the dependency levels of residents in the above settings to determine whether placements made on the basis of clinical judgement by the rehabilitation team agreed with the CAPE BRS gradings and to examine any discrepancies found.

The Mental Health of the Nation document (Royal College of Psychiatrists, 1992) recommends that health and local authorities be jointly accountable for the establishment, funding and management of services for those disabled by chronic mental illness.A wide range of facilities matched to individual needs should be developed, including both in-patient beds and domestic style environments in the community.Designated rehabilitation teams should have responsibility for the care of the long-term severely mentally ill.
The rehabilitation service for West Gloucestershire serves a population of 314000 with approximately 250 patients under its direct care.The multidisciplinary rehabilitation team, led by a consultant rehabilitation psychiatrist, meets to review in-patients weekly and those in community facilities on at least an annual basis.Individual team members are in regular liaison with the patients, their carers and primary care services.All patients in the community are registered with a local general practitioner who attends to their physical health needs, psychiatric problems being served by the rehabilitation team who respond rapidly to requests to review problems as they arise.
A range of facilities is used to accommodate the long-term severely mentally ill.These facilities include group homes, supported lodgings, long-stay rehabilitation hostels and an in-patient slow stream rehabilitation ward, providing increasing levels of support according to levels of dependency.The Clifton Assessment Procedures for the Elderly Behaviour Rating Scale (CAPE BRS) was used to assess the dependency levels of residents in the above settings to determine whether placements made on the basis of clinical judgement by the rehabilitation team agreed with the CAPE BRS gradings and to examine any discrepancies found.

The study
The CAPE BRS was developed as a shortened version of the Stockton Geriatric Rating Scale to aid the appropriate placement of elderly patients in the community by measuring their dependency needs (Gilleard & Pattie, 1977).It was also found by the authors to be a useful predictor of success of placement for long-stay general adult psychiatric patients (Pattie & Gilleard, 1979).It comprises an 18-item questionnaire to be completed by the patient's carer, divided into sections measuring physical disability (Pd), Apathy (Ap), Communication Difficulties (Cd), and Social Disturbance (Sd), giving a maximum total score of 36.Vision and hearing difficulties are also rated but not included in the total score.A total score is obtained producing five dependency grades ranging from A, full independence, to E, severe impairment with maximum dependency.
Group homes are ordinary houses in the community with up to four residents who are expected to budget, keep the house in order and cater for themselves with help from a visiting group homes officer, community occupational therapist and community psychiatric nurses who make sure bills are paid.There are nine such houses in Gloucester with 23 residents.
A supported lodgings scheme has been operating for the past decade in Gloucester, supervised by the psychiatric social services department with a supported lodgings officer and CPN support (Anstee, 1985;Robson, 1991).The type of lodgings varies from 'foster care' with up to three residents with the landlady in her own home, or a large family home of more than three residents in the landlady's own home and larger communal homes where residents share the facilities of a house and the landlady is responsible for meals and cleaning.Sixteen supported lodgings housing 76 residents were surveyed.
Four long-stay rehabilitation hostels, run as registered nursing homes by Hayburn Charitable Trust with social services funding are staffed 24 hours a day by NHS funded nurses and provide 26 placements.They cater for patients who require long-term psychiatric nursing care but do not require the facilities of a psychiatric hospital.Residents require considerable help with personal hygiene care, preparation of meals and prompting to maintain an active daily routine.There is scope for a minority to move to less intensive settings if possible.
Kingsholm Ward is a 12-bedded long-stay rehabilitation ward in Coney Hill Hospital catering for a residuum of patients requiring long-term hospital treatment (Anstee, 1991) together with beds for those patients within the rehabilitation service as a whole who suffer acute relapses.Patients from special hospitals and the regional secure unit are also rehabilitated by way of Kingsholm Ward.
The CAPE BRS was applied to the residents in the above facilities on 1 May 1993 and was completed by the residents' key-worker or landlady.

Findings
The sex distribution in each setting was similar, with males outnumbering females by more than two to one.Age distribution was also similar throughout with an average of 48 years (range 20 to 72 years, s.d.=l 1 years) for males and 54 years (range 26 to 75 years, s.d.= 12 years) for females.
According to the CAPE BRS, dependency grades should be A to C for residents in group homes, B to D in supported lodgings, C to E in long-stay rehabilitation hostels and D to E in the long-stay rehabilitation ward.In this study dependency grades were appropriate for 96% of group homes residents, average grade B, 70% of supported lodgings residents, average grade C, 73% of long-stay rehabilitation hostel residents, average grade C, and 90% of inpatients, average grade D.
The BRS subscale scores showed similar progressive increases according to setting, with the notable exception of social disturbance which was as high in supported lodgings as in long-stay hostels.The average BRS scores for each setting were statistically significantly different from one another with the exception of the long-stay rehabilitation hostels and the in-patient ward whose average scores were 10.5 (Grade C) and 13 (Grade D) respectively.

Comment
Average CAPE BRS dependency grades do correlate with actual placement with statistically significant differences between placements.Overall there was a close correlation between the clinical impressions of the staff looking after both patients and residents and their scores on the CAPE BRS.
One male in the group homes scored E and appears to be inappropriately placed.Paradoxically the high scores on the apathy and social disability subscales have led to the somewhat greater freedom he has in a group home suiting his needs best, albeit with a high level of support from his CPN.
The supported lodgings are housing several individuals who would appear not to need this level of support, but to be capable of independent living.These residents tend to have personality disorders although there is the temptation for landladies to keep less dependent tenants or those whose condition has improved since placement and a rehabilitation service must be vigilant and encourage residents to move on if appropriate.Landladies are coping with very dependent residents scoring D and E. Interestingly the residents scoring E are not always regarded by their landladies as their most difficult residents.High ratings on physical disability and apathy are often coped with by committed and caring landladies who over several years often come to regard these residents as members of their family.Antisocial behaviour is also coped with to a surprising degree by landladies.Many of them have had previous employment as psychiatric nurses, have long-standing relationships with their tenants and a financial incentive to tolerate residents' behaviour.They must have the correct mix of residents who can often accept one another's idiosyncrasies after many years acquaintance within the psychiatric system.
Four of the patients on Kingsholm Ward were for acute admissions, residing normally in group homes and supported lodgings which may explain the lack of a statistically significant difference in BRS scores compared with long-stay rehabilitation hostels.
In conclusion, the findings of this study do support the use of the CAPE BRS of dependency needs as an aid to assessment of appropriate placement for the long-term severely mentally ill in the community, both at the time of placement and to monitor ongoing need.