74 Unit 1 CURRENTTHEORIES& PRACTICE
LONG-STAY CLIENTS
Fisher et al. (2001) identify a group of clients with se-
vere and persistent mental illness who still require
acute care despite the current emphasis on decreased
hospital stays. They call this group “long-stay clients.”
This population includes clients who were hospital-
ized before deinstitutionalization and remain hospi-
talized despite efforts at community placement. It
also includes clients who have been hospitalized con-
sistently for long periods despite efforts to minimize
their hospital stays. Seventy-five percent of the pop-
ulation studied had schizophrenia, and thirty percent
had a co-morbid diagnosis of substance abuse. Eighty-
four percent of the clients had at least one major med-
ical problem, such as obesity or respiratory problems,
and many had more than one medical disorder. In ad-
dition, 69% of the clients exhibited problematic be-
havior within the past month. Community placement
of clients with problematic behaviors still meets re-
sistance from the public. All these factors were barri-
ers to successful placement in community settings.
These authors concluded that a small portion of long-
stay clients would continue to require inpatient hos-
pital care.
One approach to working with long-stay clients is
a “hospital hostel,” or a unit within a hospital that is
designed to be more home-like and less institutional.
In Great Britain, several hospital hostel projects have
been established that provide access to community
facilities and focus on “normal expectations” such as
cooking, cleaning, and doing housework. A study of one
such program found that clients had improved func-
tioning and fewer aggressive episodes and were more
satisfied with their care. Some clients remained in the
hostel setting, while others were eventually resettled
in the community (King, Singh, & Sheperd, 2000).
CASE MANAGEMENT
Case management,or management of care on a
case-by-case basis, is an important concept in both in-
patient and community settings. Inpatient case man-
agers are usually nurses or social workers who follow
the client from admission to discharge and serve as li-
aisons between the client and community resources,
home care, and third-party payers. In the community,
the case manager works with clients on a broad range
of issues, from accessing needed medical and psychi-
atric services, to carrying out tasks of daily living such
as using public transportation, managing money, and
buying groceries.
DISCHARGE PLANNING
An important concept in any inpatient treatment set-
ting is discharge planning. Gantt et al. (1999) wrote
that “as the focus of inpatient psychiatric care shifts
to an emphasis on quick resolution of acute symptoms,
and rapid transfer to stepdown, less costly treatment
interventions, the role of discharge planning has be-
come even more central” (p. 2). Environmental sup-
ports, such as housing and transportation, and access
to community resources and services are crucial to
successful discharge planning. In fact, the adequacy of
these discharge plans was a better predictor of how
long the person could remain in the community than
were clinical indicators such as psychiatric diagnosis
(Caton & Gralnick, 1987).
Impediments to successful discharge planning
include alcohol and drug abuse, criminal or violent be-
havior, noncompliance with medication regimens, and
suicidal ideation (Gantt et al., 1999). For example, op-
timal housing often is not available to people with a re-
cent history of drug or alcohol abuse or criminal be-
havior. Also, clients who still had suicidal ideas or a
history of noncompliance with medication regimens
were ineligible for some treatment programs or ser-
vices. The study found that clients with these impedi-
ments to successful discharge planning often had a
marginal discharge plan in place because optimal ser-
vices or plans were not available to them. Conse-
quently people discharged with marginal plans were
readmitted more quickly and more frequently than
those who had better discharge plans.Case Manager