Department of Psychiatry, University of Illinois at Chicago (UIC) (Cook, Burke-Miller, Jonikas, Hamilton, Norris, Markowitz, Bhaumik); TriWest Group, Boulder, Colorado (Shore); Beacon Health Options, Dallas (Ruckdeschel); Texas Health and Human Services Commission, Austin (Ferrara).
Psychiatr Serv. 2019 Mar 1;70(3):191-201. doi: 10.1176/appi.ps.201800337. Epub 2019 Jan 11.
Self-directed care allows individuals with disabilities and elderly persons to control public funds to purchase goods and services that help them remain outside institutional settings. This study examined effects on outcomes, service costs, and user satisfaction among adults with serious mental illness.
Public mental health system clients were randomly assigned to self-directed care (N=114) versus services as usual (N=102) and assessed at baseline and 12 and 24 months. The primary outcome was self-perceived recovery. Secondary outcomes included psychosocial status, psychiatric symptom severity, and behavioral rehabilitation indicators. Mixed-effects random-regression analysis tested for longitudinal changes in outcomes between the two conditions. Differences in service costs were analyzed with negative binomial and zero-inflated negative binomial regression models.
Compared with the control group, self-directed care participants had significantly greater improvement over time in recovery, self-esteem, coping mastery, autonomy support, somatic symptoms, employment, and education. No between-group differences were found in total per-person service costs in years 1 and 2 or both years combined. However, self-directed care participants were more likely than control group participants to have zero costs for six of 12 individual services and to have lower costs for four. The most frequent nontraditional purchases were for transportation (21%), communication (17%), medical care (15%), residential (14%), and health and wellness needs (11%). Client satisfaction with mental health services was significantly higher among intervention participants, compared with control participants, at both follow-ups.
The budget-neutral self-directed care model achieved superior client outcomes and greater satisfaction with mental health care, compared with services as usual.
自我指导型护理使残疾人和老年人能够控制公共资金，购买有助于他们留在机构外的商品和服务。本研究考察了自我指导型护理对严重精神疾病成年人的结果、服务成本和用户满意度的影响。
公共心理健康系统的客户被随机分配到自我指导型护理（N=114）与常规服务（N=102），并在基线和 12 个月及 24 个月进行评估。主要结果是自我感知的康复。次要结果包括心理社会状况、精神症状严重程度和行为康复指标。混合效应随机回归分析测试了两种情况下结果的纵向变化。使用负二项式和零膨胀负二项式回归模型分析了服务成本的差异。
与对照组相比，自我指导型护理组在康复、自尊、应对能力、自主支持、躯体症状、就业和教育方面的改善随着时间的推移有显著提高。在第 1 年和第 2 年以及两年期间，个人服务总成本在两组之间没有差异。然而，与对照组相比，自我指导型护理组有 6 项服务的个人零成本，4 项服务的个人成本较低。最常见的非传统购买是交通（21%）、通讯（17%）、医疗（15%）、住房（14%）和健康和保健需求（11%）。与对照组相比，干预组在两次随访中对心理健康服务的满意度都显著更高。
与常规服务相比，预算中性的自我指导型护理模式在客户结果和对心理健康护理的满意度方面都取得了更好的效果。
