Implementation of social services for the chronically mentally ill in a Polish mental health district: consequences for service use and costs.

BACKGROUND In accordance with the mental health reform in Poland, from 1970 to 1980 the following mental health facilities were established within the general health system in the Warsaw District of Targowek: general hospital psychiatric ward, day hospital, outpatient clinic (OC), and community mobile team (CMT) with some procedures of assertive community treatment (ACT). In 1998 (according to the Mental Health Act of 1994), within the social welfare system, new community facilities were established in this district with psychosocial rehabilitation programs for the chronically mentally ill. These new social welfare facilities were a vocational rehabilitation center (VCR), community center of mutual help (CCOMH), and specialized social help services at client homes (SSHS). AIM OF THE STUDY To determine the change of care delivered to chronic psychiatric patients in both the mental health and social welfare systems, and to compare the costs of care during two 2-year periods: before (Period A) and after (Period B) the 1998 implementation of the new social welfare facilities in the Warsaw District of Targowek. METHODS The sample consisted of 73 chronic psychiatric patients, admitted since 1998 to the new social welfare facilities. The authors evaluated and calculated the costs of the patients' use of mental health facilities during the two years before their first admission to VCR, CCOMH or SSHS in 1998 (Period A: 1996-1998) and their use of mental health and social welfare facilities during the two years after their admission to VCR, CCOMH or SSHS in 1998 (Period B: 1998-2000). RESULTS In this group of chronic patients, during Period B, the total duration of both full and partial hospitalizations decreased (-75.9% and -78.9% respectively), while the total number of outpatient mental health visits went up (+62.9%). In Period B the new social welfare facilities offered a substantial amount of day care and the global amount of supplied day care increased markedly. The total costs of the mental health system significantly decreased in Period B (-65.7%), but new costs emerged in the social welfare system. Taken together, the total costs of care provided by the two systems in Period B were higher than the costs incurred by the mental health system alone in Period A (+33.9 %), but the increase in the total amount of services delivered was also relevant (+98.3%). The "out of pocket" expenses incurred by patients increased in Period B (+13.9%). DISCUSSION The activity of the new social welfare facilities (VRC, CCOMH, SSHS) seems to reduce both full time and partial hospitalizations. Despite the increasing costs of medication reimbursement, and the increased use of CMT and OC, the overall costs for the mental health system were substantially reduced. The decrease in day hospital use is probably due to the large amount of daily social support and home services offered in VRC, CCOMH and SSHS. The results emphasize the importance of evaluating the coordination of care for chronically mentally ill patients in the mental health and social welfare systems.