Inpatients ́utilization of GP and psychiatric outpatient care. A comparison of a central-institution versus a local-institution based system of psychiatry. A case-register study

Introduction: The deinstitutionalization of psychiatry has in its essence been a downsizing of central psychiatric institutions in favor of outpatientand community-based services. ‘Continuity of care’ has been a key concept from the onset in these ever more complex systems, both used as a measure of outcome and processes as well as a strategic priority (1). Recent research advocates systems that facilitate continuous clinical relationships between patients and clinicians rather than collaboration between specialized teams, but findings are limited (2-4).

Introduction: The deinstitutionalization of psychiatry has in its essence been a downsizing of central psychiatric institutions in favor of outpatient-and community-based services. 'Continuity of care' has been a key concept from the onset in these ever more complex systems, both used as a measure of outcome and processes as well as a strategic priority (1). Recent research advocates systems that facilitate continuous clinical relationships between patients and clinicians rather than collaboration between specialized teams, b ut findings are limited (2-4).
At the same time, the international literature has seen an increasing interest of the General Practitioners` (GP) role in the care of mental health patients, and underlines the need for integration of primary care and psychiatric services (5,6). Recent studies suggest that for patients with severe conditions, cross boundary continuity are poor, and many are not seen in specialized care (7,8).
Purpose and methods: We review and discuss findings from studies on continuity of care in North Norway, focusing on the collaboration in the total of mental health services. We now want to focus on the continuity of care for individual patients with severe conditions between primary care and specialized mental health services: 1. Municipality (GPs), 2. Community mental health centers (CMHC), and 3. Central Mental hospitals (CMH).
The two neighboring CMHCs of Vesterålen and of Lofoten, County of Nordland, North-Norway represent an interesting opportunity for mental health services research, because they are organized quite differently in spite of almost identical catchment -area characteristics. The one may be termed a central institution based model, the other a local institution based model. Both operate in concert with the county's` CMH.
These two models compared, particularly whether if local psychiatric beds rather than at a central hospital affects the utilization of GPs and municipality care.
It is a retrospective cohort study of the total psychiatric care for all patients in two areas in North Norway, based on a prevalence sample from the routine case-registries of general practice and specialist services over the five years 2008-2012.
Results and discussion: The most interesting result is that model of services exert at profound effect on the collaborative care between primary and specialist care. From a total of 971 inpatients included in the study, a majority in the local institution based model also utilized GPs-as well as specialist outpatient consultations. This was not the case in the centralized model, where a substantial proportion of inpatients did not receive specialist outpatient care at all. Further, those patients did neither use GP-care to the same extent as those who utilized both in-and outpatient services.
Condition (diagnosis) and length of inpatient stay modified these findings, but system model still exerted an independent and profound effect on whether patients received collaborative care or not.
Demographic and clinical variables like gender, age, or diagnosis did not alter these effects.
The distinction between 'continuity systems' and 'specialization systems' described in recent literature may at least partly explain this (2). It may be that our two models facilitate continuous clinical contact between a therapist and patient to a different degree, and that this exerts an effect at both the primary and specialist level of services.
In our local institution based system, one therapist may keep continuous contact with the patients over the transition from inpatient to outpatient care, whereas the central institution based model is more specialized and that patients may establish new relationships depending on in need of inpatient or outpatient services.
Conclusion: The results suggests that smaller local inpatient units rather than central mental institutions might represent one way of achieving better continuity of care between primary and specialist services for patients with severe conditions. Further, utilization of both in-and outpatient services predicts also more use of general practitioners care. This relationship should be examined further in future research involving the North Norwegian psychiatric health services.