In 1986, after several years of dogged persistence, Estelle Douglas (Director of Psychiatric Rehabilitation at Hillside Hospital, Long Island Jewish Medical Center, New York State) succeeded in obtaining funding for the establishment of a training centre in the New York suburb of Hicksville, Long Island. Ten years later, after winning a number of awards for its innovative approach to rehabilitation, the centre has been the subject of a retrospective study by a group of neuropsychologists and rehabilitation workers at Hillside Hospital, led by Dr. Judith Jaeger*. The findings are very positive.
Dr. Judith Jaeger is full of praise both for Estelle Douglas - whose rehabilitation work she describes as "brilliant"- and for the Nassau Day Training Programme (NDTP) for severely and persistently ill psychiatric patients.
Giving the background to the establishment of the programme, she says that it incorporates several key features that had been lacking in the traditional approach to vocational rehabilitation of psychiatric patients.
"One important aspect was the nature of the work for which patients should be trained," explains Dr. Jaeger. "In the first place, people suffering from severe mental illnesses such as schizophrenia often have trouble socializing, so the work for which they are trained should preferably be tasks that offer the opportunity to work independently of others within the work team.
"Secondly, it was important to understand the limits imposed by the nature of the illness. In particular, training needs to be flexible to recognise the fact that, because of their illness, patients cannot necessarily maintain a rigid schedule.
"Thirdly, in traditional vocational rehabilitation, not enough attention is always paid to status requirements. Many of the patients are intelligent, have had a good education and come from families in which brothers and sisters are working in responsible managerial positions. They therefore want to engage in a broadly comparable activity rather than low-skill, blue-collar work."
Other principles applied in the Nassau project also reflect these needs. For example, the work should be vital and useful to the local community and should offer patients a good chance of "mainstream" employment - work in competitive industry and commerce, not in sheltered workshops. It follows that the machines on which patients receive their training need to be the up-to-date equipment that they will encounter in a normal company, not obsolete "hand-me-downs", which adds to demoralization.
A decision was taken to focus on microfilming and other office-based technologies. The state-of-the-art technology used in microfilming minimises the difficulties these patients often have learning vocational skills - it gives them the boost they need. And, apart from satisfying the patients' training requirements, micro-filming offered good employment opportunities in the surrounding locality.
NDTP is located in converted premises in a light-industry area. During the 10 years since it was established, it has succeeded in developing and maintaining strong links with the microfilming industry and with the local business community. The New York State judiciary, banks and lawyers, all of which have a large microfilming requirement, are among the employers who have recruited patients at the end of their training courses.
In addition, NDTP also undertakes a modest amount of direct and sub-contract work. It is, however, a policy that such work should only represent around 10% of the total NDTP budget. "The aim is, after all, to place people in mainstream employment," explains Dr. Jaeger. "If the centre had a thriving business of its own, there would be a strong disincentive to release the best trainees to others."
Over the years, NDTP has received several awards and citations and has been widely praised by clinicians and patient advocacy groups for its innovative approach, quality and efficacy.. However, before the study undertaken by Dr. Jaeger and her colleagues, the centre's efficacy had never been rigorously examined.
"We conducted a naturalistic descriptive study, retrospectively examining several aspects of efficacy," continues Dr. Jaeger. "We studied all patients with schizophrenia who were admitted to the programme between 1st January 1988 and 1st July 1993 and who had participated in the programme for at least one year."
NDTP, with a staff of seven (rehabilitation staff, instructors and a placement officer) has a training capacity for around 100 people. Patients with schizophrenia represent approximately 50% of the programme's enrolment and 30% of new admissions. The difference in these percentages reflects the fact that patients with schizophrenia generally stay on the programme longer than others. They are generally the most disabled subgroup of programme participants and their illness typically results in more severe neurocognitive problems, requiring a longer learning period.
Data were obtained using three methods: questionnaire, patient interview, and chart review to ensure reliability of the data. The study included analysis of their previous job history, education, mental health service utilisation (both inpatient and outpatient) and their living arrangements. All data were obtained in the period from two years before admission to NDTP (i.e. the first data incorporated in the study are from 1986) until 1st September 1994. The results reported below use the year before admission to NDTP as baseline and one to two years following admission as follow-up.
"The most striking findings related to mental health service utilization and cost," says Dr. Jaeger. "Annual inpatient days decreased precipitously from 28.3 at baseline to 2.5 and 7.7 days respectively during the first year in the programme and the following year - a decrease far greater than the general local trend for psychiatric patients during the periods studied.
"Average estimated per patient charges for all mental health services combined dropped over 70% from $20,332 at baseline to $5,478 and $5,582 during the subsequent two years respectively."
"Months per year in paid work increased from 1.32 at baseline to 5.97 (SD=4.80) after one year in the programme. However, earned income remained minimal (baseline = $1356 per year; follow-up = $ 1881 per year) since most work was below minimum wage and/or part-time. Shifts to more independent forms of housing could not be detected as a function of NDTP participation."
Dr. Jaeger and her colleagues conclude that the most remarkable impact of effective vocational rehabilitation may thus be felt in the form of reduced need for mental health services.
"The significance of this effect extends well beyond the stated mandate of vocational rehabilitation to improve functional independence and quality of life among patients with disabilities emanating from schizophrenia," points out Dr. Jaeger. "The reduction in costs is substantial. And the reduction in the need for costly clinical services may point to important opportunities for providing high-quality outpatient mental health services in a cost-conscious environment."
"On the other hand, the modest impact of this programme on sustained mainstream work and personal earnings among patients with schizophrenia may point to the barriers posed by neurocognitive deficits on the ability to acquire and utilize vocational skills."
Dr. Jaeger's ambition is for there to be much closer working links between clinical neuropsychology and psychiatric rehabilitation. She believes that closer integration would provide the best basis for a clearer understanding of the neurocognitive barriers and for the development of new prosthetic and support techniques for overcoming them.
* Members of the reporting group (all of whom work at Hillside Hospital, Long Island Jewish Medical Center): Judith Jaeger, Ph.D., M.P.A.; Stefanie Berns, Ph.D. cand.; Bonnie Creech, Ph.D. cand.; Bruce Glick, M.A.; Estelle Douglas, M.S., C.R.C.
Reprinted with permission.
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