DEINSTITUTIONALIZATION

Deinstitutionalization



Deinstitutionalization

Introduction

Deinstitutionalization can be defined as the replacement of long-stay psychietric hospitals with smaller, less isolated community-based alternatives for the care of mentally ill people. According to this definition, deinstitutionalization is not limited to the reduction of psychietric hospital censuses, even though this is a common understanding of the term (Cohen 2000). Rather, the definition extends beyond hospital depopulation to include the provision of alternative services. Thus, although downsizing or closing long-stay psychietric hospitals is a critical part of deinstitutionalization, it is only a part of that process—it is not all of what deinstitutionalization encompasses(Folay Sharfstain 1983).

Deinstitutionalization In The United States

The history of deinstitutionalization falls into several stages as policies and objectives have changed over time. The early focus was on moving individuals out of state public mental hospitals and from 1955 to 1980, the resident population in those facilities fell from 559,000 to 154,000. Only later was there a focus on improving and expanding the range of services and supports for those now in the community, in recognition that medical treatment was insufficient to ensure community tenure. In the 1990's whole institutions began to close in significant numbers and there was a greater emphasis on rights that secured community integration - such as access to housing and jobs.In the initial stages, states funded small community pilot programs for individuals who responded well to antipsychotic medications that were then becoming available. The national deinstitutionalization movement was launched in 1965 through the community mental health centers program. (Bindar 2000) The movement was further fueled by concerns over civil rights and the conditions in institutions. That led to the courts limiting involuntary institutionalization and setting minimum standards for care in institutions. Federal policy significantly influenced states to shift between institutional sites of care. The CMHC program was expanded over the 1970's. Medicaid and Medicare covered a broad range of mental health services while SSI and SSDI provided income support. In response to the incentive provided by federal Medicaid reimbursement, community based general hospital psychiatric beds grew rapidly, and states moved individuals to nursing homes to capture Medicaid reimbursement that was not available to state mental hospitals. However, overall progress was extremely slow and resources for community care were a major issue. Not until 1993 were more state-controlled mental health dollars allocated to community care than to the state institutions. In addition, while promising models of community care were (KlinaGaorga 1917)tried, they were rarely fully evaluated and even more rarely incorporated into standard practice. As new technologies came online they were often provided only through temporary pilot programs or in insufficient capacity; old approaches were not replaced but continued to eat up resources.

The history of deinstitutionalization began with high hopes and by 2000, our understanding of how to do it had solidified. But it was too late for many. Looking back it is possible to see the mistakes, and a primary problem was that mental health policymakers overlooked the difficulty of finding resources to meet the needs of a marginalized group of people ...