Acute versus sub-acute care beds: Should Australia invest in community beds at the expense of hospital beds?

Sub-acute care community units are a relatively new addition to Australia’s mental health system. A recent systematic review suggested that they might be able to provide cost-effective alternatives to hospital admissions (Thomas and Rickwood, 2013). On this basis, Commonwealth and State governments have begun to expand sub-acute care programmes with the aims of preventing unnecessary acute care admissions, shortening hospital lengths of stay and reducing readmission rates. However, questions remain about whether the introduction of these new sub-acute care units has in fact reduced the pressures on public hospitals. The outcomes of sub-acute care programmes in Brisbane and Adelaide shed further light on the ‘real-world’ effects of sub-acute care.

A recent study by Siskind et al. (2013) provides interesting results on the effectiveness of an established sub-acute care unit in reducing hospital demand. The study describes the outcomes of a crisis house in Brisbane that offered sub-acute care admissions as an alternative to hospitalisation (AtH) for people with severe and persistent mental illness. In the short-term, Siskind et al. (2013) found that AtH patients spent fewer days in hospital during the index admissions, which provided cost savings for the regional mental health service. These results suggested that mental health planners might be able to open low-cost community houses to reduce the number of expensive hospital beds. However, the AtH study presented a more complex picture in the medium term. The AtH programme did not appear to reduce patient demand on hospitals during the following year. In fact, AtH patients were relatively high users of hospital services compared to selected controls. In the year after sub-acute care, AtH patients were significantly more likely to have emergency department (ED) presentations (60 vs 40%) and require hospital readmission (46 vs 26%).

A newly released report on South Australia’s sub-acute care programme provides a further illustration of the ‘real-world’ effects of sub-acute care (Health Outcomes International, 2013). The most controversial aspect of the South Australian plan is the decommissioning of acute care hospital beds alongside the roll-out of sub-acute care community beds. Currently, South Australia appears to be the only State closing specialised psychiatric units within public acute care hospitals. Generally speaking, acute care beds are increasing in Australian public hospitals in line with overall population growth. For example, Victoria has recently commissioned a significant increase in hospital beds over 2013–2014 in response to rising patient demand.

During 2011–2012, Adelaide’s mix of mental health beds was changing as 23 acute care hospital beds were closed while 45 sub-acute care community beds were opened in newly built intermediate care centres (ICCs). This first phase of the ICC programme was funded at around AUD$7.2 million recurrent. As a consequence of these changes, South Australia sits well above the national average for community residential beds for people aged 18–65 (12.7 beds per 100,000 compared to 6.0 beds per 100,000), but significantly below the national average for non-veterans general hospital acute care adult beds (19.9 beds per 100,000 compared to 24.3 beds per 100,000). Additionally, South Australia has low numbers of non-acute care rehabilitation hospital beds (4.0 beds per 100,000 compared to 10.0 beds per 100,000) and very low rates of supported accommodation (Australian Institute of Health and Welfare, 2011; Department of Health and Ageing, 2010; Ernst & Young, 2013). In summary, South Australia has quite a different mix of beds compared to other States, including the lowest average number of State-funded, non-veterans general hospital acute care adult beds in the nation[see].

It was hoped that Adelaide’s high number of ICC sub-acute care beds would assist in reducing psychiatric presentations to EDs, as well as compensate for the low numbers of acute care hospital beds. To date, there is very little evidence of this occurring and a recent Ernst & Young review found that ‘the mental health system in South Australia has experienced growing pressure within all emergency departments in respect to acute mental health patient demand’ (Ernst & Young, 2013: 1) during the period of ICC expansion and the closure of acute care beds.

Based on the Brisbane and Adelaide studies, sub-acute care programmes do not appear to have impacted on hospital demand (Health Outcomes International, 2013). Preliminary data from the Adelaide sub-acute care programme indicated that ICC patients were slightly more likely (rather than less likely) to present to the ED and be admitted to an acute care hospital bed following sub-acute care admissions. This is consistent with the pattern of greater demand after AtH sub-acute care admissions in Brisbane (Siskind et al., 2013). The reasons behind the higher demand are unclear, but short lengths of stay in these sub-acute care programmes may have meant that treatment was insufficient to change illness trajectories. The ICC evaluation concluded that ‘given the short length of stay in an ICC, it is not anticipated that acute mental health admissions would necessarily reduce’ (Health Outcomes International, 2013: 4).

The low-risk profile of both AtH and ICC sub-acute care units may also limit their usefulness as an alternative to acute care hospitalisation. Patients in the Brisbane programme had lower levels of illness acuity than controls in the 12 months prior to an AtH admission. In the Adelaide programme, the majority of ICC patients were rated as either no-risk or low-risk for violence (97%) or suicide (90%) (Health Outcomes International, 2013: 18) and most of these patients would not have met the threshold for acute hospital care. The evaluation noted that the ICCs were neither designed nor staffed for the small proportion of higher-risk patients who were admitted to reduce pressures in the EDs and acute care wards. Because of this low-risk admission profile, the ICCs operated to a large extent as an additional community option and in practice had only a very limited ability to reduce acute care hospital demand.

In summary, despite the short-term promise of the Brisbane AtH programme, the results imply that demand on hospitals remained relatively high in the medium term. In addition, the evidence to date suggests that the introduction of the Adelaide’s sub-acute care beds has neither reduced ED demand nor provided an alternative to the chronic shortage of acute care psychiatric inpatient beds. Hence, Australian mental health planners should be cautious about decommissioning newly built and staffed mainstream acute care psychiatric beds in public hospitals, which are a pillar of the National Mental Health Strategy, in favour of a largely untested model of sub-acute care community residential care.

Australia is already operating from a low base of acute care psychiatric beds. Carr and Copolov (2011) have highlighted the major reductions in Australia’s psychiatric bed stock over recent decades. We have among the lowest numbers of psychiatric beds per capita in the developed world; much lower than the average given by the Organisation for Economic Cooperation and Development (OECD, 2013). Harris and colleagues have acknowledged that the ‘pressures on acute psychiatric inpatient units within all jurisdictions, resulting in high occupancy rates and lack of access to services to consumers in acute need, have raised doubts about whether current acute inpatient service levels are adequate’ (Harris et al., 2012: 988). Furthermore, there is scepticism about the ability of community care to compensate for the relatively low numbers of acute care beds and reduce the pressures on EDs (Cunningham, 2012).

From a social justice perspective, it is imperative that we get the balance right and prevent acutely unwell psychiatric patients from languishing for longer periods in busy EDs than medical or surgical patients while awaiting an acute care hospital bed. The provision of acute and sub-acute care beds is a significant area of policy debate for psychiatry that needs careful scrutiny and evaluation across Australia and New Zealand.

See Research by Siskind et al., 2013 47(7): 667–675.