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| ORIGINAL ARTICLE |
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| Year : 2019 | Volume
: 33
| Issue : 3 | Page : 142-147 |
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Effectiveness of medical service quality promotion project for child and adolescent patients with mental disabilities and psychiatric disorders in Taiwan
Chao- Wei Hsu M.D. , Ching- Hong Tsai M.D., M.S., Ph.D., , Yen- Cheng Chen M.S. , Hsin- Yi Chiang B.A. , Kai- Jong Huang B.A. , Cheng- Chung Chen M.D., Ph.D.
Department of Child and Adolescent Psychiatry, Kaohsiung Municipal Kai-Syuan Psychiatric Hospital, Kaohsiung, Taiwan
| Date of Submission | 09-May-2019 |
| Date of Decision | 19-Jul-2019 |
| Date of Acceptance | 22-Jul-2019 |
| Date of Web Publication | 30-Sep-2019 |
Correspondence Address:
Ching- Hong Tsai
No. 130, Kai-Syuan Second Road, Kaohsiung 802
Taiwan
 Source of Support: None, Conflict of Interest: None  | 3 |
DOI: 10.4103/TPSY.TPSY_28_19
Objective: The Ministry of Health and Welfare of Taiwan launched a project in June 2015 and provided community mental health outreach services and outpatient psychiatric treatment for child and adolescent patients with mental disabilities and psychiatric disorders from schools and institutions and in the community. The main purpose of this study project was intended to promote medical service quality for child and adolescent patients with mental disabilities and psychiatric disorders. Methods: Service team members from seven hospitals in Taiwan, including psychiatrists, clinical psychologists, and case managers, provided both outreach community services and outpatient psychiatric treatment. We collected the basic data and assessment scale scores of all outpatients from June 2015 to December 2018 (n = 163). Results: The findings revealed significant improvement in the scores of the Clinical Global Impression (CGI) – CGI-Severity Scale, Global Assessment of Functioning Scale, and Children's Global Assessment Scale (p < 0.001) and significant mild-to-moderate improvement of the CGI – Improvement Scale and internalizing problems (p < 0.05) and total problems (p < 0.01) of the Achenbach System of Empirically Based Assessment. Most outpatients presented fewer mood symptoms or behavioral disturbance, more improved adaptation, and higher academic performance at schools and institutions. Conclusion: This service model thus may provide effective medical services to the child and adolescent patients with mental disabilities and psychiatric disorders through both outreach community services and outpatient psychiatric treatment.
Keywords: community mental health outreach services, comorbidities, mental disability, outpatient psychiatric treatment
How to cite this article:
Hsu CW, Tsai CH, Chen YC, Chiang HY, Huang KJ, Chen CC. Effectiveness of medical service quality promotion project for child and adolescent patients with mental disabilities and psychiatric disorders in Taiwan. Taiwan J Psychiatry 2019;33:142-7 |
How to cite this URL:
Hsu CW, Tsai CH, Chen YC, Chiang HY, Huang KJ, Chen CC. Effectiveness of medical service quality promotion project for child and adolescent patients with mental disabilities and psychiatric disorders in Taiwan. Taiwan J Psychiatry [serial online] 2019 [cited 2023 Mar 25];33:142-7. Available from: http://www.e-tjp.org/text.asp?2019/33/3/142/268316 |
| Introduction | |  |
Child and adolescent patients with mental disabilities, such as autism spectrum disorder, have a higher rate of comorbid psychiatric disorders than individuals in the general population and children with other disabilities [1],[2],[3]. Child and adolescent patients with mental disabilities and psychiatric disorders present themselves with more mood and behavioral problems at schools and in the community [4],[5],[6]. Thus, they have lower academic achievement, high caring burdens for their care-givers, and more needs for psychiatric treatment [7].
Mental health services, including psychiatric consultation, referral, and treatment, are necessary for many child and adolescent patients with mental disabilities and psychiatric disorders. Early identification and treatment for child and adolescent patients with mental disabilities can enhance their social adaptation, reduce further medical use and costs, as well as avoid further morbidity and disability [8]. One previous study in Taiwan has shown improvements through early intervention program for children with a developmental delay during the preschool period [9]. Their family members, caregivers, and teachers must acquire better knowledge and management skills to address their mood and behavioral problems, and mental health services may help provide the family members, caregivers, and teachers with practical knowledge and management skills [10].
Under the current Taiwan National Health Insurance system, child and adolescent patients with mental disabilities and psychiatric disorders, particularly the students of special education classes and schools, often do not receive adequate medical services. Many parents and teachers claimed that their child and adolescent patients with mental disabilities and psychiatric disorders have received insufficient medical service in Taiwan, resulting in having considerable suffering and pain for the child and adolescent patients as well as pressure for the parents and teachers.
To improve the quality of health care and medical services, the Ministry of Health and Welfare of Taiwan launched a project in June 2015 and provided community mental health outreach services and outpatient psychiatric treatment for child and adolescent patients with mental disabilities and psychiatric disorders from schools and institutions in the community. This project provided budget supplements for hospitals in different areas to set up a special clinic in the hospital and send a medical team to provide outreach services to the community, schools, and institutions. This project was aimed to establish mutual referral and integrate mental community care for child and adolescent patients with mental disabilities and psychiatric disorders. The main purpose of this project was to promote medical service quality for child and adolescent patients with mental disabilities and psychiatric disorders. This project also provided sufficient reinforcement for Taiwan National Health Insurance program through early detection and management for child and adolescent patients with mental disabilities and psychiatric disorders.
In the period from June 2015 to December 2018, nationwide seven hospitals – including Taipei Veterans General Hospital, Taipei Mackay Memorial Hospital, Linkou Chang Gung Memorial Hospital, Taoyuan Psychiatric Center of Ministry of Health and Welfare, Tsaotun Psychiatric Center of Ministry of Health and Welfare, National Cheng Kung University Hospital, and Kaohsiung Municipal Kai-Syuan Psychiatric Hospital – joined the project. The service team members – including psychiatrists, clinical psychologists, and case managers – from the seven hospitals in Taiwan provided both outreach services and outpatient psychiatric treatment, and we collected the basic data and assessment scale scores of all outpatients. A few surveys were conducted to establish this medical service model for this project. The importance and effectiveness of community mental health outreach services combined with outpatient treatment, must be evaluated. In the present study, we intended to evaluate the demographic data and assessment scale scores of the outpatients and to estimate the effectiveness of outreach services and outpatient treatment for child and adolescent patients with mental disabilities and psychiatric disorders.
| Methods | | |
Data source and study procedure
In this project, the service team members included one child psychiatrist, one clinical child psychologist, and one case manager (a social worker or a nurse), from seven hospitals in Taiwan, provided both outreach community services and outpatient psychiatric treatment – including service connection with ordinary and special schools, and social welfare institutions. In the special outpatient clinic of this project, the psychiatrist must spend more than 20 minutes for each outpatient visit and tried to comprehensively evaluate and manage their mental disabilities and psychiatric disorders. The case manager kept following up each outpatient's status during and after the treatment course with telephone and provided the necessary help. The service team members made great efforts to cooperate and work with the outpatient's family members and caregivers both during the provision of outreach services and in the special clinic. Case conferences and symposia might be arranged for some outpatients with challenging mood and behavioral problems in the community.
The Ministry of Health and Welfare also provided funding to establish one management center for the supervision of special clinics and outreach services in seven hospitals nationwide. The management center established an information platform for collecting and organizing outpatient data from special clinics of these hospitals. The basic data and assessment scale scores of all outpatients treated at the special clinics were uploaded onto the information platform, and the information of all outpatients was protected by delinking any identifying information from the main database and sources. This study protocol was approved by the institutional review board of Kaohsiung Municipal Kai-Syuan Psychiatric Hospital (IRB protocol no. KSPH-2017-20 obtained on August 15, 2017) without the need to obtain informed consents from those participating patients.
We collected the basic data and assessment scale scores of all outpatients from those seven hospitals in this project from June 2015 to December 2018. Specifically, the basic data of these out were collected at the first outpatient treatment visit and comprised information of age, gender, source of referral, diagnoses of mental disabilities and psychiatric disorders, dysfunction in family-related factors (including single parent, foreign parent, grandparenting, and family with low income), as well as other factors. We used structural assessment scales to assess the children's condition, including the Clinical Global Impression (CGI) – Severity Scale (CGI-S), Global Assessment of Functioning Scale (GAF), Children's Global Assessment Scale (C-GAS), and Achenbach System of Empirically Based Assessment (ASEBA). During the subsequent outpatient treatment, the psychiatrist recorded the scores of CGI-S, CGI – Improvement Scale (CGI-I), GAF, and C-GAS in every visit, and ASEBA scores were also obtained from the outpatients' parents or caregivers at least once every three months. The inclusion criteria were being an outpatient and having complete first outpatient treatment and basic data available on the information platform. Excluded were those patients with the age of 18 years and older, loss to follow-up after the first outpatient treatment, and incomplete data of assessment scales from the subsequent outpatient treatment.
Structural assessment scales
Clinical Global Impression scale
The CGI scale was developed for use in clinical trials and has been applied for more than 40 years. From the clinician's perspective, it provides a brief and useful assessment of the patient's global functioning before and after initiating treatment. It was also an understandable quantification method that could facilitate treatment over time.
In clinical practice, this scale captures clinical impressions and tracks clinical progress across time for a wide range of psychiatric diagnoses. In clinical research, experienced clinicians can use the CGI scale to reveal the comprehensive clinical status of the patient at each visit, including illness severity and the impact of the illness on patient functioning. The CGI scale has been shown to correlate well with standard and well-known research drug efficacy scales, and it has been used across a wide range of psychiatric indications [11].
Children's Global Assessment Scale and Global Assessment of Functioning
Since 1980, C-GAS, GAF, and Axis-V in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, have been used as important assessment tools in clinical practice research. C-GAS assesses and personal functioning and symptoms as a part of global functioning evaluation among children aged 4–16 years. GAF is a hybrid of C-GAS for child and adolescent patients and GAS for adults; it does not have any age limits. GAF is used to assess functioning and symptoms separately, and only one of them should be present.
Both C-GAS and GAF can identify the effectiveness of psychiatric treatment, have predictive value, and can measure changes over time. The reliability of C-GAS and GAF varies from fair to substantial, and more than 100 papers have been published on the use of C-GAS and GAF for children. Reaching an international consensus for the use of C-GAS and GAF for child and adolescent patients has improved their reliability in clinical practice and research across different countries [12].
Achenbach System of Empirically Based Assessment
The ASEBA, created by Thomas Achenbach [13], is a questionnaire used to identify and assess child and adolescent patients with adaptive and maladaptive behaviors or a risk of psychiatric disorders. ASEBA is used in various settings – including mental health, school, research, and forensic settings – and it can be self-administered or administered by lay interviewers. ASEBA can be used to assess multiple age groups (including preschool-aged children, school-aged children, adults, and older adults). Scores for individuals in each age group are norm-referenced. ASEBA has been translated into one hundred more languages, with various multicultural applications [13].
Statistical analysis
We did statistical analyses on the study data in two stages. First, we identified demographic variables with descriptive statistics. We subsequently assessed the treatment effectiveness with the paired sample t-test.
All analyses were conducted using Statistical Package for Social Science software version 17 for Windows (International Business Machines SPSS Statistics, IBM Corp., Chicago, Illinois, USA). The differences between groups were considered significant if p-value was smaller than 0.05 (two-tailed).
| Results | | |
In this study, we collected the basic data and assessment scale scores of 163 outpatients aged younger than 18 years who completed data of the first and following outpatient treatment from the database in this project from June 2015 to December 2018. [Table 1] shows the demographic and clinical characteristics of those outpatients. We compared the first scores of CGI-S, CGI-I, GAF, C-GAS, and ASEBA of those outpatients with their latest scores, and data analysis results are listed in [Table 2]. | Table 1: Demographic and clinical characteristics of outpatients (n = 163)
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 | Table 2: The analysis of assessment scales' scores of outpatients (n = 163)
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From the database in this project, the majority of the 163 outpatients were male outpatients (n = 123, 75.5%). The common major diagnosis of these outpatients was attention-deficit/hyperactivity disorder (n = 68, 41.7%), autism spectrum disorder (n = 43, 26.4%), and intellectual disability (n = 29, 17.8%). They were referred to a psychiatrist for potential psychiatric outpatient treatment and for further evaluation and management of a possible psychiatric disorder from schools (n = 50, 30.7%), institutions (n = 16, 9.8%), and psychiatric hospitals or local medical departments (n = 10, 6.1%, [Table 1]).
Comparison of the first assessment scale scores with the latest assessment scale scores revealed the significant improvement of CGI-S, GAF, and C-GAS (p < 0.001) and minimal improvement of minimal improvement of CGI-I scores (p < 0.05). The scores of the self-reported assessment scale ASEBA also showed significant mild-to-moderate improvement for internalizing problems (p < 0.05) and total problems (p < 0.01) of ASEBA, but not externalizing problems of ASEBA [Table 2].
| Discussion | | |
Early identification and intervention of psychiatric disorders in patients with intellectual disabilities should be considered an important public mental health issue [8]. The majority of child and adolescent patients with intellectual disabilities and autism spectrum disorder have psychiatric comorbidities and behavioral problems that require more medical services [14],[15]. But family members and caregivers of those child and adolescent patients often report insufficient medical services, getting referrals and source of care, prominent impact on family, and high financial and caring burdens [16]. Many barriers and challenges of the public mental health policy and medical care system still exist for patients with mental disabilities and psychiatric disorders in many countries, including Taiwan and the United States [17].
In recent years, several countries in Asia, including Japan and Singapore, have begun providing community mental health outreach services for people with mental disabilities and psychiatric disorders, but only a few reports have been published on this medical service model. In 2011, the Japanese Ministry of Health, Labor and Welfare established the Japan Outreach Model Project to provide multidisciplinary outreach services for adult patients with mental illness in the community. Comparing regular outpatient care provided in Japan with public insurance, the study participants in this model of outreach services in Japan have had lower readmission rates, length of hospital stay, and improvement of social functioning and problematic behaviors [18]. In Singapore's national project for the mental health of child and adolescent patients, mental health professionals joined together to form community-based multidisciplinary teams that worked directly with school counselors, providing consultation-liaison services to child and adolescent patients with mental health disorders [19],[20]. This community mental health service model in Singapore has shown favorable results from CGI scale and Strength and Difficulties Questionnaire (SDQ) and adequate cost-effectiveness for child and adolescent patients with mental illness [21].
The national project in Taiwan that combined outreach services with outpatient psychiatric treatment for child and adolescent patients with mental disabilities and psychiatric disorders provided effective medical services and treatment according to our survey. The scores of clinical structured assessment scales, including CGI-S, GAF, and C-GAS, revealed significant improvement of outpatients' illness severity and their functioning (p < 0.001, [Table 2]). The results revealed significant mild-to-moderate improvement of CGI-I scores, for internalizing problems (p < 0.05, [Table 2]) and total problems of ASEBA (p < 0.01, [Table 2]), but not for externalizing problems of ASEBA (p > 0.05, [Table 2]). The quality and effectiveness of intervention programs and the results of the self-report assessment scale ASEBA were different from the outpatients and their family [Table 2]. Those factors may influence the results of the self-report assessment scale ASEBA in various ways. A need of further analysis exists to explore the correlations between assessment scales of outpatients in this project.
Comparing the community mental health service model in Singapore, the service teams in this project provided the similar outreach service to child and adolescent patients with mental health disorder and made great efforts to identify and manage child and adolescent patients with mental disabilities and psychiatric disorders. Both community mental health services in Singapore and Taiwan are both well-received by schools and institutions in the community. Clinical outcomes have also been measured, showing improvements in CGI-S, conduct problems, emotional problems, hyperactive behaviors and peer problems, and prosocial behaviors on the SDQ in Singapore's study [21]. Our study findings in this project not only presented clinical improvement by CGI-S, CGI-I, and ASEBA, but also showed functional improvement by C-GAS [Table 2]. As for the cost-effectiveness findings in Singapore's study, further data collection and analysis for cost-effectiveness survey in our project should be considered in the future.
In our experience and observations for medical services in this project, the outpatients from the database had different diagnoses, such as dual diagnosis or physical comorbidities, and they also received different methods and frequencies of outpatient treatment. For example, some of those outpatients received both outpatient treatment and outreach services at schools or in the institutions, but others received only outpatient treatment. Moreover, the caring and supportive functions of family members, caregivers, and teachers were important factors for outpatients' intervention at home and school. Our medical service team cooperated with family members, caregivers, and teachers and conducted intervention programs for the outpatients, including cognitive behavior therapy or family therapy. Some of the family members and caregivers learned the skills well for caring for their children with mental disabilities and psychiatric disorders, but others did not.
From our study's findings in this project and observations from the family members, caregivers, and teachers, most outpatients in this project, which provided community mental health outreach services and outpatient treatment, presented fewer mood symptoms or behavioral disturbance, more improved adaptation, and higher academic performance at schools and institutions. Community mental health outreach services can integrate outpatient psychiatric treatment for child and adolescent patients with mental disabilities and psychiatric disorders, who need further psychiatric referral and treatment. This medical service model may help child and adolescent patients to improve their symptoms at the early stage of psychiatric disorders, and prevent further morbidity and disability due to delayed identification and treatment.
From our experience in this project, this medical service model enabled early detection and intervention of psychiatric disorders in child and adolescent patients with mental disabilities and promoted health care and medical service quality under fair partnership and cooperation with the patients' family members, caregivers, and teachers. Our survey provided some information regarding this project, and further research on this medical service model is needed for implementing more effective public mental health policy for child and adolescent patients with mental disabilities and psychiatric disorders.
Study limitations
Our study results should be interpreted with caution due to the following six major limitations:
- This project was assigned to only seven hospitals from different areas in Taiwan. The study results and conclusion may not be applicable to all areas in Taiwan.
- Every outpatient had a different outreach service and outpatient treatment status during the treatment. The number and frequency of outpatient treatment of each outpatient and the resources of medical services varied due to different diagnoses and illness severity in all outpatients.
- Some outpatients were lost to follow-up; we did not collect comprehensive information on the causes of loss of follow-up, and we did no conduct further assessments in these outpatients. The duration of illness, previous treatment course, and current treatment including medication of all outpatients were also not obtained and analyzed
- We did not have a control group in this study. We included only outpatients in the special clinic of this project
- Many factors that may affect the functioning of child and adolescent patients were not included in this study, such as the difference of using and not using medication, the changes in family environment, the socioeconomic status, and the educational resources
- Methodological difficulty of this study included bias of the accuracy of outpatient's diagnoses and inter-rater reliability of assessment scales.
Study summary
Our study highlighted that the medical service model combining community mental health outreach services with outpatient psychiatric treatment for child and adolescent patients with mental disabilities and psychiatric disorders is effective for promoting medical service quality. One important thing of this project is the shift from traditional hospital-based clinical service to community-based mental health outreach service to improve the accessibility of services and provide patient-centered care. Based on data analysis results for this project, we conclude that this medical service model may alleviate psychiatric symptoms and improve the functioning of child and adolescent patients with mental disabilities and psychiatric disorders.
| Acknowledgment | | |
The authors would like to acknowledge the cooperation of staff at Taipei Veterans General Hospital, Taipei Mackay Memorial Hospital, Linkou Chang Gung Memorial Hospital, Taoyuan Psychiatric Center of Ministry of Health and Welfare, Tsaotun Psychiatric Center of Ministry of Health and Welfare, and National Cheng Kung University Hospital. The authors also thank the study participants who took part in this study and thank Frank Hung-Chih Chou for the comments and suggestions. This manuscript was edited by Wallace Academic Editing.
| Financial Support and Sponsorship | | |
This study was financially supported by the Ministry of Health and Welfare of Taiwan.
| Conflicts of Interest | | |
There are no conflicts of interest.
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[Table 1], [Table 2]
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