***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
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    Input: Evaluated a large-city adaptation of the assertive community treatment ( ACT ) model ( Stein & Test , 1980 ) . Outcomes were examined after 1 year for 82 clients , averaging over 17 lifetime psychiatric hospitalizations , r and omly assigned either to ACT or to a drop-in ( DI ) center . After 1 year , 76 % of the ACT clients and only 7 % of DI clients were involved in the respective programs . The ACT team averaged 2 home and community visits per week to each client . ACT clients averaged significantly fewer state hospital admissions and state hospital days than did DI clients . ACT clients reported greater satisfaction with program services , fewer contacts with the police , and less difficulty with practical problems associated with psychiatric readmission . More ACT clients were known to have stable community housing . Annual per-client treatment costs for ACT were estimated to be $ 1,500 less than for DI Seventy-one neurotic patients requiring follow-up were r and omly assigned to routine psychiatric out-patient care or to supportive home visiting from community psychiatric nurses as their main treatment agents and were assessed every six months for 18 months . No differences were found between effectiveness of the two modes of service on symptoms , social adjustment or family burden .  Patients seeing community psychiatric nurses reported greater satisfaction with treatment . Community psychiatric nursing result ed in a marked reduction in out-patient contacts with psychiatrists and other staff , more discharges , and a small increase in general practitioner contact for prescribing . Care of such patients by community psychiatric nurses is a valuable alternative mode of deployment within the psychiatric team Integrated mental health and substance abuse treatment within an assertive community treatment ( ACT ) approach was compared to that within a st and ard case management approach for 223 patients with dual disorders over three years . ACT patients showed greater improvements on some measures of substance abuse and quality of life , but the groups were equivalent on most measures , including stable community days , hospital days , psychiatric symptoms , and remission of substance use disorder OBJECTIVE To determine the effect of the Program for Assertive Community Treatment ( PACT ) model on psychiatric inpatient service use in a population of non-emergency psychiatric patients with severe chronic mental illness , and to test for variations in this effect with program staffing levels and patient characteristics such as race and age . DATA SOURCES / STUDY SETTING Data are taken from a r and omized trial of PACT in Charleston , South Carolina for 144 patients recruited from August 1989 through July 1991 . STUDY DESIGN Subjects were r and omly assigned either to one of two PACT programs or to usual care at a local mental health center . Effects on hospital use were measured over an 18-month follow-up period via multiple regression analysis . DATA COLLECTION METHODS Data were obtained from Medicaid cl aims , chart review s , subject , case manager , and family interviews ; search es of the computerized patient and financial data bases of the South Carolina Department of Mental Health and relevant hospitals ; and search es of the hard copy and computerized financial data bases of the two major local hospitals providing inpatient psychiatric care . PRINCIPAL FINDINGS PACT participants were about 40 percent less likely to be hospitalized during the follow-up period . The effect was stronger for older patients . Lower  PACT client/staff ratios also reduced the risk of hospitalization . No evidence of differential race effects was found . Given some hospital use , PACT did not influence the number of days of use . CONCLUSIONS Controlling for other covariates , PACT significantly reduces hospitalizations but the size of this effect varies with patient and program characteristics . This study shows that previous results on PACT can be applied to non-emergency patients even when the control condition is an up-to- date CMHC office-based case management program OBJECTIVE The study evaluated the effects of an intensive case management model on clients ' use of inpatient and outpatient psychiatric care  and on the costs of care . METHODS Ninety clients of a county mental health system who were frequent users of inpatient services were r and omly assigned to either an intensive case management group , a traditional case management group , or a control group who received no particular services . Outcome variables measured over a two-year period were number of units used by clients and costs of inpatient care in county and private facilities and various types of outpatient care , including day treatment and use of an emergency psychiatric unit . RESULTS Clients who received intensive case management had fewer inpatient days and reduced overall costs for mental health services . CONCLUSIONS Assertive outreach and intensive case management can reduce hospitalizations of clients who are frequent users of inpatient care and can reduce overall mental health care costs . Mental health consumers employed as case management aides can play an important role in the delivery of mental health services , particularly with frequent users of inpatient care BACKGROUND The aim was to compare the efficacy of intensive clinical case management ( ICM ) with st and ard community care in the management of ' hard to treat ' patients with a severe mental illness . METHOD A r and omised controlled trial was carried out in East Lambeth , a deprived area of inner London . Seventy people with psychosis design ated as ' hard to treat ' by referring teams were included ; 35 were r and omised to ICM ( case load eight patients per worker ) , and 35 to st and ard care , which offered follow-up by a community psychiatric nursing service ( 30 patients per worker ) . Outcome measures were admissions and hospital bed utilisation ; contact with services ; symptomatology ; social behaviour ; social functioning ; quality of life ; patients ' satisfaction with care at 9 and 18 months . RESULTS There were no differences in patients ' symptoms , social behaviour or social functioning . Quality of life was significantly improved in patients receiving ICM at 9 months . Satisfaction with care was significantly greater among case-managed patients . All  ICM patients remained in contact with services throughout the study , while six control patients were refusing all contact with services at 18 months . CONCLUSIONS ICM failed to improve the clinical outcome of ' hard to treat ' patients . The service was successful in maintaining contact with patients , was greatly appreciated and had a positive effect on their perceived quality of life This study examines the rationale for and relative effectiveness of three intervention models for treating people with severe mental illness and substance abuse disorders :  Twelve Step recovery , behavioral skills training , and intensive case management . Using clinical trial methods , 132 dually diagnosed clients were assigned to three service approaches . Changes in client psychosocial outcomes , and psychiatric and substance abuse symptomatology were tracked over a 24-month period . Differential effectiveness was evident , with clients in the behavioral skills group demonstrating the most positive and significant differences in psychosocial functioning and symptomatology , compared with the Twelve Step recovery approach . However , the case management intervention also result ed in several positive and important differences compared with the Twelve Step recovery approach . We also found significant changes over time , not only at 6 months but increasingly positive changes in psychosocial functioning at 12 and 18 months as well . These results underscore the need for clinical trials to further examine the relative cost effectiveness of treatment approaches for dually disordered clients and to incorporate means of assessing subgroup differences so that the interventions being tested can be further refined and targeted to a broad set of needs among the dually diagnosed While research has shown community-based psychiatric care to be as good as , or better than , hospital-based care , generalisation to clinical practice has been difficult . This prospect i ve , r and omised controlled study examined a community-based approach feasible within NHS conditions . Ninety-four patients were r and omly allocated to experimental and 78 to control treatments and followed for one year . The groups were well matched apart from an excess of psychotic control patients . No differences in clinical or social functioning outcome were found . Both groups improved substantially on clinical measures in the first six weeks , with some slow consolidation thereafter . There were three suicides in the control group and one in the experimental group . Access to care was better in the experimental group ( 93 % attended assessment ) than in the control group ( 75 % attended assessment ) The manpower and operating cost of home-based treatment was compared with the manpower and operating cost of hospital-based treatment during the second year and at the end of two years of treatment . Of the 155 patients destined to receive inpatient treatment , 76 were r and omly assigned to home treatment , 79 to hospital treatment .  The two groups were similar as to important social , demographic , and clinical characteristics , including psychiatric diagnosis . The manpower and operating cost of treatment , measured in two ways , was similar in the two groups during the second year . However , over the 2-year period hospital-based treatment of patients in each of the three diagnostic groups was more expensive than home-based treatment . Also , regardless of which treatment was given , the cost of treating schizophrenics was higher than the cost of treating manic-depressives which , in turn , was higher than the cost of treating individuals with depressive neurosis . Treatment failures were discussed . Over the 2-year period , failures in home-based treatment  accounted for 39.1 % of the total manpower and operating cost of home-based treatment , calculated according to Cost Model 1 , and for 67.1 % of the cost calculated according to Cost Model 2 . The concept of failure in hospital-based treatment  is also discussed Case management arose in the USA as a solution to the difficulties of providing community care to people with severe mental disorders . The basic principle of the approach is that a case manager takes responsibility for a client ; arranges an assessment of need , a comprehensive service plan , delivery of suitable services , and monitoring and assessment of services delivered . The case-management approach has been widely accepted , to the extent that recent legislation has made case-management the cornerstone of community care in the UK . We did a r and omised controlled trial to evaluate a social services case-management team for people with long-term mental disorders . Subjects were referred from hostels for the homeless , night shelters , a general-practitioner clinic for the homeless , the Oxford City Council homelessness unit , and local voluntary-sector group homes . Of 103 subjects referred , 80 consented to be r and omised to treatment or control groups . At 14-month follow-up , as assessed by st and ardised interviews , there were no significant differences between groups in number of needs , quality of life , employment status , quality of accommodation , social behaviour , or severity of psychiatric symptoms . In the case-management group there was a significant reduction in deviant behaviour on a st and ardised behaviour rating scale ( REHAB ) ( mean = 0.79 ; 95 % CI 0.26 - 1.32 ) . It is unfortunate , in view of the limited effectiveness we have shown , that social services case-management was not evaluated in r and omised controlled trials before its implementation in the UK The care programme approach was introduced in mental health services in the UK in 1991 . It was intended to improve the quality of care and prevent patients losing contact with care services and , by implication , to reduce psychiatric admissions . We did a study to find out if the approach worked . 400 patients from a London inner-city area who had been identified as psychiatrically vulnerable and included on a case register of patients with special needs were r and omised into two groups of 200 each . One group received close supervision by nominated key-workers ( as recommended in the care programme approach of the UK Department of Health ) , and the other received st and ard follow-up from psychiatric and social services . Outcome was recorded after eighteen months . Data on 393 patients was available for analysis . Of 197 patients allocated to st and ard care , 64 ( 32.5 % ) were lost to follow-up compared with 40 ( 20.4 % ) of 196 patients receiving close supervision  ( p = < 0.005 ) . However , patients under close supervision had significantly more admissions ( 30 % vs 18 % , chi 2 = 7.61 , p < 0.01 ) and spent 68 % more days in hospital than the st and ard group . The findings of greater hospital-bed use , which differ from those of studies with community-based psychiatric teams , suggest that close supervision by a single key worker , as recommended in the care programme approach , will lead to greater success in maintaining contact with vulnerable patients , but is likely to lead to more psychiatric admissions BACKGROUND This experiment evaluated the effectiveness of an innovative program of assertive community treatment ( ACT ) for homeless persons with severe and persistent mental illnesses . METHODS One hundred fifty-two homeless persons with severe and persistent mental illness were r and omized to either the experimental ACT program or to usual community services . Baseline assessment s included the Structured Clinical Interview for DSM-III-R , Quality -of-Life Interview , Colorado Symptom Index , and the Medical Outcomes Study 36-Item Short Form Health Survey . All assessment s ( except the Structured Clinical Interview ) were repeated at the 2- , 6- , and 12-month follow-up evaluations . RESULTS Subjects in the ACT program used significantly fewer psychiatric inpatient days , fewer emergency department visits , and more psychiatric outpatient visits than the comparison subjects . The ACT subjects also spent significantly more days in stable community housing , and they experienced significantly greater improvements in symptoms , life satisfaction , and perceived health status . CONCLUSIONS Relative to usual community care , the ACT program for homeless persons with severe and persistent mental illness shifts the locus of care from crisis-oriented services to ongoing outpatient care and produces better housing , clinical , and life satisfaction outcomes One hundred and twenty patients presenting for admission were r and omly allocated into two groups . Controls received st and ard hospital care and after-care . Projects were not admitted if this could be avoided ; instead they and their relatives were provided with comprehensive community treatment and a 24-hour crisis service .  Patients with a primary diagnosis of alcohol or drug dependence , organic brain disorder or mental retardation were excluded . During the 12 months study period , 96 % of controls were admitted , 51 % more than once . Of the projects , 60 % were not admitted at all and only 8 % were admitted more than once . Controls spent an average of 53.5 days in psychiatric hospitals ; projects spent an average of 8.4 days . Community treatment did not increase the burden upon the community , was considered to be 
    Output:
    
North American studies demonstrate greater differences in days in hospital but patients in their experimental services seem to spend no fewer days in hospital , implying a disparity in control services