***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 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: BACKGROUND The significant reductions in hospital admission demonstrated in US assertive community treatment ( ACT ) studies have not been replicated in the UK . Explanations cite poor UK ' model fidelity ' and /or better UK st and ard care . No international model-fidelity comparisons exist . AIMS To compare high-fidelity US ACT teams with a UK team . METHOD The UK 700 's ACT team ( n=97 ) was compared with  high-fidelity US ACT teams ( n=73 ) by using two measures : a forerunner of the Dartmouth Assertive Community Treatment schedule ( to assess adherence to ACT principles ) and 2-year prospect i ve activity data . RESULTS The UK and US teams had similar high-fidelity scores . Although significant differences were found in the amount and type of activity , practice differences in areas central to ACT were not great . CONCLUSIONS The failure of UK ACT studies to demonstrate the outcome differences of early US studies can not be attributed entirely to the lack of ACT fidelity Objective : To compare the clinical outcome and costs of care of psychiatric patients  allocated to community multidisciplinary teams or to hospital based care programmes  after discharge from inpatient care . Design : R and omised controlled trial . Setting : Inner London ( Paddington and North Kensington ) and outer London ( Brent ) psychiatric services . Subjects : 155 patients with severe mental illness with a previous admission within the past 2 years . Main outcome measures : Ratings of clinical psychopathology , depression , anxiety , and social functioning ; comprehensive costs of health care . Results : Clinical outcomes were available for 133 patients and  cost data for 144 patients after 1 year . The clinical outcomes of the two models of care were essentially similar , but admission to hospital was more likely in the hospital based care group and the costs of health care were 14 % greater per patient than in the community group . This difference , however , was dwarfed by a twofold difference in the costs of care in the outer London services compared with those in inner London . This was explained largely by greater inpatient care for outer London patients ( 58 median bed days v 18 for inner London patients ) , more of which was provided by extracontractual referrals to other psychiatric hospitals as Brent had only 0.28/1000 beds available for acute adult patients compared with 0.82/1000 in Paddington and North Kensington over the period of the study . Conclusion : Aftercare by community teams for psychiatric patients with severe mental illness has a similar outcome to hospital based aftercare but with fewer admissions to hospital . When psychiatric bed requirements are insufficient for a population , however , neither form of aftercare is effective as greater use of hospital beds elsewhere swamps any advantage of community care programmes , with disintegration and discontinuity of psychiatric services leading to escalating costs . Key messages Community psychiatric care has generally been shown to require fewer beds than more hospital focused care Clinical outcomes in psychiatric patients with recurrent psychotic illness r and omised to community focused or hospital focused care after discharge from hospital and followed up for 1 year were similar Costs were lower for patients in the community group , which had fewer admissions to hospital Costs were twice as high in one of the areas covered by the study , mainly because of the insufficient number of beds in the area , with great reliance on psychiatric beds outside the catchment area When the number of psychiatric beds in an area becomes too low there is no advantage in providing better community care because the impact of this is swamped by the disintegrating effects of inpatient care outside the catchment This study examines attitudes toward work , work incentives , and the impact of work on quality of life for people with schizophrenia , and investigates whether these findings differ among Western countries . We interviewed 24 r and omly selected subjects with schizophrenia and schizoaffective disorder ( 12 employed and 12 unemployed ) at each of three sites : Boulder , Colorado , United States ; Berlin , Germany ; and Berne , Switzerl and . No significant differences were found in the subjects ' attitudes toward work or subjective well-being , although Swiss patients had a higher cost-of-living-adjusted income . Unemployed subjects reported a lower subjective reservation ( minimum financially worthwhile ) wage than employed subjects in Berlin and Berne , whereas the reverse was true in Boulder . When subjects from all sites were combined , employed patients displayed less psychopathology and significant advantages in terms of objective and subjective measures of income and well-being : They were also more likely to stress the importance of work . The results suggest that work is associated with a markedly better quality of life for people with schizophrenia , but that disability pension programs in the United States might introduce work disincentives OBJECTIVE The authors investigated the clinical feasibility and the outcome for patients of a program design ed as an alternative to acute hospitalization . METHOD This was a r and om- design study comparing a conventional inpatient program for urban , poor , severely ill voluntary patients who usually require hospitalization to an alternative experimental program consisting of a day hospital linked to a crisis residence . Patients were assessed with st and ardized measures of symptoms , functioning , social adjustment , quality of life , and satisfaction with clinical services upon admission to the study , at discharge from the index admission , and at follow-ups 2 , 5 , and 10 months after discharge . RESULTS One hundred ninety-seven patients were enrolled in the 2-year research program and followed for 10 months . Of the voluntary patients who would have been admitted to the hospital , 83 % were appropriate for the experimental program . The clinical , functional , social adjustment , quality of life , and satisfaction outcome measures were not statistically different for the patients in the two treatment conditions ; however , there was a slightly more positive effect of the experimental program on measures of symptoms , overall functioning , and social functioning . CONCLUSIONS The experimental condition , a combined day hospital/crisis respite community residence , seems to have had the same treatment effectiveness as acute hospital care for urban , poor , acutely ill voluntary patients with severe mental illness BACKGROUND This experiment evaluated the effectiveness of 2 approaches to vocational services for persons with severe mental disorders : ( 1 ) individual placement and support ( IPS ) , in which employment specialists within the mental health center help patients to obtain competitive jobs and provide ongoing support , and ( 2 ) enhanced vocational rehabilitation ( EVR ) , in which stepwise vocational services are delivered by rehabilitation agencies . METHODS One hundred fifty-two unemployed , inner-city patients with severe mental disorders who expressed interest in competitive employment were r and omly assigned to IPS or EVR and followed up for 18 months . Following diagnostic assessment , participants were assessed with st and ardized measures of work , income , self-esteem , quality of life , symptoms , and hospitalization at baseline and at 6- , 12- , and 18-month follow-up evaluations . Employment was tracked monthly and job satisfaction every 2 months . RESULTS During the 18-month study , participants in the IPS program were more likely to become competitively employed ( 60.8 % vs 9.2 % ) and to work at least 20 hours per week in a competitive job ( 45.9 % vs 5.3 % ) , whereas EVR participants had a higher rate of participation in sheltered employment ( 71.1 % vs 10.8 % ) . Total earnings , job satisfaction , and nonvocational outcomes were similarly improved for both groups . CONCLUSION The IPS model of supported employment is more effective than st and ard , stepwise EVR approaches for achieving competitive employment , even for inner-city patients with poor work histories and multiple problems OBJECTIVE The study examined economic disincentives and incentives to work among people with serious mental illness . METHODS Fifty people with severe and persistent mental illness who were living in the community were interviewed about the amount and sources of their income and expenses . In addition , a r and omly selected group of 100 people with schizophrenia or schizoaffective disorder was interviewed about work , income , and wage requirements . RESULTS In the first sample , the mean total cash and noncash income of unemployed subjects ( $ 929 a month ) , which was derived mainly from disability supports and rent subsidies , was only slightly lower than that of subjects with part-time employment ( $ 1,028 a month ) . The limited difference was largely a consequence of reductions in entitlement income when subjects worked . To overcome these disincentives , most subjects in the second sample felt they needed to earn between $ 5 and $ 6 an hour to make working worthwhile . The mean monthly cost of psychiatric treatment  for unemployed subjects was $ 2,083 , compared with $ 910 for those with part-time employment and $ 292 for those working full time . CONCLUSIONS The findings emphasize the importance of developing higher-paying jobs for this population and reforming entitlement programs to incorporate work incentives for the mentally disabled population OBJECTIVE The authors compared service utilization and costs for acutely ill psychiatric patients treated in a day hospital/crisis respite program or in a hospital inpatient program .  METHOD The patients ( N = 197 ) were r and omly assigned to one of the two programs and followed for 10 months after discharge . Both programs were provided by a community mental health center ( CMHC ) in a poor urban community . Data were collected for developing service utilization profiles and estimates of per-unit costs of the inpatient , day hospital , and outpatient services provided by the CMHC . RESULTS On average , the day hospital/crisis respite program  cost less than inpatient hospitalization . The average saving per patient was + 7,100 , or roughly 20 % of the total direct costs . There were no significant differences between programs in service utilization or costs during the follow-up phase . Cost savings accrued in the index episode because per-unit costs were lower for day hospital/crisis respite and the average stay was shorter . Significant differences in cost were found among patient groups with psychosis , affective disorders , and dual diagnoses ; psychotic patients had the highest costs in both programs . The two programs had roughly equal direct service staff and capital costs but significantly different operating costs ( day hospital/crisis respite operating costs were 51 % of inpatient hospital costs ) . CONCLUSIONS The programs were equally effective , but day hospital/crisis respite treatment was less expensive for some patients . Potential cost savings are higher for nonpsychotic patients . Cost differences between the programs are driven by the hospital 's relatively higher overhead costs . The roughly equal expenditures for direct service staff costs in the two programs may be an important clue for underst and ing why these programs provided equally effective acute care BACKGROUND The PRiSM Psychosis Study investigated the outcomes of  community mental health services for epidemiologically representative cases of psychosis in London . METHOD The results presented in the preceding nine papers are interpreted . RESULTS ( a ) The health and social gains reported in experimental studies of community health services are replicable in ordinary clinical setting s , and are more effective than hospital-oriented services which they replace . ( b ) Dilution does occur -- these gains are less pronounced than in experimental ( efficacy ) studies . ( c ) Both models of community services produced a range of improved outcomes . ( d ) Some limited extra advantages ( in terms of met needs , improved quality of life , and social networks ) were found in the intensive sector . ( e ) There is no consistent evidence that community-oriented services ( which include in-patient beds ) fail service users , their families or the wider public . On balance the results weigh slightly in favour of the two-team model ( for acute and continuing care ) in terms of clinical effectiveness , but the general model is almost as effective and is less expensive . CONCLUSIONS The evidence supports a community-oriented rather than a hospital-oriented approach and there is little difference between the community mental health team models 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 A r and omised controlled trial of day treatment with community care for patients with schizophrenic and affective disorders , referred for in-patient psychiatric treatment , was conducted to evaluate patterns of treatment and the course of illness with its psychosocial consequences over a period of two years . METHOD Seventy patients , of whom 34 had affective and 36 had schizophrenic disorder , were assigned to the experimental condition ( day treatment with ambulatory and domiciliary care ) , and 33 patients , of whom 16 had affective and 17 had schizophrenic disorder , were assigned to the control condition of st and ard clinical care . RESULTS Day treatment with community care was feasible for 40.6 % of the affective patients and 33.3 % of the schizophrenic patients . The direct treatment costs of both disorders , based on numbers of in- and day-pat 
    Output:
    
RESULTS The evidence supports a balanced approach , including both community and hospital services .
Areas with low levels of re sources may focus on improving primary care , with specialist back-up .
Areas with medium re sources may additionally provide out-patient clinics , community mental health teams ( CMHTs ) , acute in-patient care , community residential care and forms of employment and occupation .
High-re source areas may provide all the above , together with more specialised services such as specialised out-patient clinics and CMHTs , assertive community treatment teams , early intervention teams , alternatives to acute in-patient care , alternative types of community residential care and alternative occupation and rehabilitation .