Background: Scarce attention has been paid to establishing benchmarks for tertiary care for adults with severe mental disorders. Yet, the availability and efficient utilization of residential resources partly determines the capacity of a comprehensive system of care to avoid clogging ever-shrinking acute care bed facilities. Objectives: To describe the actual utilization of and projected needs for residential resources, one part of tertiary care, in the catchment area of a psychiatric hospital in east-end Montreal. To compare results obtained against actual utilization and projected needs evaluated in other Canadian provinces and in other countries, with a view to establishing national benchmarks. Methods: Two surveys were undertaken to establish the number of places in these facilities that were utilized and needed for adults aged 18 to 65 years with severe mental disorders, without a primary diagnosis of mental retardation or organic brain syndrome, and originally from the catchment area. A first survey ascertained the number of places utilized and of those needed for residential care among all long-stay inpatients and all adults in supervised residential facilities. A second survey identified the need for such long-stay hospitalization, nursing homes, and supervised facilities as an alternative or as a complement to hospitalization among acute care inpatients. Results: The actual ratio of places in long-stay hospital units, nursing homes, and supervised residential facilities was 150:100 000 inhabitants. The ideal ratio, according to estimated needs, is 171:100 000. The figure breakdown is as follows: 20:100 000 for long-stay hospital units, 20:100 000 for nursing homes, 40:100 000 for group homes, 40:100 000 for private hostels or foster families, and 51:100 000 for supervised apartments. The needs of this urban, blue-collar population for supervised residential places hovered in the upper range of utilization and standards for European countries and within the proposed standards for Canadian provinces. Discussion: Needs for long-stay hospitalization or for supervised residential facilities cannot be treated as absolute. For example, evaluation conducted in this hospital-led system of psychiatric care may produce higher estimates of institutional care. Comparing actual utilization and projected needs in this urban catchment area with current utilization in other jurisdictions in Canada and Europe should contribute to establishing sound national benchmarks within ranges. Conclusions: It is possible to establish benchmarks that guide the development of supervised residential settings to best meet the needs of the population of adults with severe and persistent mental disorders. The methods used here to assess needs should serve as guidelines for future research, because they were designed to contain the bias of over- or underprovision of care in the current utilization.

SummaryAims– Psychiatric hospitals remain the main venue for long-term mental health care and, despite widespread closures and downsizing, no country that built asylums in the last century has done away with them entirely – with the recent exception of Italy. Differentiated community-based residential alternatives have been developed over the past decades, with staffing levels that range from full-time professional, to daytime only, to part-time/on-call.Methods– This paper reviews the characteristics of community-based psychiatric residential care facilities as an alternative to long-term care in psychiatric hospitals. It describes five factors decision makers should consider: 1. number of residential places needed; 2. staffing levels; 3. physical setting; 4. programming; and 5. governance and financing.Results– In Italy, facilities with full-time professional staff have been developed since the mid-1990s to accommodate the last cohorts of patients discharged from psychiatric hospitals. In the United Kingdom, experiments withhostel wardssince the 1980s have shown that home-like, small-scale facilities with intensive treatment and rehabilitation programming can be effective for the most difficult-to-place patients. More recently in Australia,Community Care Units(CCUs) have been applying this concept. In the Canadian province of British Columbia (BC),Tertiary Psychiatric Residential Facilities (TPRFs)have been developed as part of an effort to regionalise health and social services and downsize and ultimately close its only psychiatric hospital.Conclusions– This type of service must be further developed in addition to the need for forensic, acute-care and intermediate-level beds, as well as for community-based care such as assertive community treatment and intensive case management. All these types of services, together with long-term community-based residential care, constitute the elements of a balanced mental health care system. As part of a region's balanced mental health care plan, these Tertiary Psychiatric Care Facilities have the potential to act as hubs of expertise not only for treatment, rehabilitation, community integration and ser-vice co-ordination for the severely mentally ill, but also for research and training.Declaration of Interest: None.

L'auteur propose une synthèse des éléments essentiels qui permettent de différencier la gestion de cas du suivi intensif dans le milieu pour les personnes souffrant de troubles mentaux graves. En situant le développement de ces deux approches dans leur contexte social, l'auteur identifie les points de repère qui permettent de les distinguer à la fois au plan conceptuel et pratique. Cet exercice permet de dissiper la confusion répandue dans les écrits et d'outiller les cliniciens afin qu'ils puissent identifier les modèles les plus appropriés pour répondre aux besoins de leur clientèle. Cela implique de prendre en considération les caractéristiques du système dans lequel ils interviennent car sa configuration exerce une influence considérable sur leur travail.The author proposes a synthesis of the essential elements to distinguish Case Management from Assertive Community Treatment with people suffering from severe mental illness. By situating these two approaches in their social context, the author identifies points of reference that allow to distinguish them one from the other on both practical and conceptual levels. This exercise allows to dissipate the widespread confusion in the literature as well as give clinical workers the necessary tools to identify the appropriate models to meet the needs of the clientele. This also implies taking into consideration the characteristics of the system in which they intervene for its configuration exerts a considerable influence on their work.El autor propone una smtesis de los elementos esenciales que permiten diferenciar la gestion de casos del seguimiento intensivo en el medio, para las personas que sufren de desordenes mentales graves. Situando en su contexto social el desarrollo de estos dos enfoques, el autor identifica los puntos de referenda que permiten distinguirlos a nivel conceptual y practico. Este ejercicio permite disipar la confusion generalizada en los escritos y ofrece utiles a los clînicos para que puedan identificar los modelos mas apropiados para responder a las necesidades de sus clientes. Esto implica que hay que tomar en consideraciôn las caracterîsticas del sistema en el que intervienen puesto que su configuraciôn ejerce una influencia considerable en su trabajo

Aim– Instruments to measure the process - the daily activities of home care workers - have received little attention and may impede research in refining the active ingredients, the clientele best served and continuous quality improvement. We developed a decade ago in Quebec, Canada, a new daily contact log (relevé quotidien des contacts or RQC) that has now reached in practice 1 million entries.Methods– Three features distinguish the RQC development, namely, practical ergonomics, a clear logic, and response categories easy to understand and retain. The instrument is filled following any 10-minute or more contact with or about the client, and covers the location, time and actors of the episode of care, and the nature of the intervention (crisis, representing, accompanying, discussing) in 10 areas (i.e. medication, daily living activities, housing, relationships, substance abuse, legal, etc.). Inter-rater agreement for eachRQCresponse category and rater agreement with a criterion measure (coded vignettes) were evaluated.Results– Kappa coefficients and intra-class correlation coefficients yielded results ranging from at least moderate to generally substantial agreement for all 77 response categories.Conclusions– The newRQCmay support international studies of the implementation and application of various forms of intensive home care, refining its indications, and serves as a clinical and managerial tool to ensure quality of the interventions.Declaration of Interest:The study was financed by funds from the Fonds de la recherche en santé du Québec (FRSQ) and the Canadian Institutes of Health Research (CIHR). The authors have not been involved with any other forms of financing that might be considered a conflict of interest in connection with the submitted article.Declaration of Interest:The study was financed by funds from the Fonds de la recherche en santé du Québec (FRSQ) and the Canadian Institutes of Health Research (CIHR). The authors have not been involved with any other forms of financing that might be considered a conflict of interest in connection with the submitted article.