A Patient-Centered Alternative to Psychiatric Hospitalization for Veterans
William B. Hawthorne, PhD; Elizabeth E. Green, PhD; Todd Gilmer, PhD; Piedad Garcia, EdD; Richard L. Hough, PhD; Martin Lee, PhD; Linda Hammond, PhD; James B. Lohr, MD

Objective: A variety of alternatives to acute psychiatric hospital care have

been developed over the past several decades, including San Diego’s

short-term acute residential treatment (START) program, now comprising

a certified and accredited network of six facilities with a total of 75

beds. This study compared outcomes, patient satisfaction, and episode

costs for a sample of 99 veterans who received acute care either at an inpatient

unit at a Department of Veterans Affairs (VA) hospital or at a

START facility. Methods: Consenting participants were randomly assigned

to one of the two treatment settings. Follow-up was conducted at two

months. During the follow-up period, participants received treatment as

usual. Multiple standardized measures were used to maximize validity in

assessing symptoms, functioning, and quality of life. Results: Participants

who were treated in either a hospital or the START program showed significant

improvement between admission, discharge, and two-month follow-

up, with few statistically significant differences between the groups in

symptoms and functioning. There was some evidence that START participants

had greater satisfaction with services. Mean costs for the index

episode were significantly lower for START participants (65 percent lower)

than for those who were treated in the hospital. Conclusions: The results

of this study suggest that the START model provides effective voluntary

acute psychiatric care in a non–hospital-based setting at considerably

lower cost. Efforts to replicate and evaluate the model at additional locations

merit attention. (Psychiatric Services 56:1379–1386, 2005)


Dr. Hawthorne is affiliated with the department of psychiatry of the University of California,

San Diego (UCSD) and with the Community Research Foundation in San Diego.

Dr. Green is in private practice in San Diego and works on projects for San Diego County

Mental Health Services. Dr. Gilmer is with the department of family and preventive

medicine at UCSD. Dr. Garcia is director of Adult and Older Adult Systems of Care at San

Diego County Mental Health Services. Dr. Hough is with the department of psychiatry of

UCSD and the departments of psychiatry and family and community medicine at the University

of New Mexico at Albuquerque. Dr. Hammond is with the Community Research

Foundation. Dr. Lee is with the biostatistics department of the University of California,

Los Angeles. Dr. Lohr is with the department of psychiatry of UCSD and with the Department

of Veterans Affairs (VA) San Diego Healthcare System.