Showing papers in "Administration and Policy in Mental Health in 1998"
TL;DR: Outcomes indicated the IOT group had significantly fewer admissions and hospital days after the court order, and the full impact of IOT requires more study, particularly directed toward IOT's effects on insight and quality of life.
Abstract: One means to address some of the unintended consequences of the shift of treatment for individuals with serious mental illness from hospitals to communities has been involuntary outpatient treatment (IOT). Using Massachusetts data, 19 patients with court orders for IOT were matched to all and to best fits on demographic and clinical variables, and then to individuals with the closest fit on utilization before the IOT date. Outcomes indicated the IOT group had significantly fewer admissions and hospital days after the court order. The full impact of IOT requires more study, particularly directed toward IOT's effects on insight and quality of life.
63 citations
TL;DR: Mental health centers that emphasized supported employment programs achieved higher rates of competitive employment than centers that continued to offer pre-employment programs, such as day treatment and sheltered workshops.
Abstract: The supported employment approach offers the potential to increase rates of competitive employment for persons with severe mental illness, but implementation and outcomes vary considerably. The authors examined regional variation in rates of employment across one state to ascertain the factors that affect outcomes. Mental health centers that emphasized supported employment programs achieved higher rates of competitive employment than centers that continued to offer pre-employment programs, such as day treatment and sheltered workshops. Mental health centers that attained high rates of competitive employment spent a larger proportion of their total budget on vocational services than other centers. Rural centers were also more likely to attain high employment rates than urban centers.
59 citations
TL;DR: Findings are presented from a study designed to identify and describe models for integrating primary care and mental health services in rural communities and the authors identify four integration models—diversification, linkage, referral and enhancement.
Abstract: This paper presents findings from a study designed to identify and describe models for integrating primary care and mental health services in rural communities. Data were obtained from telephone interviews with staff at rural primary care sites around the country. Findings are based on the responses of 53 primary care organizations in 22 states. The authors identify four integration models—diversification, linkage, referral and enhancement—which appear to exist in combination, rather than as pure types. The proposed analytic framework outlines aspects of integration that are readily amenable to study.
51 citations
TL;DR: Investigation of clinical case managers in a large California county found that assertive outreach was done more often by more experienced case managers, and less often by those with larger caseloads.
Abstract: The authors investigated the impact of provider characteristics on the performance of clinical case managers. Case managers in a large California county were interviewed using a structured instrument that assessed service linkage, assertive outreach, and family management. Findings indicate that assertive outreach was done more often by more experienced case managers, and less often by those with larger caseloads. Belief in the efficacy of an activity was associated with doing it much more frequently.
31 citations
TL;DR: It is important for researchers to clarify the extent to which managed care affects the practice of psychiatry, and how the changing practice climate in turn affects patients seeking mental health care.
Abstract: It is estimated that 50% of all practicing psychiatrists have at least one contract with a managed care organization (AMA, 1994). As the field of psychiatry increasingly adopts the tools of managed care, it is important for researchers to clarify the extent to which managed care affects the practice of psychiatry, and how the changing practice climate in turn affects patients seeking mental health care. A diverse array of managed care techniques have been introduced into the profession of psychiatry in an effort to alter treatment patterns. One commonly used tool, utilization review, can alter treatment patterns by restricting access to treatment alternatives and providing incentives to practitioners to meet managed care goals. Other managed care tools are the determination of "medical necessity" and the use of triage and treatment guidelines among insured enrollees requesting services. These guidelines serve as selection criteria to help determine not only which members of the insured population receive treatment for mental health care, but also to determine the allocation of enrollees to staff members and to prescribe the starting point for the types of services received. Managed care psychiatrists may find changes not only in their client populations and treatment alternatives, but in many other aspects of their practice. Some psychiatrists working in managed care have become increasingly involved in treatment teams. Other psychiatrists contracting with MCOs are reserved for medication management, consultation, or administration in carved-out mental health departments or agencies. Little is known about the extent to which managed care restrictions affect psychiatrists' patient care roles, collaborative relationships with other mental health professionals, and the degree to which psychiatrists are involved in administration of managed mental health care benefits. The era of managed care has constrained the clinical decision making of psychiatrists whose magnitude and impact on job satisfaction and labor market responses are unknown. Surveys of general physicians in MCOs have provided a framework for understanding some of the difficulties and opportunities faced by managed care psychiatrists, but have failed to shed much light on many aspects of medical practice specific to the provision of mental health care within the boundaries of managed care. Future research in this area would help fill this gap, and assist in shaping the roles of psychiatrists in managed mental health care organizations.
26 citations
TL;DR: The authors examine recent trends in the supply and earnings of various mental health providers from 1989 to 1995, in the context of major changes in the financing and delivery of mental health care.
Abstract: The authors examine recent trends in the supply and earnings of various mental health providers from 1989 to 1995. The makeup of the mental health workforce is fundamentally different now than a decade ago. The number and earnings of psychiatrists have been relatively flat. The number of psychologists increased by 24%, with their earnings rising rapidly in the 1980s, and remaining level since 1990. The number of clinically trained social workers increased by 87% over the same period, and the number of advanced practice nurses certified in mental health specialties almost doubled, with the earnings of these master's-level providers increasing steadily over the period described. These trends are discussed in the context of major changes in the financing and delivery of mental health care.
26 citations
TL;DR: Results revealed that aftercare, i.e., outpatient treatment, is an important factor in reducing the utilization of inpatient resources, even when controlling for demographic and psychiatric history variables.
Abstract: Inpatient treatment continues to be the most expensive form of mental health service. This study sought to improve the methodological weaknesses, e.g., poor statistical controls, in the literature by using multivariate statistics to predict hospitalization. Results revealed that aftercare, i.e., outpatient treatment, is an important factor in reducing the utilization of inpatient resources, even when controlling for demographic and psychiatric history variables. Further, background characteristics, while easily measured, are not important predictors of hospitalization.
24 citations
TL;DR: The results indicate that the hospital is increasingly treating a poorer, sicker group of patients with shorter lengths of stay and more readmission, and the rise in readmissions, particularly within vulnerable populations, could represent an inadequate length of initial treatment.
Abstract: This study examines the composition and delivery of services in a general hospital inpatient psychiatry unit during a 10-year period. Multiple regression techniques were used to assess the association of clinical, insurance, and demographic data with length of stay and likelihood of readmission for all admissions from 1985–1993. Two variables became progressively associated with readmission—Medicaid and psychotic diagnosis. The results indicate that: (1) the hospital is increasingly treating a poorer, sicker group of patients with shorter lengths of stay and more readmissions, and (2) the rise in readmissions, particularly within vulnerable populations, could represent an inadequate length of initial treatment. Future research should further investigate the generalizability of these results and implications for quality of inpatient care.
24 citations
TL;DR: The authors present the findings of the first phase of a 3-year study developing a skills training curriculum for mental health team leaders, where a factor model empirically generated from clinical team members was compared to Bass' (1990) Multifactor Model of Leadership.
Abstract: The authors present the findings of the first phase of a 3-year study developing a skills training curriculum for mental health team leaders A factor model empirically generated from clinical team members was compared to Bass' (1990) Multifactor Model of Leadership Members of mental health teams generated individual responses to questions about effective leaders Results from this survey were subsequently administered to a sample of mental health team members Analysis of these data yielded six factors: Autocratic Leadership, Clear Roles and Goals, Reluctant Leadership, Vision, Diversity Issues, and Supervision Additional analyses suggest Bass' Multifactor Model offers a useful paradigm for developing a curriculum specific to the needs of mental health team leaders
23 citations
TL;DR: Strong leadership and clear policies regarding the mixture of public, private nonprofit, and private for profit entities are necessary if the state is to achieve its aim of integration without fragmenting a system of care for people with severe mental illness.
Abstract: The Oregon Health Plan was implemented in 1994 with a 50% expansion of Medicaid enrollment to include some of the working poor. Over 75% of Oregon Medicaid clients are now enrolled in health maintenance organizations (HMOs). Outpatient chemical dependency services have been capitated since May 1995. Capitated mental health services have been provided for the 25% of eligibles who live in demonstration counties since January 1995. Expansion and capitation appear to have been achieved without major trauma. More challenging has been the attempted integration of public sector behavioral health services with private sector health plans. Stakeholders interviewed for this study were especially concerned about the long-term impact on Medicaid clients with chronic mental illness. Strong leadership and clear policies regarding the mixture of public, private nonprofit, and private for profit entities are necessary if the state is to achieve its aim of integration without fragmenting a system of care for people with severe mental illness.
21 citations
[...]
TL;DR: The success of SMHA leaders in reaching an understanding of the forces that impact upon the public mental health system operating within a palpably turbulent and uncertain environment will help shape their response in these times of uncertainty.
Abstract: State mental health agencies (SMHAs) currently exist within a palpably turbulent and uncertain environment. In a recent article discussing organizational strategy and tactics under conditions of uncertainty, Courtney, Kirkland, and Viguerie (1997) note that \"underestimating uncertainty can lead to strategies that neither defend against threats nor take advantage of the opportunities that higher levels of uncertainty may provide.\" The success of SMHA leaders in reaching an understanding of the forces that impact upon the public mental health system operating within that environment will help shape their response in these times of uncertainty.
TL;DR: As mental health system reform proceeds, the need for culturally informed programs, practices, and practitioners has not diminished, and the challenge is to bring cultural expertise to bear within new organizational arrangements and financing schemes.
Abstract: Managed care in mental health has changed practice patterns and utilization with largely unknown consequences for ethnic minority populations. Managed care promotes oversight and continuity, but may inadvertently create barriers to access beyond those already apparent under fee-for-service. Capitation rewards efficiency and flexibility but may promote incentives that discourage minority inclusion. As mental health system reform proceeds, the need for culturally informed programs, practices, and practitioners has not diminished. The challenge is to bring cultural expertise to bear within new organizational arrangements and financing schemes.
TL;DR: Assessment of the Massachusetts Medicaid Managed Mental Health/Substance Abuse Program in year four found that substantial problems were reported in the integration of services, in linkages with support services, and with administration of the program.
Abstract: A stratified, random sample of 80 providers in the Massachusetts Medicaid Managed Mental Health/Substance Abuse Program were interviewed by phone to assess their views of the program in year four. Providers continued to believe that access and quality were the same or better than a year earlier, that client severity continued to increase while length of stay decreased, that readmissions and emergency room admissions were the same as a year earlier, and that aftercare was the same or better than a year earlier. Substantial problems were reported in the integration of services, in linkages with support services, and with administration of the program.
TL;DR: The authors suggest that community alternatives to institutionalizadon, which emphasized treatment-rehabilitation of people with serious mental health problems in the community, with the prevention of rehospitalization and the development of life skills as goals, have been effective in achieving these goals, but several problems have been noted.
Abstract: Geoffrey Nelson, Ph.D., and Richard WalshBowers, Ph.D., are with the Department of Psychology, Wilfrid Laurier University, Ontario. G. Brent Hall, Ph.D., is with the School of Urban and Regional Planning, University of Waterloo, Ontario. The authors are grateful to the National Health Research Development Program of Canada, the Ontario Ministry of Health, Community Mental Health Branch, Wilfrid Laurier University, and the University of Waterloo for funding their research, and the Ontario Mental Health Foundation for supporting the principal investigator with a Senior Research Fellowship. The authors also thank the residents and staff of the different types of housing for their participation in the research and the following persons for their research assistance: Donna Cameron, Gary Edwards, Lorie Fioze, Judy Gould, Karen Hayward, Janice McCarthy, Cari Patterson, Leslea Peirson, Kelly Peters, Ruth Slater, Denise Squire, Colleen Wiltshire, as well as Isaac Prilleltensky for his helpful comments. Address for correspondence: Geoffrey Nelson, Ph.D., Department of Psychology, Wilfrid Laurier University, Waterloo, Ontario, Canada, N2L 3C5. high; and abuse and neglect of patients was widespread in these settings (Rappaport, 1977). To address these problems, various community alternatives to institutionalizadon were developed. These programs emphasized treatment-rehabilitation of people with serious mental health problems in the community, with the prevention of rehospitalization and the development of life skills as goals. While community alternatives have been effective in achieving these goals (e.g., Stein & Test, 1985), several problems have been noted (Nelson & Walsh-Bowers, 1994). First, the expert role of mental health professionals, with insufficient attention to the preferences and experiential knowledge of people with serious mental health problems and their family members, maintains the power imbalances between professionals and service-users. Second, the focus on deficits and professional treatment can contribute to stigma and encourage dependence on professionals. Third, locating problems within service-users ignores the social conditions (e.g., poverty, poor quality housing, unemployment), that such individuals face.
TL;DR: In this paper, the authors present data from three national surveys that compare the relationship between mental illness and work loss across all DSM categories, and offer perspectives on what factors determine who works within a DSM category.
Abstract: Mental illness reduces the capacity of individuals to work. The extent of this reduction and its cost to society have long been of interest. The existing literature on this subject is extensive but is primarily focused on specific DSM disorders or on follow-up studies on small groups (often the participants have schizophrenia). The authors present data from three national surveys that compare the relationship between mental illness and work loss across all DSM categories, and offer perspectives on what factors determine who works within a DSM category. They also update information on the aggregate work loss due to mental illness.
TL;DR: Managed care appears to have increased access to private services across all racial and ethnic groups, although admissions of non-white patients were still more likely to take place in publicly operated settings, suggesting that equalizing access to putatively better inpatient treatment settings may be an externality of managed care.
Abstract: This study investigates the effect of managed care on access patterns among people of color who are severely and persistently mentally ill. The distribution of admissions to public and private psychiatric hospitals was compared for African-American, Asian, Latino, and white case managed clients of the Massachusetts Department of Mental Health before and after implementation of Medicaid managed mental health care in October 1997. Managed care appears to have increased access to private services across all racial and ethnic groups, although admissions of non-white patients were still more likely to take place in publicly operated settings. These data suggest that equalizing access to putatively better inpatient treatment settings may be an externality of managed care.
TL;DR: This work proposes that the social emphasis on cost-saving in the U.S. and corresponding shifts in the organization, financing, and management of psychiatric and mental health care, have begun to affect research on the use of coercion in psychiatric admissions.
Abstract: Historically, the use of coercion in psychiatric hospital admissions, and research on such use, have reflected social circumstances that impact on psychiatric care. Currently, the social emphasis on cost-saving in the U.S. and corresponding shifts in the organization, financing, and management of psychiatric and mental health care, have begun to affect research on the use of coercion in psychiatric admissions. Such research has begun to incorporate hospital organizational dynamics which affect the use of coercion in these admissions. The authors propose that this emphasis should be expanded into a comprehensive research agenda that examines the most pertinent organizational features affecting the use of coercion in psychiatric hospital admissions.
TL;DR: The poet narrates that Ulysses was forewarned about seductive sirens whose bewitching song lured sailors to their rocky island, near Scylla and Charibdis, and ordered his crew to fill their ears with wax to hear the enchanted song.
Abstract: The poet narrates that Ulysses was forewarned about seductive sirens whose bewitching song lured sailors to their rocky island, near Scylla and Charibdis. These fabulous creatures promised seafarers knowledge, but brought about their death, Ulysses ordered his crew to fill their ears with wax. But he, desiring to hear the enchanted song, bade his sailors bind him to the mast. His heart throbbed with desire,
TL;DR: Results indicate that there is substantial variation among the community programs in practice patterns and hospitalization rates, and the two are negatively correlated.
Abstract: Basic indicators of community support program treatment outcome as well as the degree to which the programs conform to practice guidelines for major depression are evaluated. Hospitalization rates subsequent to treatment are measured, and the correlation between hospitalization rates and practice patterns is determined. Data sets that describe outpatient and inpatient services over a 4-year period, but do not include common person identifiers were analyzed using probabilistic population estimates. Results indicate that there is substantial variation among the community programs in practice patterns and hospitalization rates, and the two are negatively correlated.
TL;DR: Large and significant differences among payers exist in treatment characteristics, controlling for diagnosis and patient age, and length of stay is longest among commercial and Medicare payers.
Abstract: This study examines the relationship among types of insurance and characteristics of inpatient psychiatric treatment. Data include 46,998 adult psychiatric or substance abuse cases from all 1991–1992 Washington State discharges from short-stay general hospitals. Large and significant differences among payers exist in treatment characteristics, controlling for diagnosis and patient age. For example, length of stay is longest among commercial and Medicare payers. Emergency admissions are more common among public payers, and elective admissions are more common among private payers, including HMOs. Results are discussed in light of policy and administration issues that will arise as financing for mental health services comes under greater capitation.
TL;DR: Faced with frequent funding changes at the federal level, state and local governments must plan services in a framework of uncertainty, which puts the provision of mental health care to older persons in jeopardy.
Abstract: The provision of mental health care to older Americans poses a unique set of challenges to service providers. Barriers to the provision of care exist at both system and individual levels. Changes in political ideology from the Reagan through the Clinton administrations brought spending cuts and increasing uncertainty about the future of social welfare programs. Faced with frequent funding changes at the federal level, state and local governments must plan services in a framework of uncertainty. This uncertain political atmosphere puts the provision of mental health care to older persons in jeopardy. Medicare reimbursement rates for mental health care are low—about one half the usual and
TL;DR: Persons with mental illness have been the shared responsibility of the mental health systems (MHS) and criminal justice systems (CJS) for centuries, but dialog and collaboration between these two agencies (M HS and CJS) is rare.
Abstract: Persons with mental illness have been the shared responsibility of the mental health systems (MHS) and criminal justice systems (CJS) for centuries. Dorothea Lyndee Dix and Albert Deutsch (1937), L. Penrose (Jemelka, 1989) and more recently Teplin (1984), Steadman (1989), and Torrey (1992) and others have consistently found substantial numbers of these persons in jails and prisons. While public policy has clearly emphasized humane treatment in community-based treatment facilities, dialog and collaboration between these two agencies (MHS and CJS) is rare. Deinstitutionalization and lack of community-based services for persons with major mental illness have for the past three decades greatly increased the numbers of these individuals in the CJS. This inadvertent consequence of an inadequately im-
TL;DR: Attitudes and reactions of leaders in mental health organizations to these changes and the importance of facilitating dynamic interactional processes between leaders and non-leaders in regard to mutual expectations are explored.
Abstract: Mental health organizations are in the midst of massive changes brought about by managed care. This paper explores attitudes and reactions of leaders in mental health organizations to these changes. The leader's own conflicts regarding this approach to mental health care is a major determinant of why some organizations adapt more readily than others. Strategies for leaders that recognize the need to address conflict within the individual and the organization are discussed. The importance of facilitating dynamic interactional processes between leaders and non-leaders in regard to mutual expectations also is emphasized.
TL;DR: The evolution of clinical practice protocols is described within the context of its origins in utilization review and utilization management and competing guidelines from the AHCPR and the American Psychiatric Association are described.
Abstract: The evolution of clinical practice protocols is described within the context of its origins in utilization review and utilization management. Physician concerns and barriers to implementation, as well as the role of the Agency for Health Care Policy and Research (AHCPR) are discussed. An example of competing guidelines from the AHCPR and the American Psychiatric Association is described in detail. The available literature on cost savings related to utilization management and clinical guidelines is reviewed and summarized. With over 1,800 medical practice guidelines catalogued, practice protocols have become ubiquitous and continued research into their cost and impact on quality are needed.
TL;DR: Results indicate that women were less satisfied with inpatient care, but were mixed on their satisfaction with overall mental health care, and males and females did not differ on the quality of inpatient Care, but women had significantly higher quality of outpatient care.
Abstract: This study examines whether male and female veterans differ on either subjective or objective measures of the quality of VA mental health care. The study sample were all discharged with a psychiatric diagnosis from a VA inpatient mental health program. Results indicate that women were less satisfied with inpatient care, but were mixed on their satisfaction with overall mental health care. Males and females did not differ on the quality of inpatient care, but women had significantly higher quality of outpatient care. These results not only highlight the need to stratify or adjust quality measures by gender, but also highlight the potential confounding effect of sub-group specific health behaviors on measures of quality.
TL;DR: Findings about the extent of client movement in and out of service clusters over time suggest caution in the implementation of risk-adjusted capitation plans, particularly those based primarily on past service utilization.
Abstract: Risk-adjusted capitation rates based on a group's expected cost to a provider have been proposed to create incentives for including people with severe mental disabilities in managed healthcare systems. The most appropriate methods for classifying people according to levels of risk, however, have yet to be determined. This research employed cluster analysis statistical techniques to identify patterns of services delivered to a sample of 4,346 consumers in Ohio. Findings about the extent of client movement in and out of service clusters over time suggest caution in the implementation of risk-adjusted capitation plans, particularly those based primarily on past service utilization.
TL;DR: The authors explore the problems of preserving patient rights as an ever greater proportion of care is provided in general hospitals under the mechanism of managed care by providing a “status report” of patient rights, identified through a national survey.
Abstract: During the 1980s and 1990s the locus of psychiatric treatment in many states shifted from state hospitals to the psychiatric units of general hospitals. The extent to which the rights guaranteed to psychiatric inpatients by state mental health agencies will survive this “privatization” process is unclear. The authors explore this issue by providing a “status report” of patient rights, identified through a national survey. They discuss the problems of preserving these rights as an ever greater proportion of care is provided in general hospitals under the mechanism of managed care.
TL;DR: The mental health services described in this paper were among services that were mandated by the Mental Health Reform Act of 1989, legislation that decentralized authority formental health services in Washington State.
Abstract: There is broad recognition in the mental health field that a continuum of care is essential to increased community tenure for mentally ill individuals at risk for high inpatient utilization (Bachrach, 1993). Evaluations of model case management programs that provide for a continuum of need offer the empirical support for this service approach (Bond, Miller, Krumwied, & Ward, 1988; Brekke & Test, 1987; Field & Yegge, 1982; Test, Knoedler & Allness, 1985). Through legislative mandates, financing mechanisms, economic incentives, and organizational restructuring, state governments attempt to ensure that the continuum of need by public mental health clients is met. Over the last decade, many states have decentralized administrative and fiscal responsibility for publicly funded mental health services. Typically, local mental health authorities are responsible for mental health services for all residents in catchment areas that are geographically defined subregions of the state. Thus, analysis at the level of the catchment area is required to understand the extent of implementation of various state mental health policy initiatives. The mental health services described in this paper were among services that were mandated by the Mental Health Reform Act of 1989, legislation that decentralized authority for mental health services in Washington State. The statute describes the community mental health continuum of care in broad categories that involve activities and concrete assistance by mental health providers. This paper focuses on those services that meet two criteria: (1) they are hypothesized to be important alternatives to use of inpatient psychiatric services by individuals with severe mental illness, and (2) estimates of the extent to which the need for the services is met varies significantly among local catchment areas in Washington State. Implementation of the mental health Jeanette Semke, Ph.D., is Research Assistant Professor, School of Social Work, University of Washington. Sondra Perdue, Dr.P.H., is Senior Statistical Scientist and Owner, Analysis Plus. This study was funded by the National Institute of Mental Health, Grant #1 R29 MH5147S01, and was presented at the 1995 National Association of State Mental Health Program Directors Research Institute Conference. Address for correspondence: Jeanette Semke, Ph.D., School of Social Work JH-30, University of Washington, Seattle, WA 98195.
TL;DR: The interplay between mental health service availability and prevalence of offenders with mental illness (OMI) has been documented in numerous studies over the past half century.
Abstract: The interplay between mental health service availability and prevalence of offenders with mental illness (OMI) has been documented in numerous studies over the past half century (Jemelka, Trupin, & Chiles, 1989). These studies have documented the correlation between insufficient mental health service and corresponding increased prevalence of persons with severe and persistent mental illness in the criminal justice system. The so-called \"criminalizing of the mentally ill\" (Torrey et al., 1992) phenomenon is largely due to insufficient psychiatric and social services
TL;DR: Studies show that work and employment can be a skills training for normal living for chronic schizophrenic patients and therapeutic treatment for mentally ill patients.
Abstract: For persons with mental illness, work has been used as a kind of "treatment" ever since the implementation of the Poor Law in Britain. Today, work has become even more important with the shift in locus of treatment from large asylums to community programs. Vocational rehabilitation is recognised as crucial in social integration and rehabilitation of currently and formerly mentally ill individuals (Baker, 1956; Black, 1988; Ciardiello, 1981; Ciardiello & Bell, 1988; Cohen, 1990 & Bond, 1992; Davies, 1972; Griffiths, 1974; Kline & Hosington, 1981; Kunce, 1970; Olsen, 1984; Olshansky, 1968; Simmons, 1965; Walker & McCourt, 1965; Warr, 1987; Watts & Bennett, 1983; Wehman & Moon, 1988). Studies show that work and employment can be a skills training for normal living for chronic schizophrenic patients (Black, 1988; Griffiths, 1974; Watts, 1983) and therapeutic treatment for mentally ill patients (Baker, 1956; Kunce, 1970; Olsen, 1984). Work