Parent satisfaction with children's mental health services in a children's mental health managed care demonstration

This article presents findings from a quasi-experiment that included the use of satisfaction scales to compare parent's satisfaction with the services their children received through two different mental health care delivery systems. Satisfaction with the following three types of service were compared: (1) intake assessment during the admission process to any service setting, (2) outpatient services, and (3) residential treatment including inpatient hospitalization and residential treatment centers (RTCs). Additionally, satisfaction with several areas of care (e.g., access, treatment process, therapist relationship, parent and family services, discharge and transition planning), as well as global satisfaction, was assessed. In general, parents whose children received services through an innovative continuum of care system reported significantly higher satisfaction with intake assessment and outpatient services than did parents whose children received care in a traditional fee-for-service system. Fewer differences were found in satisfaction with residential services.     

The quality of services in a children's mental health managed care demonstration

The Fort Bragg Demonstration and evaluation was designed to test the cost-effectiveness of a continuum of care model of service delivery for children and adolescents. A crucial aspect of the evaluation was the measurement of the quality of services provided in the Demonstration. Two key service components were examined: intake assessment and case management. It was concluded that these key components of the continuum of care were implemented with sufficient quality to have the theoretically predicted effects on mental health.     

The evaluation of a children's mental health managed care demonstration

This article introduces the Fort Bragg managed care experiment. This study was a 5-year, $80 million effort to evaluate the cost-effectiveness of a full continuum of mental health services for children and adolescents. The article describes the development of the Demonstration, the program theory underlying intervention, and how this theory was tested.     

Clinical outcomes of a children's mental health managed care demonstration

The Fort Bragg Evaluation Project hypothesized that the mental health of children treated in the Demonstration's continuum of care would improve more than that of children receiving traditional mental health services at a comparison site. Program theory further predicted site differences in outcome for certain subgroups of children, such as those with severe mental health problems. These hypotheses were tested at 6-month and 1-year follow-ups in several ways, but results showed only slightly more site differences than expected by chance. For the evaluation sample of N = 984 treated children aged 5-17, site differences favored the Comparison about as often as the Demonstration. Children at both sites improved, but there was no overall superiority in mental health outcomes at the Demonstration.     

Implications of a children's mental health managed care demonstration evaluation

This article summarizes the major findings of the Fort Bragg Evaluation and considers alternative explanations for the results. The evaluation found that the continuum of care provided a high-quality system of care but was more expensive and produced no better clinical outcomes than traditional services. The possibility of implementation failure at both the systems and services levels is considered and rejected as an explanation for the results. Support for the validity of the measurement, design, and the analysis is also presented. The implications for research and policy are described.     

Methodological issues in evaluating mental health outcomes of a children's mental health managed care demonstration

A key question of the Fort Bragg Evaluation was whether the continuum of care model implemented at the Demonstration produced better mental health outcomes for children and adolescents than a traditional system of care. This article describes a few of the key methodological issues that were addressed to help ensure that findings about mental health outcomes were valid. The research design was quasi-experimental and longitudinal. Nearly 1,000 families participated, and attrition was low throughout the study. Multiple informants responded to a comprehensive array of widely used instruments in the area of children's mental health and mental health services. Despite the absence of random assignment, sites were comparable upon entry to the study on numerous factors that might affect outcome. Further, data lost through the course of study did not vary appreciably across sites. Finally, some evidence suggests that the findings of the Outcome Study may generalize to other populations of low-middle to middle-class youth in treatment.     

Developing outpatient mental health services for managed care.

One of the characteristics of the best outpatient treaters is their capacity to manage their own anxieties so as not to interfere with their patients' progress. This does not mean "sitting on," shutting out, or otherwise ignoring those signals to prevent their intruding into the therapeutic space. On the contrary, this requires that a clinician be acutely aware of his or her internal dialogue and be able to listen to use it to facilitate the treatment. This has meant simultaneously listening to oneself while paying complete attention to one's patient. This paradox is part of the nature of this work and remains one of its important features. Today, those who choose to treat psychiatric patients in this setting are presented with many more such paradoxes, including the necessity of being aware of (1) populations needing to be served while providing the best care for individual patients; (2) limited resources; and (3) balancing ethical, fiscal, legal, and clinical concerns. This article demonstrates that the successful development of outpatient services in a managed care environment requires attention to these same tensions on a larger scale. It also shows that understanding the evolution of managed care and the myriad competing interests involved are necessary to be able to care successfully for psychiatric patients.     

Interagency collaboration for children's mental health services: The San Mateo County model for managed care

This article describes how a managed care system is being established in San Mateo County to coordinate the delivery of mental health, probation, social and education services to children with mental health problems. The evolving system assesses program outcomes, uses centralized authorization and treatment management, and merges the funding streams in order to develop a seamless web of services.     

The cost of access to mental health services in managed care

Managed care has controlled the cost of specialty mental health services, but its impact on access to care is not well described. In a retrospective design, the study used empirical data to demonstrate a direct relationship between managed care plans' claims costs per member per month and the proportion of plan members who use specialty mental health services annually. Each increment of $1 per member per month in spending on claims was associated with a.9 percent increase in the proportion of enrollees receiving specialty mental health treatment. These data raise concerns that plans with low per-member per-month costs may unduly restrict access to specialty treatment.     

Barriers to children's mental health services

OBJECTIVE: To examine the characteristics associated with barriers to children's mental health services, focusing on the effect of children's psychosocial problems on parents. METHOD: Data come from a first-grade, prevention-intervention project conducted in Baltimore, Maryland. Analyses were restricted to 116 families who participated in seventh-grade interviews and indicated the index child needed services. The Services Assessment for Children and Adolescents was used to measure barriers to children's mental health services. RESULTS: More than 35% of parents reported a barrier to mental health services. Types of barriers included those related to structural constraints, perceptions of mental health, and perceptions of services (20.7%, 23.3%, and 25.9%, respectively). Although parenting difficulties were associated with all barriers (structural: OR = 10.63, 95% CI: 2.37, 47.64; mental health: OR = 8.31, 95% CI: 1.99, 34.79; services: OR = 5.22, 95% CI: 1.56, 17.51), additional responsibilities related to attendance at meetings was associated only with structural barriers (OR = 5.49, 95% CI: 1.22, 24.59). CONCLUSIONS: Researchers and policymakers interested in increasing children's access to mental health services should consider strategies to reduce barriers related to perceptions about mental health problems and services, in addition to structural barriers. Particular attention should be given to programs that focus on the needs of families who are most affected by their child's psychosocial problems.     

An evolving managed care system: Public mental health services in San Francisco

This article describes the San Francisco Division of Mental Health's evolution toward managed care for its Medicaid eligible population. The reorganization of services reflects a local reform initiative documented in the Division's strategic plan. In addition to responding to federal mandates for serving the seriously mentally ill and the state guidelines for the managed mental health carve-out, the author also discusses the obstacles to implementing managed care as well as the future issues to be addressed.The author is grateful to the following persons who assisted with this study: Jeff Jue, Deputy Director; and William McConnell, Section Director and Co-Investigator, Institute for Mental Health Services Research; Roy Crew, Director of the Consumer Office of Self-Help; Nancy Presson, Section Director; Jo Ruffin, Section Director; Tina Yee, Assistant Section Director; Linda Wang, Section Director; and Sherry Barto, Quality Management Section — all from the Division of Mental Health and Substance Abuse, City and County of San Francisco; Ken McLaren, Director of Thunderseed Adult Day Treatment at the California Pacific Medical Center in San Francisco.     

Community mental health centers in a managed care environment

Managed care has become the dominant force in both public and private mental health and substance abuse services. The authors describe how one community mental health center organized itself to take advantage of the increasing demands for managed mental health services.     

Coordinated services for children's mental health: a process evaluation

This article reports on a process evaluation of the Texas Children's Mental Health Plan, a statewide initiative to provide interagency coordinated mental health services to severely emotionally disturbed children and their families. Researchers followed the activities of the state management team and three local sites during the first year and a half of the project's implementation. This article delineates the major positive effects of the plan as well as the facilitating factors and barriers to the development of such an effort.     

How mental health providers see managed care

This paper reports findings from two focus groups on managed care conducted in a large U.S. city in 1989. Questions addressed included how managed care had affected mental health practice, specific experiences with managed care, the mechanisms of managed care, and how managed care could be improved. The practitioners complained of multiple problems, but clearly distinguished between "good" and "bad" firms. Firms seen as more positive struck a balance between quality care and cost containment, built ongoing relationships with providers, and negotiated with providers, rather than prescribing a treatment plan. The authors conclude that some of the poor reception by providers of managed care may have been created unnecessarily by firms which have not attended to these factors, and that attention to such factors might lead to a more ready acceptance of managed care.     

Quality assurance and managed mental health care

Quality assurance demands that health professionals meet the timeless mandate of helping (when we can) and doing no harm. The delivery of quality care has been profoundly influenced by systems of managed care, which may represent the principal trend in organized medicine in the 1980s. This chapter first defines quality and quality assurance. We then define managed care and managed mental health care. The implications of managed care on patients and health professionals are then addressed. Finally, we discuss examples of what has been done and what can be done to help ensure the continued provision of quality care in a cost-conscious society.     

Linking physical and mental health: Comparing users and non-users of mental health services in medical care utilization

Higher medical costs incurred by persons with mental disorders was assessed by comparing users and non-users of mental health services in their use of medical (non-mental health) services. Insurance claims data for 4.8 million persons enrolled in the Federal Employees Plan in 1978 were examined. Policy-related recommendations include the need for coordinated mental and physical health care in primary care settings. In particular, the physical health problems of patients in mental health settings should not be ignored as these may cause or exacerbate distress and reduce the effectiveness of mental health treatment.     

Use of psychiatric emergency services and enrollment status in a public managed mental health care plan.

OBJECTIVE: This study examined the sociodemographic and clinical characteristics of acute-care psychiatric patients who visited the emergency department at a large public hospital in terms of the patients' enrollment status in the region's public managed mental health care plan. The results of the analyses were expected to provide information about the degree and types of access to care for individuals who are and are not enrolled in the plan. METHODS: Data were collected over a seven-month period for 2,419 patients who visited a large, inner-city crisis triage unit. Patients were grouped according to whether they were currently enrolled, previously enrolled, or never enrolled in the public managed mental health care plan. Univariate and logistic regression models were used to determine differences between the three groups. RESULTS: In general, patients who were currently enrolled in the plan had a higher rate of functional psychosis, past use of psychiatric services, and functional disability and lower rates of substance use and homelessness. Previously enrolled patients had a more moderate rate of psychosis but a higher rate of substance use, functional disability, and homelessness. The never-enrolled patients had a lower rate of psychosis, functional disability, and past use of psychiatric services, and moderate substance use. CONCLUSIONS: The region's public health plan appeared to be succeeding in engaging and keeping the most psychiatrically impaired patients in treatment; however, individuals with moderate psychiatric symptoms and high levels of substance abuse may never have been enrolled in the plan because of Medicaid ineligibility or because they dropped out of treatment. Problematic behavior and history of hospitalization were the best predictors of enrollment status.     

A model for rural children's mental health services

Rural mental health services face unique problems. These include population dispersion, lack of adequate resources, paucity of qualified providers, and inefficient communication systems. This paper describes the Rural Partnership Model serving children and youth in a 10,000 square mile catchment area. Strategies are offered to assist others in developing a similar model of preventive, treatment, and after-care services to more effectively meet the mental health needs of children and their families.     

The utilization of Medicaid mental health services

The experience of Medicaid recipients in the public mental health system is examined for a cohort of new users with respect to time spent in treatment and patterns of care. The analysis shows that 47% of the user cohort do not receive services again over the 4-year study period. Approximately 25% are found to be using services 4 years later, 19% of whom are continuous users throughout the period. These long-term users tend to be the most seriously mentally ill based on diagnosis and disability status and display patterns of care that shift, over time, from inpatient care to outpatient services. Inpatient services were used by 29% of the new cohort during their first year in treatment which has implications for managing mental health care since a large percent of crisis patients are new or unknown to the system each year.